Sierra, Rafael J

Aims Two-stage exchange arthroplasty with an antibiotic-eluting cement spacer remains the predominant strategy in the USA for managing chronic periprosthetic joint infection (PJI) following total hip arthroplasty (THA). The aim of this study was to evaluate a commercially available, partially intraoperatively fabricated articulating high-dose antibiotic cement spacer, focusing on survival, complications, and patient-reported outcomes. Methods A total of 298 patients (302 THAs) underwent two-stage exchange arthroplasty for PJI using a specific articulating antibiotic spacer between August 2005 and May 2022. Patients with a previous failed two-stage exchange were excluded, although 121 THAs (302, 40%) had undergone previous PJI-related procedures. The mean age of the patients was 65 years (SD 11), the mean BMI was 32 kg/m 2 (SD 7), and 116 (38%) were female. Most patients were classified as McPherson host B (158; 52%) and limb grade 2 (165; 55%), and 265 (88%) met the 2011 Musculoskeletal Infection Society criteria. The mean follow-up was six years (2 to 16). Results At five years after reimplantation, survival free of reinfection, aseptic rerevision, any rerevision, or any reoperation were 89% (95% CI 85.2 to 93.1), 93% (95% CI 89.3 to 96.1), 86% (95% CI 81.3 to 90.3), and 80% (95% CI 74.7 to 84.9), respectively. Dislocation accounted for most aseptic rerevisions (15/20). McPherson host C (HR 3.7 (95% CI 1.4 to 9.6); p = 0.007) and limb grade 3 (HR 3.3 (95% CI 1.0 to 11.1); p = 0.049) were significantly associated with an increased risk of reinfection. The mean Harris Hip Score at the latest follow-up was 76 (29 to 100). A total of 17 patients underwent revision or removal of a spacer for concerns about persistent infection and two for dislocation of the spacer. Eight patients underwent a non-rerevision reoperation during the spacer interval for wound drainage (n = 5), dislocation of the spacer (n = 2), and perispacer fracture (n = 1). A total of 26 spacer-related complications were treated nonoperatively (15 perispacer fractures, 11 dislocations). Dislocation of the spacer was strongly associated with dislocation after reimplantation (HR 6.2 (95% CI 2.3 to 16.9); p < 0.001). Conclusion This commercially available, partially intraoperatively fabricated articulating spacer showed excellent reinfection-free five-year survival (89%). Spacer-related fracture and dislocation each occurred in 5% of patients. Dislocation of the spacer significantly increased the risk of dislocation following reimplantation, supporting the use of higher-stability bearings in these high-risk patients. Cite this article: Bone Joint J 2026;108-B(9):1104–1112.

Background: Prior studies have reported higher rates of periprosthetic fracture, superficial infection, and neurologic deficit with the direct anterior approach (DAA), and higher rates of dislocation with the posterior approach (PA) for total hip arthroplasty (THA). Despite these differences, the overall clinical burden of complications between approaches remains unclear. The purpose of this study was to compare the profiles, severity, impact, and resolution of 5 clinically important complications between DAA and PA THA. Methods: A retrospective review was conducted of 11,783 consecutive primary THAs performed between 2010 and 2021 across 3 centers within a single healthcare system, using either the DAA (n = 4,451) or the PA (n = 7,332). Complications assessed included dislocation, infection, periprosthetic fracture (PPFx), aseptic loosening, and neurologic deficit. Severity was graded using the Clavien-Dindo classification (I = minor, V = death). Impact was defined by reoperation burden, and outcomes were categorized as resolved or persistent. Kaplan-Meier survivorship and propensity-weighted Cox proportional hazards models were used to compare complication risk. Results: The overall 1-year risk of surgical complications did not differ between DAA and PA (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.75-1.06; p = 0.208). Dislocation occurred more frequently with PA THA than DAA THA (1.9% vs. 0.4%; HR, 5.20; 95% CI, 3.04-8.90; p < 0.001). Superficial infections were more frequent with the DAA (1.6% vs. 0.8%; HR, 2.43; 95% CI, 1.68-3.53; p < 0.001). The risk of deep infection, PPFx, aseptic loosening, and neurologic deficit did not differ significantly between approaches. Among patients with complications, the proportion classified as severe (Clavien-Dindo III–V) was similar, and adjusted analyses showed no difference in the odds of severe complications (adjusted odds ratio 1.34 for PA vs DAA; 95% CI, 0.95-1.91; p = 0.099). Complication impact and resolution were likewise comparable. Conclusion: Although the profile of complications differed between DAA and PA THA, the severity, early clinical impact, and resolution of complications appeared similar. Notably, DAA was associated with a lower risk of dislocation and a higher risk of superficial infection compared with PA THA. Level of Evidence: Level III , Retrospective Comparative Study. See Instructions for Authors for a complete description of levels of evidence.

Background: Greater trochanteric (GT) fractures after total hip arthroplasty (THA) are typically managed nonoperatively. However, outcome data for patient counseling remain limited. We evaluated the nonoperative results, focusing on fracture union rates and the presence of persistent limp in relation with fracture location, displacement magnitude, and direction. Methods: We retrospectively reviewed 82 postoperative GT fractures not associated with trochanteric osteolysis following primary THA performed between 1984 and 2020. The mean follow-up was 9 years. Fracture location was classified relative to the contralateral lesser trochanter as tip, waist, or base. Initial displacement, migration, final displacement, and bony union were assessed radiographically. Clinical outcomes included the presence of a persistent limp and Harris Hip Score. Multivariable analyses were performed to identify factors associated with nonunion and limp. Results: Fractures were classified as tip (n = 32), waist (n = 29), or base (n = 21). The mean initial displacement was 8.9 mm, with 43% displaced >10 mm. Initial displacement was significantly lower in base fractures (4.8 mm) compared with tip (10.1 mm) or waist (10.8 mm) fractures (p < 0.05). The mean final displacement was 14.6 mm. 45% of fractures achieved complete bony union, and 38% of patients demonstrated a persistent limp. In multivariable analysis, greater final displacement (>12 mm), and tip and waist fractures were independently associated with nonunion. Posterior fracture displacement was significantly associated with persistent limp. Conclusions: Outcomes following nonoperative management of GT fractures after THA depend on fracture morphology and displacement characteristics. Tip and waist fractures and fractures with final displacement >12 mm have a higher risk of nonunion, whereas posterior and superior displacement is associated with persistent limp. Greater than 20 mm of displacement is associated with both limp and nonunion. These findings may assist surgeons in counseling patients and in identifying fracture patterns at higher risk for adverse outcomes of nonoperative management. Level of Evidence: Level III (Prognostic Study). See Instructions for Authors for a complete description of levels of evidence.

Purpose To investigate outcomes among patients undergoing total hip arthroplasty after hip arthroscopy (HA‐THA) compared with a matched cohort undergoing primary THA without prior arthroscopy (Only‐THA). Methods Patients who underwent THA after primary hip arthroscopic labral repair from 2009 to 2022 at a single institution were identified. Cases were propensity‐matched 1:4 to primary THA controls by age at THA, sex, body mass index (BMI), surgical approach, and year of surgery. At minimum 2‐year follow‐up, patient‐reported outcomes (PROs)—Forgotten Joint Score (FJS), modified Harris Hip Score (mHHS), and Hip Disability and Osteoarthritis Outcome Score Pain (HOOS‐Pain)—were analyzed. Results Sixty‐two hips (age: 47.5 ± 9.3 years, BMI: 29.7 ± 6.2 kg/m 2 ) were matched to 248 Only‐THA hips (age: 47.9 ± 10 years, BMI: 29.5 ± 5.8 kg/m 2 ). Although both HA‐THA and Only‐THA patients showed significant ( P < .001) postoperative improvements in PROs, HA‐THA patients reported significantly lower postoperative FJS, mHHS, HOOS‐Pain, and inferior Visual Analog Scale pain scores ( P < .001) compared with Only‐THA controls. A cohort‐specific minimal clinical important difference for mHHS was calculated as 9.6 points, with 75.7% of HA‐THA and 87.5% Only‐THA patients achieving this threshold ( P = . 077). At mean 6.6 ± 3.3 years follow‐up, HA‐THA patients with preoperative Tönnis grades 1 reported significantly decreased FJS, mHHS, and HOOS‐Pain compared with HA‐THA patients with preoperative Tönnis grade 2‐3 ( P ≤ .05). HA‐THA patients with Tönnis grade 1 also exhibited worse PROs ( P < .001) compared with Only‐THA controls. Although there were no differences in complication rates between HA‐THA and Only‐THA patients (8% vs. 5%, P = .49), all‐cause reoperation was greater amongst HA‐THA (10% vs. 2%, P = .01). Conclusions Patients undergoing THA after prior hip arthroscopy showed modestly inferior subjective outcomes at mid‐term follow up compared with an age‐matched cohort without prior arthroscopy. Although both groups showed meaningful improvement, a smaller proportion of HA‐THA patients achieved the cohort‐specific MCID for mHHS compared with Only‐THA controls. Level of Evidence Level III, retrospective cohort study.

Background: Total knee arthroplasty (TKA) is the treatment of choice for end-stage knee osteoarthritis in many patients. In younger patients with predominantly medial compartment disease, high tibial osteotomy (HTO) is performed as a joint-preserving treatment. However, concerns remain regarding potentially compromised outcomes of TKA after previous HTO given the axial deviation, osteotomy site, secondary surgery, previous hardware, and instrumentation. Therefore, this study compared long-term implant survival, revision, and infection rates, and patient-reported outcomes between patients undergoing TKA after HTO and matched TKA-only controls. Methods: Postoperative complications and revision surgeries were prospectively recorded in patients who underwent TKA from 2000 to 2023 at a single academic center. Patients with previous ipsilateral HTO formed the study group and were propensity matched 1:2 to TKA-only patients without a previous osteotomy based on age, sex, and body mass index. Knee Society Scores (KSS) were collected prospectively. Implant survivorship was analyzed using Kaplan-Meier survival curves and Cox proportional hazards models. Results: The study included 134 HTO-TKA and 268 matched TKA-only patients, with a mean follow-up of 10.5 ± 6.4 years (range: 0-24 years) after TKA. Both groups showed significant postoperative improvements in KSS (p < 0.02) with comparable clinical outcomes (HTO-TKA: 79.0 (6.0), TKA-only: 79.0 (11.8)). Revision arthroplasty rates were 5.2% for HTO-TKA and 4.5% for TKA-only (p = 0.69); the mean time to revision was 8.1 ± 8.7 years vs. 4.4 ± 3.5 years, respectively (p = 0.30). Infection rates were 2.2% and 1.1%, respectively (p = 0.74). Conclusions: Revision and infection rates were comparable between HTO-TKA and matched TKA-only patients, with no statistically significant differences. Our findings demonstrate comparable patient-reported outcomes in both groups. These findings indicate that a previous HTO does not adversely affect TKA implant longevity or clinical outcomes when compared with matched primary TKA patients within the US population. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Long-term outcomes of femoroacetabular impingement (FAI) surgery, particularly survivorship, are critical to guide treatment decision-making and patient counseling, yet only a limited number of studies have reported mid- to long-term survivorship. The purpose of this study was to report survivorship rates at a mean 10-year follow-up in a large, multicenter FAI surgery cohort and to identify clinical predictors of survivorship. Methods: A prospective, multicenter cohort study assessed patients treated for FAI with hip arthroscopy or surgical dislocation from 2008 to 2012. At a minimum of 8 years, 362 hips (80.1%) had follow-up that permitted assessment of total hip arthroplasty (THA)-free survivorship. A Cox proportional-hazards model was developed to identify risk factors for THA. Results: tThe cohort included 362 hips with a mean patient age of 32.1 years; 53% were in females, and 95.6% were in Caucasian patients. The THA-free survivorship of the cohort was 90.6% at a mean of 10.4 ± 1.6 years postoperatively. Risk factors for THA were older age at surgery (p = 0.01), male sex (p = 0.02), body mass index of ≥30 kg/m 2 (p = 0.009), and femoral head chondromalacia (p < 0.001). Conclusions: This study demonstrates that FAI surgery yielded durable 10-year THA-free survivorship of 90.6%. Older age at surgery, obesity, male sex, and femoral head chondromalacia were key predictors of conversion to THA. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Chronic hip abductor insufficiency remains a challenging problem to treat and can result in significant disability in some patients. Tendon transfers involving the gluteus maximus (GM) or combined GM with tensor fascia latae (GM+TFL) are common options for surgical reconstruction. The purpose of this systematic review was to compare clinical outcomes, complications, and revisions rates of patients who underwent GM transfer or GM+TFL transfer for irreparable hip abductor tears. Methods: PubMed (MEDLINE), Scopus (EMBASE, MEDLINE, COMPENDEX), and Cochrane databases were used to conduct a systematic review of articles from inception to February 2025. A total of 18 studies were included (11 GM transfer, 7 GM+TFL transfer). Demographics, hip setting (native hip, primary total hip arthroplasty [THA], revision THA), patient-reported outcome measures, presence of Trendelenburg gait, abduction strength, complication rates, and revision rates were analysed. Results: A total of 207 patients (208 hips) underwent GM transfer, while 55 patients (55 hips) underwent GM+TFL transfer. Meta-analyses demonstrated that both techniques yielded significant preoperative to postoperative improvements in modified Harris Hip Scores/Harris Hip Scores and Visual Analogue Scale pain scores ( p < 0.001). In total, 33.9% of patients who underwent GM transfer had a persistent Trendelenburg gait postoperatively, compared to 48.1% of those who underwent GM+TFL transfer. The complication rate was 16.8% (23/137) for patients who underwent GM transfer and 2.7% (1/37) for those who underwent GM+TFL transfer; while revision rates were 5.9% (9/152) and 3.6% (2/55), respectively. Conclusions: Both GM and GM+TFL transfers yielded comparable outcomes in patients with chronic hip abductor insufficiency not amendable to primary repair. The complication rate was substantially higher in patients who underwent GM transfer, whereas revision rates were comparably low for both techniques. In particular, a sizeable proportion of patients continued to exhibit a persistent Trendelenburg gait postoperatively following both surgical techniques, highlighting the complexity of this pathology. PROSPERO registration number: CRD420251002466

Aims Total knee arthroplasty (TKA) for end-stage osteonecrosis has historically been associated with concerns regarding aseptic loosening, and long-term data are limited. The purpose of this study was to update and expand our previous series with long-term follow-up, with specific emphasis on implant survivorship, risk factors for failure, complications, and clinical outcomes in a consecutive cohort of TKAs performed for primary and secondary osteonecrosis. Methods We retrospectively identified 295 consecutive TKAs in 266 patients for osteonecrosis performed at a single tertiary care academic institution from January 2002 to July 2022. Of these, 207 TKAs (70%) were performed for primary osteonecrosis, and 88 (30%) for secondary osteonecrosis. The predominant cause of secondary osteonecrosis was steroid use (59%; n = 52), followed by post-traumatic (25%; n = 22), radiation-induced (9%; n = 8), and alcohol-induced (7%; n = 6) osteonecrosis. Implant survivorship was analyzed as a time-to-event outcome using Kaplan-Meier estimation. The mean age was 61 years (18 to 93), with 67% being female (n = 197). The mean follow-up was nine years (2 to 20). Results The 15-year survivorship free of any revision for the entire cohort was 92% (95% CI 87 to 97), with similar rates between primary and secondary osteonecrosis (92% (95% CI 87 to 98) vs 93% (95% CI 87 to 100), respectively; p = 0.459). Varus-valgus constraint implant designs (HR 10.8 (95% CI 2.7 to 43.4); p < 0.001) and tibial stem use (HR 12.0 (95% CI 4.1 to 35.1); p < 0.001) were associated with an increased risk of any revision. The 15-year survivorship free of aseptic loosening was 97% (95% CI 93 to 100) for the entire cohort. Age under 65 years (HR 2.7 (95% CI 1.4 to 5.4); p = 0.005) and secondary osteonecrosis (HR 1.9 (95% CI 1.0 to 3.4); p = 0.044) were associated with an increased risk of any reoperation at 15 years. Conclusion TKA is a durable and reliable option for primary osteonecrosis at long-term follow-up. However, TKAs performed for secondary osteonecrosis carry a higher reoperation risk. Cite this article: Bone Joint J 2026;108-B(4):455–462.

Background: Hip decompression effectively treats early-stage osteonecrosis of the femoral head (ONFH) by slowing disease progression and potentially delaying joint replacement. Biological adjuvants like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) support bone regeneration and improve outcomes 1–7 . The present video article demonstrates a simple, coreless hip decompression technique with BMAC and PRP injection for early-stage ONFH. Description: The procedure is performed in the same operating room setting as traditional core decompression, with the patient supine on a radiolucent table for fluoroscopic guidance. One or both legs are draped free for access to the iliac crests. Bone marrow is harvested percutaneously from the anterior superior iliac crest with a trocar needle kit, centrifuged, and prepared for injection. We recommend precoating needles and syringes with 1:1,000 heparin to prevent clotting. The BioCUE System (Zimmer Biomet) is typically utilized for centrifugation. Hip decompression is performed with use of a trocar and cannula (PerFuse System; Zimmer Biomet), with subsequent injection through the cannula into the femoral head. A 0.5-cm skin incision is made. The trocar is placed lateral to the femur and advanced percutaneously through the lateral femoral cortex, with a starting point proximal to the lesser trochanter. The trocar is then advanced along the femoral neck into the necrotic region by performing mallet strikes on the instrument’s strike cap. Anteroposterior and frog-leg lateral views assist in positioning the trocar within the necrotic area. Internal leg rotation, which aligns the patella upward, helps position the trocar horizontally parallel to the floor. Positioning is adjusted using repeated imaging as needed. Once the patient is positioned, the trocar is removed, leaving the cannula in place. With the cannula retracted 1 cm, a 30-mL syringe is utilized to inject BMAC and PRP into the necrotic lesion. Because of sclerotic resistance, substantial pressure is needed, but retraction of the cannula helps. Following injection, the cannula is withdrawn another 1 cm, and demineralized bone matrix is injected to prevent escape of the BMAC. Alternatives: Alternative treatments for ONFH include traditional core decompression with a sliding hip screw drill or an X-REAM device (Stryker), both of which carry a higher risk of fracture because of the larger diameter of the tract and require limited weightbearing postoperatively. Bone-cement injection can stabilize the femoral head but lacks regenerative properties. Core decompression with either BMAC or PRP alone, rather than in combination, also serves as an alternative treatment strategy. Open approaches, like osteotomy, are more invasive, have longer recovery times, and may complicate future hip arthroplasty if unsuccessful. Rationale: This technique enables minimally invasive hip decompression and delivery of adjuvant cell therapy or grafting, typically without the use of power instruments. This approach avoids the risk of injuring the bone due to the heat from power tools, protecting the BMAC injection site. Patients are generally discharged the same day and permitted full weight-bearing immediately, even in bilateral surgeries. Expected Outcomes: Hip decompression for ONFH has shown variable rates of success 8,9 , but adding BMAC or PRP may improve outcomes 1–3 . Houdek et al. reported that among 35 hips treated with decompression plus BMAC and PRP for corticosteroid-induced ONFH, 88% avoided THA at 3 years 2 and 70%, at 7 years 3 . Patients with grade-1 or 2 Kerboul angles had a 90% survivorship rate, underscoring the benefits of BMAC and PRP. Important Tips: Insert the trocar into the lateral cortex, positioned distal to the vastus ridge and proximal to the lesser trochanter, to reduce iatrogenic subtrochanteric fracture risk. Avoid advancing closer than 5 mm to the subchondral cortex to prevent joint-surface disruption or collapse, especially with eccentric lesions. If resistance occurs during injection, retract the cannula a few millimeters laterally to increase delivery space and reduce pressure. Acronyms and Abbreviations: BMAC = bone marrow aspirate concentrate ONFH = osteonecrosis of the femoral head PRP = platelet-rich plasma AP = anteroposterior THA = total hip arthroplasty ARCO = Association Research Circulation Osseous classification MRI = magnetic resonance imaging