Hip-preserving surgery for nonunion about the hip

Latent infections in conversion total hip arthroplasty following internal fixation of femoral neck fractures: a systematic review and meta-analysis of diagnostic methods

BACKGROUND

Accurate diagnosis of latent infections prior to conversion total hip arthroplasty (THA) following internal fixation of femoral neck fractures is crucial for successful surgical outcomes. This systematic review aimed to provide a comprehensive evaluation of the current literature regarding the diagnosis of latent infections before conversion THA.

METHODS

Systematic search of PubMed, EMBASE, and Cochrane (CENTRAL) databases was conducted, and the diagnostic accuracy of various markers and techniques was assessed. The quality of the included studies was evaluated using the QUADAS-2 instrument.

RESULTS

Five studies comprising 661 patients were included in the review. Pooled analysis using C-reactive protein (CRP) as a diagnostic marker resulted in a sensitivity and specificity of 72% and 76%, respectively, while using erythrocyte sedimentation rate (ESR) yielded a sensitivity and specificity of 75% and 78%, respectively. Fibrinogen and platelet count showed lower sensitivity and specificity compared to CRP and ESR. The best combined markers were CRP and serum platelet count, with a sensitivity of 76% and specificity of 86% based on one study.

CONCLUSION

Our review underscored the limitations and inconsistencies present in current diagnostic methods for latent infections in conversion surgery. Future research needs to focus on standardizing threshold values, exploring the potential of synovial fluid analysis, imaging techniques, and molecular methods, as well as developing tailored diagnostic algorithms.

PROSPERO

CRD42023394757.

Pertrochanteric Nonunion: When and Why to Consider a Medullary Implant

SUMMARY

Pertrochanteric nonunion management is a technically challenging problem. When repair is undertaken rather than conversion arthroplasty, successful treatment revolves around accurate deformity correction, preservation of vascularity, and stable durable fixation. The decision to use an extramedullary or intramedullary implant should be influenced by nonunion-specific characteristics and patient-related conditions. Failure to understand these nuances when selecting an implant strategy often results in treatment failure. The primary purpose of this article was to discuss these variables and delineate when an intramedullary implant should be considered for treatment of a pertrochanteric nonunion. The secondary purpose was to describe the author's preferred surgical technique for implant-driven deformity correction and compression when choosing an intramedullary nail.

Measures of Corticalization

After the insertion of dental implants into living bone, the condition of the peri-implant bone changes with time. Implant-loading phenomena can induce bone remodeling in the form of the corticalization of the trabecular bone. The aim of this study was to see how bone index (BI) values behave in areas of bone loss (radiographically translucent non-trabecular areas) and to propose other indices specifically dedicated to detecting corticalization in living bone. Eight measures of corticalization in clinical standardized intraoral radiographs were studied: mean optical density, entropy, differential entropy, long-run emphasis moment, BI, corticalization index ver. 1 and ver. 2 (CI v.1, CI v.2) and corticalization factor (CF). The analysis was conducted on 40 cortical bone image samples, 40 cancellous bone samples and 40 soft tissue samples. It was found that each measure distinguishes corticalization significantly (p < 0.001), but only CI v.1 and CI v.2 do so selectively. CF or the inverse of BI can serve as a measure of peri-implant bone corticalization. However, better measures are CIs as they are dedicated to detecting this phenomenon and allowing clear clinical deduction.