Radiographic axial spondyloarthritis (r-axSpA), a chronic inflammatory disease, can cause significant radiographic damage to the axial skeleton. Regarding the pathogenic mechanism, association of r-axSpA with tumor necrosis factor (TNF) and the interleukin-23/17 (IL23/ IL17) pathway has been reported. Development of extraarticular manifestations, including uveitis, inflammatory bowel disease, and psoriasis, has been reported in some patients. The pivotal role of human leukocyte antigen-B27 in the pathogenesis of r-axSpA remains to be clarified. Symptoms usually start in late adolescence or early adulthood, and disease progression can vary in each patient, with clinical manifestations ranging from mild joint stiffness without radiographic changes to advanced manifestations including complete fusion of the spine, and severe arthritis of the hip, and could include peripheral arthritis and extraarticular manifestations. The modified New York criteria was used previously in diagnosis of r-axSpA. However, early diagnosis of the disease prior to development of bone deformity was required due to development of biological agents. As a result of Assessment of SpondyloArthritis international Society (ASAS), the classification was improved in part for diagnosis of spondyloarthritis prior to development of bone deformity. The diagnosis is based on comprehensive laboratory findings, physical examinations, and radiologic findings. Medical treatment for r-axSpA involves the use of a stepwise strategy, starting with administration of nonsteroidal anti-inflammatory drugs and physiotherapy, and progressing to sulfasalazine or methotrexate and biologics including TNF-α inhibitors or IL-17 inhibitors as needed. Use of Janus kinase inhibitors has been recently reported.

Due to its distinct features, rheumatoid arthritis (RA), an inflammatory autoimmune disorder, poses challenges in planning for surgical interventions. This review includes available evidence regarding perioperative considerations in management of RA patients, with a focus on hip surgery. RA can affect multiple joints, with development of extra-articular manifestations; therefore, preoperatively, comprehensive medical assessments, including cardiovascular or pulmonary evaluation must be considered in addition to surgical considerations. Modification of medications capable of controlling RA-related disease activity is critical, and requires collaboration with rheumatologists. Surgical considerations include the choice of surgical approach, implant selection, and problems related to weakened soft tissues, fragile bone density, and bony deformity such as protrusio acetabuli. Careful monitoring and more active rehabilitation are recommended for RA patients due to higher risk of postoperative complications. For achievement of optimal outcomes, use of a multidisciplinary perioperative approach is required for patients with RA.

Osteoporosis and osteopenia can affect patients undergoing arthroplasty of the hip, which is typically recommended for patients with severe osteoarthritis or elderly patients with a femoral neck fracture. Preoperative screening for this type of bone loss could be helpful to patients and prevent poor outcomes due to the rate of underdiagnosis of osteoporosis, which can reach 73% in patients undergoing hip arthroplasty. Complications associated with low bone mineral density include periprosthetic fractures as well as an increased revision rate. Although the benefit of antiresorptive medications postoperatively has been demonstrated, when administered preoperatively, worse outcomes were reported compared to its non-usage. Surgical management is as important as pre-medication. According to general recommendations, cemented implants provide greater benefit in osteoporotic patients. However, when using cementless implants, ribbed stems, straight tapered stems, stems with medial calcar contact, and titanium-composed stems can be used to prevent periprosthetic loss of bone mineral density; however, they should not be placed in a varus position. These stems can also be coated with zoledronate and other products.

Purpose: Therapies for treatment of rheumatoid arthritis (RA) have shown significant improvement since the introduction of biological agents (BIO) in 2003 and Janus kinase inhibitors (JAKi) in 2013 in Japan. The rate of orthopedic surgery, including total hip arthroplasties (THA), may reflect trends in disease severity, management, and health outcomes.
Materials and Methods: An analysis of data on THAs performed at our institutes for treatment of RA with BIO or non-BIO therapy from 2004 to 2021 was conducted.
Results: A total of 40,328 orthopedic surgeries, including 5,938 primary THAs and 204 RA-THAs, were performed between 2004 and 2021. An increase in the annual rate of THA performed for patients undergoing orthopedic surgery was observed. The rates of THA decreased annually for patients with RA when compared to the total number of orthopedic surgeries and primary THAs performed.
Conclusion: The number of THAs performed for patients with RA may show an annual decrease resulting from early and aggressive drug therapy for management of RA in the era of BIO and JAKi. However, patients with RA undergoing THA have several unmet needs, including secondary osteoarthritis, dislocation, periprosthetic joint infection, and periprosthetic fracture with osteoporosis.

Purpose: There is limited evidence regarding the outcomes of hip hemiarthroplasty (HA) following trauma in individuals living with Down syndrome (DS). This study aims to summarize the outcomes of hip HA in a series of individuals living with DS following femoral neck fractures.
Materials and Methods: This retrospective study includes five cases of hip HA in four individuals with DS and displaced femoral neck fractures. Subjects (four males) had a mean age of 49.3 years (range, 26.1-59.7 years) at the time of surgery. All subjects presented with hip pain, loss of weight-bearing ability, and decreased activity level as reported by the subject caregivers. In all cases, the precise time of injury was not known.
Results: After a mean follow-up of 15.2 months, all subjects had returned to the pre-injury activity level without any recorded complications. One individual died 32 months after surgery for unrelated causes; the remaining subjects are alive and ambulating without pain at a mean of 24.2 months since the surgery.
Conclusion: When treating femoral neck fractures in those living with DS, careful history taking should be performed as regards the timing of trauma and the individual’s functional status. Hip HA seems a viable treatment option for those living with DS if a proper surgical procedure is utilized.

Purpose: The effectiveness of pericapsular nerve group (PENG) block versus suprainguinal fascia iliaca block (SFIB) for pain relief after hip arthroplasty is a topic of ongoing debate. This study aimed to examine the association of PENG block with lower consumption of opioids during the first 24 hours following surgery compared to SFIB.
Materials and Methods: In this single-center, double-blind, randomized controlled trial, 60 patients scheduled for an elective posterior approach to total hip arthroplasty (THA) were randomized according to two groups: ultrasound-guided PENG block (PENG group) or SFIB (SFIB group). The 24-hour consumption of intravenous fentanyl was the primary outcome. Secondary outcomes included perioperative consumption of intravenous fentanyl, pain scores, sensorimotor function, and functional measures.
Results: No significant intergroup difference was observed in 24-hour total fentanyl consumption (SFIB group: 117.4±99.8 μg, PENG group: 145.9±122.7 μg; mean difference: 22.6 μg [95% confidence interval –36.6 to 81.8]; P=0.45). No statistically significant difference in terms of fentanyl consumption in intraoperative, post-anesthetic care unit, at 6-hour and 48-hour postoperatively was observed between the two groups. No statistically significant differences in scores for rest and dynamic pain for all aspects of hip joint and surgical incision were observed between the groups (P>0.05). Better cutaneous sensory perception in the hip region and 12-hour postoperative quadriceps muscle strength at 90° were observed in the PENG group compared with the SFIB group (P<0.05).
Conclusion: Compared to SFIB, the addition of PENG block to multimodal analgesia did not reduce fentanyl consumption or pain scores after posterior approach THA.

Purpose: The objective of the current study is to introduce a proposed method and evaluate its efficacy using the greater trochanter (GT) tip rather than the lesser trochanter (LT) as an anatomical landmark to reduce leg length discrepancy (LLD) during performance of hip arthroplasty.
Materials and Methods: Thirty-two patients who underwent hip arthroplasty were divided according to the GT group (n=17) and the LT control group (n=11); four patients were excluded. LLD was determined by assessing the vertical lengths parallel to the line connecting the lower margin of the teardrop to the most prominent part of the LT on a standing anteroposterior pelvic X-ray taken 30 days after the procedure. The mean and median LLD of the two groups were compared. Analysis of planning for femoral stem depth insertion and postoperative results was also performed.
Results: No significant differences in characteristics including age, sex, or body mass index were observed between the two groups. However, the type of arthroplasty differed significantly between groups (P=0.016). The mean postoperative LLD was significantly smaller in the GT group compared with the control group (P=0.004). The results of linear regression of femoral stem depth showed a significant association between intraoperative planning and postoperative measurement (t=2.705, r²=0.672, P=0.016).
Conclusion: Preoperative measurement in determining femoral stem depth insertion using the GT tip as an anatomical reference can effectively minimize LLD in patients who underwent hip arthroplasty.

Purpose: Fracture union after osteosynthesis of a fracture neck femur (FNF) occurs by compression of the fracture ends and potential neck shortening. Selection of an implant for fixation of a femoral fracture of the neck can be challenging when making management decisions. Femoral neck shortening after internal fixation of FNFs using a femoral neck system (FNS) or multiple cannulated cancellous screws (MCS) was compared.
Materials and Methods: This prospective interventional single-blinded randomized controlled trial was conducted at a university teaching hospital. Sixty patients undergoing internal fixation for management of sub-capital or trans-cervical FNFs were randomized and assigned, to one of the two groups—the test group (FNS group) and the control group (MCS group). Primary outcome was determined by measuring the difference in 1-year shortening of the femoral neck on radiographs between FNS and MCS. The secondary objective was to determine the correlation between neck shortening with patient reported outcome measures (PROMs) at the end of the final follow-up.
Results: At the final follow-up, shortening of the femoral neck was 3.77±1.87 mm in the FNS group, significantly lower compared with the MCS group, 6.53±1.59 mm.
Conclusion: Significantly less shortening of the femoral neck was observed in the FNS group compared with the MCS group. No statistically significant difference in PROMs was observed at 1-year follow-up. The findings of the study suggest that FNS can be regarded as a suitable alternative for internal fixation in young adults (<60 years) with trans-cervical and subcapital FNFs.

The fully porous structure of the Lübeck prosthesis is designed to closely resemble cancellous bone. Several studies have reported ‘good’ to ‘excellent’ mid- to long-term results for use of the Lübeck, but stem fractures have been reported as a complication. We report on the case of an 85-year-old patient who underwent total hip arthroplasty (THA) using the Lübeck more than 25 years ago who underwent revision surgery for management of two periprosthetic femoral fractures and a stem fracture. A subtrochanteric fracture and a fracture of the stem were observed on radiographs, and a radiolucent line was observed in the proximal portion of the stem and a well-fixed distal portion was observed. Revision THA using a proximal femoral replacement stem and resection of the proximal femur has been proven as an effective procedure for treatment of an elderly patient with a fractured Lübeck stem with a well-fixed distal stem.