Our understanding of pre-arthritic hip disease has evolved tremendously but challenges remain in categorizing diagnosis, which ultimately impacts choice of treatments and clinical outcomes. This study aims to report patient reported outcome measures (PROMs) comparing four different condition groups within hip preservation surgery by a group of fellowship-trained surgeons.

From 2018 to 2021, 380 patients underwent hip preservation surgery at our center and were classified into five condition groups: dysplasia: 82 (21.6%), femoro-acetabular impingement (FAI): 173 (45.4%), isolated labral tear: 103 (27.1%), failed hip preservation: 20 (5.3%) and history of childhood disease/other: 2 (0.5%). International hip outcomes Tool 12 (IHOT-12), numeric pain score and patient-reported outcomes measurement information system (PROMIS) were collected pre-operatively and at 3 months and 1 year post-operatively, with 94% and 82% follow-up rate respectively.

Arthroscopy (75.5%) was the most common procedure followed by peri-acetabular osteotomy (PAO) (22.4%) and surgical dislocation (2.1%). Re-operation rate were respectively 18.3% (15), 5.8% (10), 4.9% (5), 30% (6) and 0%. There were 36 re-operations in the cohort, 14 (39%) for unintended consequences of initial surgery, 10 (28%) for mal-correction leading to a repeat operation, 8 (22%) progression of arthritis, and 4 (11%) for incorrect initial diagnosis/intervention. Most common re-operations were hardware removal 31% (7 PAO, 3 surgical hip dislocation and 1 femoral de-rotational osteotomy), arthroscopy 31% (11) and arthroplasty 28% (10). All groups had significant improvements in their IHOT-12 as well as PROMIS physical and numerical pain scales, except those with failed hip preservation. Dysplasia group showed a slower recovery.

Overall, this study demonstrated a clear relation between the condition groups, their respective intervention and the significant improvements in PROMs with isolated labral pathology being a valid diagnosis. Establishing tertiary referral centers for hip preservation and longer follow-up is needed to monitor the overall survivorship of these various procedures.

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons.

This is a single-centre, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture. Radiographic analysis was performed using validated software to measure femoral- (canal flare index [CFI], morphological cortical index [MCI], calcar-calcar ratio [CCR]) and pelvic- (Ilium-ischial ratio [IIR], ilium overhang, and ASIS to greater trochanter distance) morphologies and surgical technique (% canal fill). Multivariate and Receiver-Operator Curve (ROC) analysis was performed to identify predictors of fracture.

Femoral factors that differed included CFI (3.7±0.6 vs 2.9±0.4, p<0.001) and CCR (0.5±0.1 vs 0.4±0.1, p=0.006). The mean IIR was higher in fracture cases (3.3±0.6 vs 3.0±0.5, p<0.001). % Canal fill was reduced in fracture cases (82.8±7.6 vs 86.7±6.8, p=0.007). Multivariate analysis and ROC analyses revealed a threshold CFI of 3.17 was predictive of fracture (sensitivity:84.6% / specificity:75.6%). Fracture risk was 29 times higher when patients had CFI>3.17 and II ratio>3 (OR:29.2 95%CI: 9.5–89.9, p<0.001).

Patient-specific anatomical parameters are important predictors of fracture-risk. When considering the use of short stems via the AA, careful radiographic analysis would help identify those at risk in order to consider alternative stem options.

Aims

In computer simulations, the shape of the range of motion (ROM) of a stem with a cylindrical neck design will be a perfect cone. However, many modern stems have rectangular/oval-shaped necks. We hypothesized that the rectangular/oval stem neck will affect the shape of the ROM and the prosthetic impingement.

Aims

The aim of this study was to radiologically evaluate the quality of cement mantle and alignment achieved with a polished tapered cemented femoral stem inserted through the anterior approach and compared with the posterior approach.

Aims

The aim of the current study was to assess the reliability of the Ottawa classification for symptomatic acetabular dysplasia.

Osteochondroplasty procedure for cam deformity provides excellent outcomes on alleviating pain, improving quality of life and clinical function in femoroacetabular impingement syndrome (FAIS) patients. Although medium-term outcomes on gait biomechanics have been reported, it is unclear how it would translate to better hip muscle forces and joint loading in high range of motion tasks. The purpose of this study was to compare the muscle forces and hip joint contact forces (HCF) during a squat task in individuals before and after cam-FAIS surgical correction. Ten cam-FAIS patients prior and 2-years after osteochondroplasty, and 10 BMI- age- and sex-matched healthy control participants (CTRL) underwent 3D motion and ground reaction forces capture while performing a deep squatting task. Muscle and HCF were estimated using musculoskeletal modeling and comparisons were done using statistical parametric mapping (SPM).

Postoperatives squatted down with a higher anterior pelvic tilt and higher hip flexion compared with the preoperatives. Preoperative semimembranosus generated lower forces than the two other groups on the squat ascending, with no differences detected between post-ops and CTRLs. Preoperatives also showed reduced forces for the distal, ischial and medial portions of the adductor magnus relative to the CTRLs, which although reduced, still presented differences postoperatively. Preoperative anterior and medial contact forces were significantly lower than the CTRL group during both phases of the squat. Postoperative vertical and medial forces were also lower compared to the CTRLs. However, with higher vertical forces during the ascent phase of the squat compared to the preoperative, the postoperative group, significantly increased its HCF magnitude. A higher anterior pelvic tilt was associated with an innate restoration of the pelvis position, once the cam deformity no longer existed. The increased force of the semimembranosus muscle while ascending the squat generated higher vertical HCF, which also influenced the increased HCF total magnitude.

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Introduction

Porous coated cups have a low modulus of elasticity that enhances press-fit and a surface that promotes osseointegration as well as permitting modularity. Monoblock ceramic acetabular cups represent a subtype of uncemented cup permitting the use of large femoral heads. The aim of this study was to compare the short-term clinical and radiographic performances of both cups.

Aims

This study of patients with osteoarthritis (OA) of the hip aimed to: 1) characterize the contribution of the hip, spinopelvic complex, and lumbar spine when moving from the standing to the sitting position; 2) assess whether abnormal spinopelvic mobility is associated with worse symptoms; and 3) identify whether spinopelvic mobility can be predicted from static anatomical radiological parameters.

Aims

Cardiac magnetic resonance (CMR) was used to assess whether cardiac function or tissue composition was affected in patients with well-functioning metal-on-metal hip resurfacing arthroplasties (MoMHRA) when compared with a group of controls, and to assess if metal ion levels correlated with any of the functional or structural parameters studied.

Aims

This study aims to: determine the difference in pelvic position that occurs between surgery and radiographic, supine, postoperative assessment; examine how the difference in pelvic position influences subsequent component orientation; and establish whether differences in pelvic position, and thereafter component orientation, exist between total hip arthroplasties (THAs) performed in the supine versus the lateral decubitus positions.

Background

Hip dysplasia has traditionally been classified based on the lateral center edge angle (LCEA). A recent meta-analysis demonstrated no definite consensus and a significant heterogeneity in LCEA values used in various studies to define hip dysplasia and borderline dysplasia. To overcome the shortcomings of classifying hip dysplasia based on just LCEA, a comprehensive classification for adult acetabular dysplasia (CCAD) was proposed to classify symptomatic hips into three discrete prototypical patterns of hip instability; lateral/global, anterior, or posterior. The purpose of this study was to assess the reliability of this recently published CCAD.

Aims

What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI.

Aims

Joint-preserving surgery of the hip (JPSH) has evolved considerably and now includes a number of procedures, including arthroscopy, surgical dislocation, and redirectional osteotomies of the femur and acetabulum. There are a number of different factors which lead to failure of JPSH. Consequently, it is of interest to assess the various modes of failure in order to continue to identify best practice and the indications for these procedures.

Aims

Total joint arthroplasty (TJA) is commonly performed in elderly patients. Frailty, an aggregate expression of vulnerability, becomes increasingly common with advanced age, and independently predicts adverse outcomes and the use of resources after a variety of non-cardiac surgical procedures. Our aim was to assess the impact of frailty on outcomes after TJA.

The acetabular labrum is a soft-tissue structure which lines the acetabular rim of the hip joint. Its role in hip joint biomechanics and joint health has been of particular interest over the past decade. In normal hip joint biomechanics, the labrum is crucial in retaining a layer of pressurised intra-articular fluid for joint lubrication and load support/distribution. Its seal around the femoral head is further regarded as a contributing to hip stability through its suction effect. The labrum itself is also important in increasing contact area thereby reducing contact stress. Given the labrum’s role in normal hip joint biomechanics, surgical techniques for managing labral damage are continuously evolving as our understanding of its anatomy and function continue to progress. The current paper aims to review the anatomy and biomechanical function of the labrum and how they are affected by differing surgical techniques.

Take home message: The acetabular labrum plays a critical role in hip function and maintaining and restoring its function during surgical intervention remain an essential goal.

Cite this article: Bone Joint J 2016;98-B:730–5.

The primary purpose of this study of metal-on-metal (MoM) hip resurfacing was to compare the effect of using a cementless or cemented femoral component on the subsequent bone mineral density (BMD) of the femoral neck.

This was a single-centre, prospective, double-blinded control trial which randomised 120 patients (105 men and 15 women) with a mean age of 49.4 years (21 to 68) to receive either a cemented or cementless femoral component. Follow-up was to two years. Outcome measures included total and six-point region-of-interest BMD of the femoral neck, radiological measurements of acetabular inclination, neck-shaft and stem-shaft angles, and functional outcome scores including the Harris hip score, the Western Ontario and McMaster Universities Osteoarthritis Index and the University of California at Los Angeles activity scale.

In total, 17 patients were lost to follow-up leaving 103 patients at two years. There were no revisions in the cementless group and three revisions (5%) in the cemented group (two because of hip pain and one for pseudotumour).

The total BMD was significantly higher in the cementless group at six months (p < 0.001) and one year (p = 0.01) than in the cemented group, although there was a loss of statistical significance in the difference at two years (p = 0.155).

All patient outcomes improved significantly: there were no significant differences between the two groups.

The results show better preservation of femoral neck BMD with a cementless femoral component after two years of follow-up. Further investigation is needed to establish whether this translates into improved survivorship.

Cite this article: Bone Joint J 2015;97-B:1608–14.

Objectives

To quantify and compare peri-acetabular bone mineral density (BMD) between a monoblock acetabular component using a metal-on-metal (MoM) bearing and a modular titanium shell with a polyethylene (PE) insert. The secondary outcome was to measure patient-reported clinical function.

Purpose

The importance of femoral head-neck morphology in the development of early hip osteoarthritis is recognized in femeroacetabular impingement (FAI), however no studies have examined FAI morphology in the developing hip, i.e. pre-closure of the proximal femoral physis. We developed a pilot project to study prevalence of CAM-type FAI hip morphology in both the pre- and post-closure proximal femoral physes of asymptomatic children using MR-imaging. We also examined biologic markers possibly related to FAI etiology, including Vitamin D metabolites, BMI, family history, and activity levels.

Purpose

The purpose of the study was to determine the rate of conversion from RSA to THR in a number of Canadian centers performing resurfacings

Purpose

Primary uncemented total hip arthroplasty is the fixation of choice for most patients undergoing hip replacement in North America. Initial stem stability will be detected by the fit and fill of the implant to the bone as well as the overall stem geometry as it relates to its mechanical stability. This study aims to determine the geometric and structural parameters of common cementless tapered femoral stems to better understand their early clinical performance with respect to bony fixation.

Purpose

Use of a large femoral head metal-on-metal bearing in total hip arthroplasty may offer an advantage in terms of dislocation rates and more natural joint kinematics. The acetabular component is more rigid however in these prostheses and if not placed accurately can lead to increased levels of metal ion release. A prospective randomized controlled trial was conducted to quantify bone mineral density on the acetabular side, as well as compare metal ion levels from a standard metal-on-polyethylene bearing to a large head metal-on-metal bearing in primary total hip arthroplasty.

Purpose

Transfusion rates after primary total hip has been reported up to 39.2%. The purpose of our study was to evaluate the efficacy of TXA in minimizing risk of allogeneic blood transfusion after primary total hip and hip resurfacing arthroplasty.

Advanced MRI cartilage imaging such as T₁-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (sd 9.95) and 36.71 ms (sd 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028).

These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.

The renewed interest in the clinically proven low wear of the metal-on-metal bearing combined with the capacity of inserting a thin walled cementless acetabular component has fostered the reintroduction of hip resurfacing. As in other forms of conservative hip surgery, i.e. pelvic osteotomies and impingement surgery, patient selection will help minimize complications and the need for early reoperation.

Femoral neck fractures remain the leading cause of early failure after metal-on-metal hip resurfacing. Although its' exact pathomechanism has yet to be fully elucidated, current retrieval analysis has shown that either an osteonecrotic event and/or significant surgical trauma to the femoral head neck junction are the leading causes. It is most likely that no single factor like patient selection and/or femoral component orientation can fully avoid their occurrence. As in osteonecrosis of the native hip joint, a certain cell injury threshold may have to be reached in order for femoral neck fracture to occur. These insults are not limited to the surgical approach, but also include femoral head preparation, neck notching, and cement penetration.

Although some have argued that the posterior approach does not represent an increased risk fracture for ON after hip resurfacing because of the so-called intraosseous blood supply to the femoral head, to date, the current body of literature on femoral head blood flow in the presence of arthritis has confirmed the critical role of the extraosseous blood supply from the ascending branch of the medial circumflex, as well as the lack of any substantial intraosseous blood supply. Conversely, anterior hip dislocation of both the native hip joint as well as the arthritic hip preserves femoral head vascularity. The blood supply can be compromised by either sacrificing the main branch of the ascending medial femoral circumflex artery or damaging the retinacular vessels at the femoral head-neck junction. Thus an approach which preserves head vascularity, while minimizing soft tissue disruption would certainly be favorable for hip resurfacing. This presentation will review the current state of knowledge on vascularity of the femoral head as well as surgical techniques enhancing its preservation.

Purpose: Recently, there has been concern raised on the occurrence of pseudotumors after metal on metal hip resurfacing. A pseudotumor is defined as a local soft tissue mass associated with localized bony and/or tissue (muscle) destruction. The primary purpose of this study is to determine the incidence of this complication in several high volume Canadian academic centres.

Method: Nine of the 11 Canadian academic centres who perform metal on metal hip resurfacings were surveyed. The number of metal on metal hip resurfacing arthroplasties performed at each centre was first determined, as were the number of those who have presented with a pseudotumour, and subsequently gone on to revision surgery. The basic demographics of the group were recorded, as were the radiographic and implant design variables for those cases presenting with a pseudotumour.

Results: A sample of 3,400 hip resurfacing arthroplasties performed between 2002 and December 2008 were surveyed. Demographics were tabulated for a sub-sample of these patients. 76% were male, the mean length of follow-up was 3.02 years, mean BMI was 28.65, and mean age was 52.10 years. Three of 3,400 cases presented with a pseudotumour, an incidence of .09%.

Conclusion: Although pseudotumors remain a concern after metal on metal hip resurfacing, the incidence at short to mid term follow-up is very low in this multi-centre academic survey. This information is significantly lower than what other groups have recently reported. Continued close monitoring is required in order to determine what clinical factors are at play.

Purpose: The Quality of Recovery-40 questionnaire (QoR-40) has been developed, validated and extensively used to assess the quality of life of patients following major surgery. It is composed of 40 questions answered by the patient and organized into six dimensions: emotional state, physical comfort, psychological support, physical independence, pain, and global score. However, this questionnaire has not been validated in an orthopaedic population. The objective of the study was to assess the psychometric properties of the QoR-40 in a population of patients undergoing total knee or hip arthroplasty.

Method: Sixty seven patients undergoing total knee arthroplasty and 65 patients undergoing total hip arthroplasty were recruited. Patients were assessed with the QoR-40 and the SF-12, a validated generic quality of life questionnaire, at the following seven times: three and one week pre-operative; one, two and three days post-operative (short-term); one and three months post-operative (long-term). The following psychometric properties of the QoR-40 were assessed: reliability between three and one week pre-operative using intra-class correlation coefficients (ICC), construct validity with the SF-12 using Pearson product moment correlations, responsiveness to change using effect sizes, floor and ceiling effects, and predictive validity of short-term QoR-40 scores of long-term SF-12 scores.

Results: All dimensions and global scores of the QoR-40 appeared reliable, with ICCs’ ranging from 0.75 to 0.84. For construct validity, physical dimension scores of the QoR-40 (physical comfort, physical independence, pain) were weakly or not significantly related to the physical component scale of the SF-12 (−0.09 to 0.34), except for long-term where the correlations were moderate (0.35 to 0.62). The emotional state score of the QoR-40 was moderately to substantially related to the mental component scale of the SF-12 for all periods (0.40 to 0.78). Effect sizes were higher for the QoR-40 when compared to the SF-12 in the intervals of the first month, while they were higher for the SF-12 in the intervals above one month. The QoR-40 demonstrated ceiling effects for the physical independence dimension pre-operatively and three months post-operatively, and for all periods for the psychological support dimension. As for predictive validity, short-term post-operative QoR-40 scores were weakly or not significantly predictive of long-term postoperative SF-12 scores (0.01 to 0.41).

Conclusion: The QoR-40 appears to be a reliable tool assessing a quality of life construct different from the SF-12 and more responsive to change during the short-term follow-up to surgery. The QoR-40 could be used to assess short-term quality of life following surgery. The QoR-40 should not be used to predict long-term quality of life. To further improve the tool, the psychological support dimension of the QoR-40 should be reconceptualized because of ceiling effects.

Purpose: Although femoral neck fractures remain a concern in terms of short term failures for hip resurfacing, acetabular component position and fixation are increasingly being recognized as causes of mid term failures for hip resurfacing. The purpose of our study was to evaluate the migration pattern of a cementless acetabular component for a metal on metal hip resurfacing.

Method: Between January 2006 and June 2007, 130 patients underwent metal on metal hip resurfacing; 66 hips in 60 patients were included in this analysis. Forty-eight patients were male and 12 were female, with a mean age of 50 (range, 32–66). Ninety-five percent of the surgeries were performed for osteoarthritis. All surgeries were performed by two surgeons using the Conserve Plus (Wright Medical Technology, Memphis, TN) hip resurfacing system. The acetabular component is a monoblock cobalt chrome with a porous beaded surface for osteointegration. In all cases acetabular migration was measured both vertically and horizontally, on serial radiographs using the computer-assisted Ein Bild Röntgen Analyse (EBRA) method. A minimum of three comparable radiographs is necessary for calculating the migration curves. We scored medial migration as negative horizontal movement.

Results: At a mean follow up 25.3 months (range, 24–36 months), each hip had an average of 5.1 radiographs for analysis. The software excluded two cases for poor comparability ending finally with 64 cases for the analysis. Eighty-seven point five per cent of the cups showed less than 1 mm migration in the medium-lateral axis and 54.7% less than 1 mm in the vertical axis. Seventy-seven percent of the cups showed a combined migration of less than 2 mm in the observation period, without radiolucencies, leaving 23% of the acetabular components with 2 mm or greater of component migration. One of these cases required revision for aseptic loosening at 34 months.

Conclusion: In our study the majority of the acetabular components were stable with some of the migration observed secondary to lack of complete initial seating due to the rigidity of the shell. Krismer et al did report on the migration of the PCA shell (also a porous beaded cobalt-chrome shell) using EBRA, with 27.5% of the shells demonstrating > 1 mm of migration. Although hip resurfacing has only mid term followup, results have been good to excellent. Caution should still be maintained since the higher frictional torque generated by the larger femoral head size as well as the nanometer size particles could negatively affect long term fixation of the acetabular component.

Purpose: The surgical correction of FAI deformity is a well accepted treatment in patients presenting with hip pain with associated labral-chondral damage. The anterior approach with assisted hip arthroscopy provides access to the anterior head-neck junction with potentially quicker recovery for patients. The purpose of this study is to present the safety and efficacy of this approach in performing impingement surgery.

Method: Forty-eight Hueter procedures were performed in 45 patients (13 males and 32 females). Mean age was 42.09 years (range, 21–65 years), and mean BMI was 24.31(range, 21–33). The scope was performed first to deal with intra-articular damage. All patients were diagnosed with CAM type FAI with labral pathology based on MRI arthrogram with an alpha angle > 50.5 degrees.

Results: At a mean follow-up of 21.8 months (range 12–30 months), Harris Hip scores improved from 64.66 (range, 42.0–93.0) to 79.97 (range, 47.0–96.0). There were 5 re-operations at a mean time of 15.2 months (range, 4–22). One had a repeat hip scope for intra-articular adhesions, and another for recurrent traumatic tear of the labrum. Three cases with residual hip dysplasia had corrective surgery with a peri-acetabular osteotomy at an average of 16.67 months (range, 15–18 months).

Conclusion: Overall, we have found this to be a reliable, safe and reproducible approach to the treatment of FAI. This is a day care procedure as compared to the classic open procedure. Uncorrected hip dysplasia in the presence of a CAM deformity is a risk factor for early failure.

Purpose: A functional centre of rotation (CoR) is often required in biomechanical analysis of the hip or as a landmark in computer guided surgery. It was previously shown that circumduction motions predict a CoR that is inferior and lateral to the geometric centre of the hip bearing surfaces. It is therefore necessary to establish the best method for determining the CoR to improve surgical planning. The objective of this study was to compare the predicted CoR from circumduction and star motions, and to compare these to the geometric centre of the joint.

Method: Eight cadaveric hips from four cadavers were tested. Prior to testing, CT scans of the cadavers were made from the iliac crest to the tibial plateau; the alpha angle for all hips was less than 50° so all hips were considered ‘normal’. Reflective marker arrays were rigidly mounted on the femoral diaphysis and iliac spine using 4mm Steinman pins. A five-camera Vicon system (Oxford, UK) was used to track the motions of the arrays during manipulation of the lower limb. To determine the functional hip centre, trials consisting of five cycles each of circumduction, flexion-extension and abduction-adduction were performed on each lower limb; three trials of each motion were performed. The range of motion was approximately 45° in the coronal and sagittal planes. For the ‘star’ motion, the flexion-extension and abduction-adduction trial data were combined. Following the trials the hip was dissected to expose the articular surfaces of the femoral head and acetabulum. These surfaces were traced using a pointer equipped with reflective markers to determine the geometric centre. To calculate the functional centre, the 3D coordinates of the markers were used to construct a local-to-global 3D transform for each frame throughout the trial. The geometric centre was calculated using a least-squares sphere fit (Gauss-Newton) of the trace data, calculated in the respective local coordinate systems. The coordinates of the functional centres were then transformed to an anatomic coordinate system, using the geometric centre as the origin. All calculations were performed using Matlab (Mathworks, Inc, MA, USA). A t-test was performed in each anatomic direction to detect differences in CoR predicted by the two motions.

Results: Both the circumduction and star motions resulted in a similar CoR. Differences were 0.41±2.25mm in the anterior-posterior direction; 0.09±0.72mm in the superior-inferior direction; and 0.21±0.82mm in the medial-lateral direction, none of which were significant (p> 0.5). The overall mean distance between the CoR predicted by the two motions was 2.0±1.3mm. The functional centre was also found to be lateral and inferior to the geometric centre, and was consistent for each motion. Results for the acetabulum showed similar trends.

Conclusion: This study has shown that circumduction and star motions are equivalent in predicting the hip functional CoR; differences were small compared to the dimensions involved in studies such as gait analyses. However, both motions predicted a CoR that was inferior and lateral to the spherical centre of the femoral head, suggesting that the hip does not act as a true ball-and-socket joint with congruent spherical bearing surfaces. This may have important consequences in studies at the scale of the hip joint, especially for pathological conditions such as femoroacetabular impingement.

Purpose: LFCN neuropraxia is a known complication of the anterior approach to the hip joint. The objective of this study was to define the incidence, functional impact and natural history of this neuropraxia in the anterior approach after both hip resurfacing (HR) and primary total hip arthroplasty (THA).

Method: Between September 2006 and January 2008, 132 consecutive patients underwent a direct anterior hip approach (DAA) (55 THR; 77 HR). Sixty-two patients were female and 70 were male; the mean age was 55.54 (range, 29.9 to 88.7). Self reported questionnaires for sensory deficits of LFCN, a neuropathic pain score (DN4) as well as SF-12, UCLA and WOMAC scores were completed. A subset of 60 patients (30 THA, 30 resurfacing) was evaluated at two time intervals (6 and 12 months).

Results: One hundred and seven patients (81%) reported LFCN neuropraxia, with a mean severity score of 2.32/10 (SD, 2.11); mean DN4 score of 2.42/10 (SD, 2.37). Hip resurfacing had a higher incidence of neuro-praxia compared to THA: 91% versus 67% (p=0.02), respectively. No functional limitations were reported on SF-12, WOMAC or UCLA scores. Of the subset of 60 patients, 53 (88.3%) reported neuropraxia at the six month follow-up interval with only three (5.7%) having complete resolution at 12 months. Patients who reported neuropraxia at both testing intervals did report an improvement in DN4 scores: 3.6 versus 2.5 at 6 and 12 months, respectively (p=0.02).

Conclusion: Although LFCN neuropraxia is a frequent complication after DAA total hip arthroplasty, it does not lead to any functional limitations. A decrease in symptoms does occur over time, with only a small number of patients reporting complete resolution.

Purpose: Femoroacetabular impingement (FAI) is recognized as a pathomechanical process that leads to hip osteoarthritis (OA). Past research has been focused on treatments for FAI; however, few studies have been done to link FAI with the progression of OA. It is hypothesized that elevated mechanical stimuli could provoke bone remodeling in the subchondral bone and articulating surfaces due to cam FAI (aspherical head-neck deformity), which would accelerate the progression of OA. Using finite element analysis (FEA), the aim is to compare healthy hips to hips with cam FAI – investigating the mechanical stimuli effect of FAI towards OA.

Method: Net joint reaction forces were obtained from joint kinematics, kinetics, and by inverse dynamics calculation for a dynamic squat motion of a control subject and a cam FAI patient (both males with comparable age, BMI, and femur lengths). CT scans were acquired from both subjects. Data slices were compiled using 3D-DOCTOR (Able Software Corp, MA) to form a 3D model with slice thickness calibrated at 1.25mm in the superior-inferior axis. ANSYS (ANSYS, PA) software was used for FEA. The femur models were given quadrilateral shell elements and modeled as linear elastic orthotropic materials. The ground reaction forces were applied to the femur models, simulating dynamic loads, using boundary conditions specific to hip loading. Von Mises stresses were determined to examine stress concentrations and adverse loading conditions. Strain energy distributions were determined to examine the effect of stimuli on the initiation and rate of bone remodeling.

Results: At the maximum squat-depth, the FEA results demonstrated that the net forces acting on the FAI hip produced high mechanical stimuli regions around the head and neck. The highest stress concentration (590 MPa) was located at the anterosuperior head-neck junction, where cam FAI is most prominent. For the control hip, stresses were significantly lower (maximum of 151 MPa) and dissipated around the head. For both the FAI and the control hip, the maximum strain energy concentrations were seen at the superior portion of the head (4.725 kJ vs. 2.192 kJ for FAI vs. control hip respectively).

Conclusion: The increase in mechanical stimuli can be due to the loading configurations as well as to the abnormal geometry of the cam deformity. Assuming that the strain energy density (SED) and its rate is linearly proportional to the rate of bone turnover, based on a recent semi-mechanistic bone remodeling theory, a higher rate of bone turnover is expected in the FAI than in a normal hip. Depending on the level and rate of SED, the rate of bone remodeling will vary in order to provide a new homeostatic configuration. The next-step analysis, examining the mechanical stimuli in the acetabulum and its cartilage, is currently in progress. This would provide useful information about the possible locations of OA initiation and establish a link between FAI with cartilage degeneration.

Purpose: It is thought that the anterior approach better restores gait mechanics after total hip arthroplasty (THA) being a pure intermuscular/internervous approach. The purpose of this study was to compare three-dimensional (3-D) kinematics and kinetics of THA patients that had an anterior (ANT) vs. a lateral (LAT) approach. It is hypothesized that the ANT group will exhibit fewer differences than the LAT group when compared to a control group (CON).

Method: Fifty-four participants were divided into three groups of 18: ANT (12 women, 6 men; age: 60.9 ± 6.2 yr; BMI: 28.8 ± 4.9 kg/m2), LAT (10 women, 8 men; age: 65.2 ± 6.3 yr; BMI: 27.5 ± 5.1 kg/m2) and CON (9 women, 9 men; age: 63.9 ± 4.4 yr; BMI: 25.4 ± 3.2 kg/ m2). All THA patients had primary unilateral THA due to osteoarthritis and had no other lower-limb pathology. They were evaluated five to 17 months after surgery. 3-D kinematics and kinetics were obtained using a nine-camera motion analysis system and a force platform placed on the first step of a staircase. Each participant performed three trials of stair ascending. A series of one-way ANOVAs were used to compare peak angles, range of motion (ROM), peak resultant joint forces as well as moments and powers of the hip, knee and ankle joints in all three planes.

Results: Most differences occurred during transitions between double- to single-legged stance. Both LAT and ANT groups ascended the staircase with a more abducted hip than the CON group, resulting in reduced hip abduction moment. This could be the result of the implant’s position and its potential abductor lever arm reduction. Both groups also showed reduced peak internal rotation moments. These results have previously been found in THA patients who have been operated through lateral and posterior approaches, and are thought to be caused by hip abductor muscle damage inherent to the surgical approach. However, only the LAT group had lower compression forces at the hip, knee and ankle joints compared to the CON group. This indicates that LAT group uses a strategy that reduces the loading on the operated leg, which may be due to the detachment of the anterior third of the gluteus medius. It could be speculated that the muscle sparing aspect of ANT approach allows patients to load adequately their operated leg, even if their frontal plane kinematics and kinetics are altered.

Conclusion: Some studies have failed to find differences with the anterior approach. However, they have only looked at spatiotemporal gait parameters. 3-D kinematics and kinetics can provide a more detailed assessment of function and detect more subtle differences. In this study, 3-D biomechanical analysis has detected differences in THA patients operated through different surgical approaches during stair ascent. The data obtained showed similar frontal plane kinematics for both groups, but different lower-limb compression forces. This study supports the use of the anterior approach for better restoration of function after total hip arthroplasty.

Purpose: We aimed to measure the early migration pattern of a titanium alloy, tapered, plasma and hydroxyapatite coated femoral stem and any factors associated with subsidence.

Method: Between January 2005–June 2007, 387 Accolade cementless femoral stems (Stryker, Allendale NJ) were implanted at our institution. Seventy-seven had a minimum of two years post operative follow up and a complete set of pre and postoperative radiographs for analysis. Our group inlcuded 45 females with a mean age of 71.4 years, and 32 males with a mean age of 68.5 years. The primary diagnosis was degenerative osteoarthritis in 71 patients, avascular necrosis in two, and post fracture in four patients. The average BMI was 27.1. We measured the canal index to assess bone quality and the canal calcar index to assess the proximal femoral morphology. Immediate postoperative radiographs were assessed for canal fill of the prosthesis and implantation varus/valgus angles. The EBRA-FCA software was used to obtain migration curves for each stem. Best fit curve of subsidence over time was calculated and the data was analysed using a Kaplan Meier survivorship with 1.5 mm of subsidence as an endpoint. We then performed a multivariate and univariate regression analysis for predictors of subsidence.

Results: The mean follow up was 29.3months (24–48). The mean canal index was 0.55 (0.36–0.68) with a mean canal calcar index of 0.54 (0.39–0.79). The average canal fill index at the midpoint of the stem was 80 in 40 stems. A total of 414 radiographs were analysed for the EBRA measurements. Of these 21 (5%) were discarded by the software as they did not meet the criteria for comparability. This led to the exclusion of seven patients, leaving the final study group of 77. All remaining patients had a minimum of four radiographs with an average of 4.6 for analysis. The average subsidence at 24 months was 2 mm and this had risen to 2.4 mm by 36 months postoperatively. When analysed using a Kaplan Meier curve using 1.5 mm as an end point we found a survivorship of 63.4% (52.3–74.5) at 24 months and this had worsened to 41.6% (26.6–56.5) by 36 months. Multivariate and univariate regression analysis of measured variables did not reveal any significant hazard for any factor other than the larger stem sizes doing worse.

Conclusion: Although several cementless tapered stem designs have had an excellent track record, our migration analysis of the Accolade stem is somewhat concerning. Thirty three percent of stems had reached the 1.5 mm subsidence point by two years. This is of concern as work has previously shown this to predict failure of stems with aseptic loosening at ten years with an accuracy of 79%. If these stems go on to fail at the predicted rate this would represent an unacceptably high level of failure. Our data raises serious concerns about the overall clinical performance of this stem design due to poor initial stability and integration.

Purpose: Iatrogenic acetabular retroversion is a known complication after pelvic osteotomy leading to persistent hip pain and increasing risk of subsequent osteoarthritis. The purpose of this study is to document the incidence of acetabular retroversion and signs of impingement in patients who have had a Salter pelvic osteotomy in childhood.

Method: Twenty eight patients (32 hips) had a Salter Osteotomy between 1980 and 1999, 16 were lost to follow-up. Of the 12 studied, eight had a diagnosis of DDH and four had Legg Calve Perthes. Clinical assessment for the presence of the impingement sign, range of motion and leg length discrepancy was done as well as functional scores. AP pelvic radiographs were taken to assess acetabular retroversion (cross-over or ischial sign), osteoarthritis using the Tonnis grade, center-edge and Tonnis angles.

Results: The mean age of the sample was 17.25 years (SD=7.27) with a mean follow-up of 10.56 years (SD=6.27). Impingement sign was positive in seven patients (58.3%). Nine out of the 12 had acetabular retroversion. Nine had Tonnis grade 1, two Tonnis grade 2, and one had a Tonnis grade 3. Mean center edge and Tonnis angles were 26° (SD=16.43) and 9.09° (SD=6.49), respectively. There was no correlation between presence of acetabular retroversion with Tonnis grade (p=.700), hip pain (p=.317) or impingement sign (p=.621).

Conclusion: Retroversion is highly prevalent (69.2%) in patients who underwent a Salter pelvic osteotomy for a childhood hip disease. Although acetabular retroversion is a known cause of impingement in adulthood, our patient cohort was too small to detect a significant impact on the functional scores.

Femoroacetabular impingement is a cause of hip pain in adults and is potentially a precursor of osteoarthritis. Our aim in this study was to determine the prevalence of bilateral deformity in patients with symptomatic cam-type femoroacetabular impingement as well as the presence of associated acetabular abnormalities and hip pain. We included all patients aged 55 years or less seen by the senior author for hip pain, with at least one anteroposterior and lateral pelvic radiograph available. All patients with dysplasia and/or arthritis were excluded. A total of 113 patients with a symptomatic cam-impingement deformity of at least one hip was evaluated. There were 82 men and 31 women with a mean age of 37.9 years (16 to 55).

Bilateral cam-type deformity was present in 88 patients (77.8%) while only 23 of those (26.1%) had bilateral hip pain. Painful hips had a statistically significant higher mean alpha angle than asymptomatic hips (69.9° vs 63.1°, p < 0.001). Hips with an alpha angle of more than 60° had an odds ratio of being painful of 2.59 (95% confidence interval 1.32 to 5.08, p = 0.006) compared with those with an alpha angle of less than 60°. Of the 201 hips with a cam-impingement deformity 42% (84) also had a pincer deformity.

Most patients with cam-type femoroacetabular impingement had bilateral deformities and there was an associated acetabular deformity in 84 of 201 patients (42%). This information is important in order to define the natural history of these deformities, and to determine treatment.

Damage to and repair of the acetabular labral-chondral complex are areas of clinical interest in the treatment of young adults with pain in the hip and in the prevention of degenerative arthritis of the hip. There are varying theories as to why most acetabular tears are located anterosuperiorly. We have studied the prenatal development of the human acetabular labral-chondral complex in 11 fetal hips, aged from eight weeks of gestation to term.

There were consistent differences between the anterior and posterior acetabular labral-chondral complex throughout all ages of gestation. The anterior labrum had a somewhat marginal attachment to the acetabular cartilage with an intra-articular projection. The posterior labrum was attached and continuous with the acetabular cartilage. Anteriorly, the labral-chondral transition zone was sharp and abrupt, but posteriorly it was gradual and interdigitated. The collagen fibres of the anterior labrum were arranged parallel to the labral-chondral junction, but at the posterior labrum they were aligned perpendicular to the junction.

We believe that in the anterior labrum the marginal attachment and the orientation of the collagen fibres parallel to the labral-chondral junction may render it more prone to damage than the posterior labrum in which the collagen fibres are anchored in the acetabular cartilage. The anterior intra-articular projection of the labrum should not be considered to be a pathological feature.

Obtaining fixation in DDH with Surface arthroplasty (SA) with a two part polyethylene (PE ) socket was technically challenging. Although dislocation was rare there was a high loosening rate secondary to polyethylene wear. The purpose of this study was to evaluate the results of Conserve Plus metal-on-metal SA in Crowe class I and II Developmental Dysplasia of the Hip patients.

54 patients (59 hips), 72% females, average age43.7 years (15 to 63.8) met these inclusion creteria with 2 years of follow-up minimum. Seven hips were Crowe type II and fifty-two were type I.

Harlan C. Amstutz, John Antoniades, Michel J. Le Duff, Paul E. Beaulé

The results of MMSA are much improved over those of prior generations of SA and socket fixation is stable even in Crowe type II with the porous coated acetabular components without adjuvant fixation despite incomplete acetabular coverage of the socket. The hips have-been stable even with important range of motion. Recent short term failure and radiolucencies have been eliminated by improved technique despite a high incidence of femoral cysts and reduced area of fixation.

The purpose of the present study was to identify risk factors for femoral loosening and neck fracture for Conserve+ metal-on-metal hybrid surface atrhroplasty.

The first 500 hips (of over 700 implanted by the senior author) in 436 patients were reviewed. Mean age was 48.6 with 74% of males patients.

16 hips were converted to THR secondary to aseptic failure on the femoral side (11 femoral component loosenings and 5 femoral neck fractures). 14 hips showed radiolucencies around the short metaphyseal stem at last follow-up. A retrieval analysis was performed and analyzed specimens compared with the intra operative photos of the prepared femoral head and the post-op X-rays. The cause of neck fractures is multifactorial. Risk factors include: uncovered reamed bone, leaving the component proud, notching the neck, impingement, osteopenia and cysts, and trauma. Avoidance of technical deficiencies and proper patient selection can eliminate neck fractures. Loosening is also multifactorial. Risk factors for loosening included: cysts > 1 cm, small femoral head size, female gender, early cases (before improved acrylic fixation including femoral suctioning measures were instituted) and reduced stem shaft angle.

Meticulous initial preparation of the femoral bone surfaces, drying with suctioning, and maximizing the fixation area are critical when the fixation area is small, especially with osteopenia and cystic degeneration. These techniques have dramatically diminished the incidence of loosening and radiolucencies. Cementing the femoral metaphyseal stem is a meaningful technical improvement towards the prevention of early femoral failure in patients with risk factors.

Femoroacetabular impingement is recognised as being a cause of labral tears and chondral damage. We report a series of five patients who presented with persistent pain in the hip after arthroscopy for isolated labral debridement. All five had a bony abnormality consistent with cam-type femoroacetabular impingement. They had a further operation to correct the abnormality by chondro-osteoplasty of the femoral head-neck junction. At a mean follow-up of 16.3 months (12 to 24) all had symptomatic improvement.

Because the femoral head/neck junction is preserved in hip resurfacing, patients may be at greater risk of impingement, leading to abnormal wear patterns and pain. We assessed femoral head/neck offset in 63 hips undergoing metal-on-metal hip resurfacing and in 56 hips presenting with non-arthritic pain secondary to femoroacetabular impingement. Most hips undergoing resurfacing (57%; 36) had an offset ratio ≤ 0.15 pre-operatively and required greater correction of offset at operation than the rest of the group. In the non-arthritic hips the mean offset ratio was 0.137 (0.04 to 0.23), with the offset ratio correlating negatively to an increasing α angle. An offset ratio ≤ 0.15 had a 9.5-fold increased relative risk of having an α angle ≥ 50.5°. Most hips undergoing resurfacing have an abnormal femoral head/neck offset, which is best assessed in the sagittal plane.

During hip resurfacing arthroplasty, excessive valgus positioning or surgical technique can result in notching of the femoral neck. Although mechanical weakening and subsequent fracture of the femoral neck are well described, the potential damage to the retinacular vessels leading to an ischaemic event is relatively unknown. Using laser Doppler flowmetry, we measured the blood flow in 14 osteoarthritic femoral heads during routine total hip replacement surgery, before and after notching of the femoral neck. In ten hips there was a reduction in blood flow of more than 50% from the baseline value after simulated notching of the femoral neck. Our results suggest that femoral head vascularity in the osteoarthritic state is similar to the non-arthritic state, where damage to the extraosseous vessels can predispose to avascular necrosis. Surgeons who perform resurfacing arthroplasty of the hip should pay careful attention to these vessels by avoiding excessive dissection around the femoral neck and/or notching.

There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel.

A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (> 3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17).

All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p < 0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d’Aubigné and Postel score of 13.7.

The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.

Studies on the migration of an implant may be the only way of monitoring the early performance of metal-on-metal prostheses. The Ein Bild Roentgen Analyse - femoral component analysis (EBRA-FCA) method was adapted to measure migration of the femoral component in a metal-on-metal surface arthroplasty of the hip using standard antero-posterior radiographs. In order to determine the accuracy and precision of this method a prosthesis was implanted into cadaver bones. Eleven series of radiographs were used to perform a zero-migration study. After adjustment of the femoral component to simulate migration of 3 mm the radiographs were repeated. All were measured independently by three different observers.

The accuracy of the method was found to be ± 1.6 mm for the x-direction and ± 2 mm for the y-direction (95% percentile). The method was validated using 28 hips with a minimum follow-up of 3.5 years after arthroplasty. Seventeen were sound, but 11 had failed because of loosening of the femoral component. The normal (control) group had a different pattern of migration compared with that of the loose group. At 29.2 months, the control group showed a mean migration of 1.62 mm and 1.05 mm compared with 4.39 mm and 4.05 mm in the failed group, for the centre of the head and the tip of the stem, respectively (p = 0.001). In the failed group, the mean time to migration greater than 2 mm was earlier than the onset of clinical symptoms or radiological evidence of failure, 19.1 versus 32.2 months (p = 0.001) and 24.8 months (p = 0.012), respectively.

EBRA-FCA is a reliable and valid tool for measuring migration of the femoral component after surface arthroplasty and can be used to predict early failure of the implant. It may be of value in determining the long-term performance of surface arthroplasty.

Purpose: A classification system for fractures is an important communication tool for surgeons allowing the development of management schemes as well as an estimation of the prognosis. The purpose of our work was to evaluate the inter- and intra-observer reproducibility of the Letournel classification system for acetabular fractures.

Material methods and results: Sixty-five x-rays (AP and Judet views) and computed tomography (CT) series were chosen at random from a data base containing 800 fractures. The distribution of the fracture types followed data in the literature. Three groups of observers were formed, each composed of three orthopaedic surgeons. Group 1 included surgeons who had studied with Letournel, group 2 surgeons specialised in acetabular fractures, and group 3 surgeons qualified for general traumatology surgery. The kappa coefficient was determined to assess agreement between observers. Each observer read the images twice without knowledge of the treatment. The observers first classed the fractures using the x-rays alone then with the x-rays in combination with the CT. Two sessions were organised, two months apart to avoid any possible memorisation. Reproducibility without then with CT for the first session were: group 1: 0.07 and 0.74; group 2: 0.71 and 0.69; group 3: 0.51 and 0.512. Results were similar in the second session. Intra-observer reproducibility without then with CT was: group 1: 0.80 and 0.83; group 2 0.80 and 0.80; group 3: 0.64 and 0.69. Among the six more experimented observers (groups 1 and 2), 100% agreement was found for 66% of the x-rays compared with 22% for the new observers.

Discussion and conclusion: The Letournel classification system using x-rays in combination or not with CT is reliable (kappa > 7) for properly trained surgeons with regular experience in treating acetabular fractures. The value of the CT in the assessment of acetabular fractures is well established for identifying detached elements and joint crush. Conversely, CT does not appear to be essential to class ace-tabular fractures. The Letournel classification can be used as a reliable tool for the description of acetabular fractures and taught to surgeons desiring to undertake regular treatment of these fractures.

Purpose: Diverse extended approaches have been described for the treatment of complex acetabular fractues. Little data is however available concerning the results, morbidity, and complications of acetabular fractures treated with this approach. The purpose of this work was to assess outcome in procedures performed by a single operator using the extended iliofemoral approach as described by Letournel for the treatment of acetabular fractures.

Material and methods: The database of the senior author included 833 acetabular fractures, 156 of which were operated via the extended iliofemoral approach in 109 patients who had a minimal two years follow-up. The series included 69 women and 40 men, mean age 34 years (11–93). Fracture type was: BC 64; TR+PW 15; T 12; ACH: 3; PW: 2; AC: 2. Delay before surgery was less than 21 days for 76 patients, between 21 days and three months for 22 and greater than three months for 11. There was a femoral head injury in 21% of the cases and 6% had had an earlier operation.

Results: At mean follow-up of 5.4 years (2–12), all fractures had healed. Reduction was anatomic in 69% of the cases, imperfect in 13ù and fair (interfragment gap > 3 mm) in 18%. The mean Postel Merle d’Aubigné score was 15 (5–18) with 63% excellent or good results. Complications were observed in 9% of the cases: seven infections, two serous discharges, and one necrosis of the scar borders. Ectopic ossifications were noted in 56% of the patients, 16% required surgical resection. Total arthroplasty was performed for 7% of the patients, arthrodesis for 4% and haematoma evacuation for 8%. The arthroplasty was revised two years after recurrent dislocation in one patient.

Discussion: This work allows us to conclude that the extended iliofemoral approach is safe and effective for the treatment of complex acetabular fractures. The percentage of excellent and good results is closely related to the quality of the reduction, and can be considered satisfactory known that the extended iliofemoral approach is used for more complex fractures less susceptible of healing. We recommend this approach for experimented operators well trained in the use of the iliofemoral approach.