(1) Background: Lower extremity microvascular reconstruction aims at restoring function and preventing infection while ensuring optimal cosmetic outcomes. Muscle (M) or fasciocutaneous (FC) free flaps are alternatively used to treat similar conditions. However, it is unclear whether one option might be considered superior in terms of clinical outcomes. We performed a meta-analysis of studies comparing M and FC flaps to evaluate this issue. (2) Methods: The PRISMA guidelines were followed to perform a systematic search of the English literature. We included all articles comparing M and FC flap reconstructions for lower limb soft tissue defects following trauma, infection, or tumor resection. We considered flap loss, postoperative infection, and donor site morbidity as primary outcomes. Secondary outcomes included minor recipient site complications and the need for revision surgery. (3) Results: A total of 10 articles involving 1340 patients receiving 1346 flaps were retrieved, corresponding to 782 M flaps and 564 FC flaps. The sizes of the studies ranged from 39 to 518 patients. We observed statistically significant differences (p < 0.05) in terms of donor site morbidity and total flap loss with better outcomes for FC free flaps. Moreover, the majority of authors preferred FC flaps because of the greater aesthetic satisfaction and lesser rates of postoperative infection. (4) Conclusion: Our data suggest that both M and FC free flaps are safe and effective options for lower limb reconstruction following trauma, infection, or tumor resection, although FC flaps tend to provide stronger clinical benefits. Further research should include larger randomized studies to confirm these data.

Wear, corrosion and periprosthetic osteolysis are important causes of failure in joint arthroplasty, especially in young patients. Ceramic bearings, developed 40 years ago, are an increasingly popular choice in hip arthroplasty. New manufacturing procedures have increased the strength and reliability of ceramic materials and reduced the risk of complications. In recent decades, ceramics made of pure alumina have continuously improved, resulting in a surgical-grade material that fulfills clinical requirements. Despite the track record of safety and long-term results, third-generation pure alumina ceramics are being replaced in clinical practice by alumina matrix composites, which are composed of alumina and zirconium. In this review, the characteristics of both materials are discussed, and the long-term results with third-generation alumina-on-alumina bearings and the associated complications are compared with those of other available ceramics. Cite this article: EFORT Open Rev 2018;3:7-14. DOI: 10.1302/2058-5241.3.170034

Objective: Low-grade inflammation plays a pivotal role in osteoarthritis (OA) through exposure to reactive oxygen species (ROS). In chondrocytes, NADPH oxidase 4 (NOX4) is one of the major ROS producers. In this study, we evaluated the role of NOX4 on joint homoeostasis after destabilisation of the medial meniscus (DMM) in mice. Methods: Experimental OA was simulated on cartilage explants using interleukin-1β (IL-1β) and induced by DMM in wild-type (WT) and NOX4 knockout (NOX4^-/-) mice. We evaluated NOX4 expression, inflammation, cartilage metabolism and oxidative stress by immunohistochemistry. Bone phenotype was also determined by micro-CT and histomorphometry. Results: Whole body NOX4 deletion attenuated experimental OA in mice, with a significant reduction of the OARSI score at 8 weeks. DMM increased total subchondral bone plate (SB.Th), epiphysial trabecular thicknesses (Tb.Th) and bone volume fraction (BV/TV) in both NOX4^-/- and wild-type (WT) mice. Interestingly, DDM decreased total connectivity density (Conn.Dens) and increased medial BV/TV and Tb.Th only in WT mice. Ex vivo, NOX4 deficiency increased aggrecan (AGG) expression and decreased matrix metalloproteinase 13 (MMP13) and collagen type I (COL1) expression. IL-1β increased NOX4 and 8-hydroxy-2'-deoxyguanosine (8-OHdG) expression in WT cartilage explants but not in NOX4^-/-. In vivo, absence of NOX4 increased anabolism and decreased catabolism after DMM. Finally, NOX4 deletion decreased synovitis score, 8-OHdG and F4/80 staining following DMM. Conclusion: NOX4 deficiency restores cartilage homoeostasis, inhibits oxidative stress, inflammation and delays OA progression after DMM in mice. These findings suggest that NOX4 represent a potential target to counteract for OA treatment.

Purpose: Short stems use has increased substantially despite variable results reported in the literature. The purpose of this study was to report the rate of complications using a short stem implanted through the direct anterior approach (DAA), and to evaluate mid-term clinical and radiological results focusing on femoral stem fixation. Methods: Between April 2009 and November 2014, 698 elective total hip arthroplasties (THAs) were performed using a fully hydroxyapatite-coated short stem (AMIStem-H®). The mean age was 65.7 years (SD 12.6). Patients were invited for clinical and radiological evaluation, and to complete patient-reported outcomes questionnaires at two and five years after surgery. The mean follow-up was 6.2 years (range 2–9.73 years). Results: During the study period, 59 (8.5%) patients died and 24 (3.4%) were lost to follow-up. There were six (0.9%) dislocations and 12 (1.7%) fractures, seven occurred intra-operatively. Twenty-nine (4.2%) THAs required revision surgery. Eleven THAs were revised for aseptic loosening of the stem at a mean 4.9 years (1.2–7.3 years). Five years after surgery, radiographs of 324 THAs (324/425 eligible = 76.2%) were available. Stem subsidence ≥ 2 mm was present in 42 cases (12.9%), proximal radiolucencies in 101 hips (31.5%), cortical thickening in 52 (16.0%), and a pedestal in 219 (67.6%). An Engh score between − 10 and 0 was associated with lower HHS pain subscore (p = 0.005), a higher risk of stem revision for aseptic loosening (18.8% vs. 2.7%; p = 0.008), and was more frequent in younger patients with ASA score 1. Conclusion: Patients presenting radiological alterations at five years had an increased risk of revision for aseptic stem loosening and also inferior clinical results. Our study warrants further continued scrutiny of mid- and long-term survivorship of the AMIStem-H®, with radiological results at five years indicating suboptimal fixation of the stem in younger and active patients.

Background: Objectives were first to evaluate by education level one-year trajectories of pain, function and general health, as well as hospital resource and medication needs in patients undergoing primary total hip arthroplasty (THA); and second, to evaluate whether outcome differences are related to existing baseline differences in health and disease severity.Methods: We included all primary THAs from a public hospital-based prospective arthroplasty registry, performed in a high-income country 2010 to 2017. Education was classified in three levels: ≤8years of schooling (low), 9-12years (medium), and ≥13years (high). Pain and function prior to and one-year after surgery were assessed with the Western Ontario McMaster Universities score (WOMAC) and general health with the 12-item short-form health survey (SF-12).Results: Overall 963 patients were included, 340 (35.3%) with low, 306 (31.8%) with medium, and 317 (32.9%) with high education. With increasing educational level preoperative scores for pain, function and SF-12 mental health component increased. One year after surgery improvement was observed in all education categories for WOMAC pain and function, SF-12 mental and physical component. However, absolute postoperative scores remained lower in all four domains for the low education group. After adjustment for baseline characteristics differences were much attenuated and no longer significant. There was also greater resource need in low educated patients.Conclusions: The inferior absolute results one year after surgery in less educated patients were largely due to older age, worse preoperative health and greater symptom severity calling for greater attention to timely and equal management, for more targeted perioperative care and increased support for the lower education group.

Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.