Scope and Mission Mentors in Orthopedics is a peer-reviewed, Open Access journal dedicated to the clinical and technical advancement of surgical practice. The journal serves as a bridge between academic research and practical application in the operating room, with a primary focus on the operative management of joint pathologies (hip, knee, shoulder, and ankle) as well as hand and foot surgery. Editorial Focus The publication emphasizes mentorship and the transmission of surgical expertise. Its content includes: Original peer-reviewed research studies. Technical surgical insights and "pearls." Expert commentaries on clinical innovations. Resources for both seasoned surgeons and emerging specialists. Publication & Governance Editor/Publisher: Maîtrise Orthopédique Headquarters: 21 rue de la Ravinelle, 54000 Nancy, France Publishing Director: Olivier Melison Access Model: Open Access (OA) Target Audience: Orthopedic surgeons, surgical residents, and musculoskeletal healthcare professionals worldwide.
Hip resurfacing through the direct anterior (Hueter) approach
Hip resurfacing (HR) is an attractive option for the young and active patient with hip osteoarthritis, offering preservation of femoral bone stock, a very low dislocation rate, near-physiological biomechanics and a favourable return to sport. It is, however, technically demanding and is conventionally performed through a posterior approach. The direct anterior (Hueter) approach (DAA) spares the peri-articular musculotendinous structures and the medial femoral circumflex artery, potentially adding more rapid recovery and a reduced risk of femoral head osteonecrosis to the recognised benefits of resurfacing. Combining the two procedures has, nonetheless, been described in only a handful of publications. Surgical technique: We describe HR performed through the DAA with the patient supine on a traction table. The key steps are presented in sequence: pre-operative planning of implant size and cervical guide-wire trajectory; the Hueter approach and capsular release; anterior dislocation and exposure of the femoral head; guide-wire placement and femoral preparation; acetabular reaming and cup impaction; completion of the femoral component; and reduction, stability testing and femoral neck plasty. The specific pitfalls — femoral notching, restricted access to the superior neck and acetabular exposure — are highlighted, alongside the value of intra-operative fluoroscopy and the traction table. Results: A continuous, prospective, single-surgeon series of 44 resurfacings in 41 patients (mean age 51.8 years), performed between 2024 and 2025 with a metal-on-metal implant, is presented. At a mean follow-up of 12.2 months, all clinical scores improved markedly (Harris Hip Score 49.7 to 94.7; Oxford Hip Score 19.9 to 44.8). The mean operating time was 67.9 minutes; the mean acetabular inclination was 34.9° and the mean femoral valgus 7.97°, with no component in varus or excessive inclination. No femoral neck fractures, early complications or revisions occurred; two cases of psoas tendinopathy were recorded during follow-up. Conclusions: Performed meticulously and with optimal implant positioning, HR through the DAA combines the advantages of resurfacing with preservation of the soft tissues and of the femoral head blood supply, without an apparent increase in early complications.
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Hip resurfacing is the safer and more effective choice
Hip resurfacing arthroplasty (HRA) remains controversial because of concerns surrounding metal-on-metal bearings, pseudotumours and metallosis. Yet a 2013 propensity-matched analysis of more than 30,000 English patients reported that metal-on-metal HRA carried a lower all-cause mortality than both cemented and uncemented total hip arthroplasty (THA), with a survival advantage that widened over ten years. This narrative review examines that paradox and proposes a coherent mechanistic explanation: that resurfacing confers its survival benefit by restoring normal physical activity. The argument is built by synthesising evidence across several domains. Large cohort and meta-analytic data confirm a dose-response relationship between habitual physical activity and reduced all-cause, cardiovascular and cancer mortality. Gait laboratory studies, wearable step-count data and 24-hour activity monitoring consistently show that, although THA reliably relieves pain, it does not restore activity to healthy levels; stride length, hip extension and walking speed remain reduced and asymmetric. By contrast, HRA preserves the native femoral head and restores a normal flexion-extension arc, stride length and symmetrical gait indistinguishable from healthy controls. Newly completed UK Biobank accelerometry confirms this in real life: THA patients take significantly fewer steps than matched controls, whereas resurfaced patients do not differ from controls and walk approximately 9% more than THA patients. Imaging corroborates these functional findings. Following THA, progressive proximal femoral stress shielding and bone loss occur irrespective of stem design, whereas intertrochanteric bone density is preserved or improved after resurfacing. For patients with adequate bone quality and a life expectancy of at least ten years—particularly younger, active individuals—resurfacing may therefore represent the safer and more effective choice. Although modern resurfacings and THA show comparable revision rates, the salvage of a failed resurfacing is a well-functioning THA, whereas revision of a failed THA typically leaves patients with lifelong pain and inferior function. Emerging ceramic-on-ceramic devices promise comparable functional restoration while avoiding the complications of metal ions, with important implications for patient selection and shared decision-making.
Minimizing soft-tissue damage in direct anterior total hip arthroplasty preservation of the ascending branch of the lateral femoral circumflex artery and no-release femoral preparation
Total hip arthroplasty through the direct anterior approach has gained considerable popularity because it exploits an intermuscular interval to spare the surrounding musculature. Working between muscle planes does not, however, in itself guarantee minimal soft-tissue trauma: additional injury may occur during deep exposure, capsulotomy, retractor placement, vascular management and, above all, femoral preparation. This article describes two complementary technical principles intended to reduce such trauma — preservation of the ascending branch of the lateral femoral circumflex artery and a no-release technique for femoral preparation. The ascending branch is the dominant blood supply to the tensor fasciae latae and is traditionally ligated to improve exposure. In a consecutive series of 172 primary procedures, the vessel was deliberately preserved in 75.6% of patients, with no excessive bleeding, haematoma or infection; preservation was favoured by female sex, younger age and lower body weight. The technique relies on identifying the circumflex bundle as the distal limit of fascial dissection, leaving it within its fatty sheath, and protecting it during capsulotomy and retraction. The no-release technique addresses the femoral step, at which most additional damage arises. Using a dedicated leg positioner, controlled maximal external rotation of approximately 160–180° with slight extension, and an anterior-specific offset broach handle, the proximal femur is orientated rather than forcibly elevated, allowing femoral access without a trochanteric Hohmann retractor, hook or routine capsular release in over 95% of primary cases. Preserving the posterior and superior capsule and limiting traction maintains stability, reduces bleeding and avoids thigh pain from adductor release. The principal limitation is that vessel patency was not confirmed postoperatively and functional benefit, although biologically plausible, remains unproven. These principles are not mandatory but offer surgeons familiar with the anterior approach a reproducible framework for reducing unnecessary soft-tissue damage, extending the philosophy of the approach from muscle-sparing in theory to soft-tissue-sparing throughout the operation.
The global uptake of the direct anterior approach for total hip arthroplasty
Over the past two decades, advances in surgical technology including specialised traction tables, fluoroscopic guidance and minimally invasive techniques have driven growing interest in the direct anterior approach (DAA) for total hip arthroplasty (THA). Adopters of the DAA have demonstrated comparable clinical outcomes, improved patient reported outcome measures (PROMs) and accelerated postoperative recovery compared to other established THA approaches. Despite a growing number of comparative publications on arthroplasty approaches, the global pattern and uptake of the anterior approach remains unknown and incomplete. Global adoption has been far from uniform internationally and there is no study in the literature reviewing the global uptake of the DAA. Our aim was to investigate the global uptake of the anterior approach in THA in order to analyse adoption across different countries and regions. Methods: A multi-method analysis was undertaken, combining a review of national arthroplasty registry data and orthopaedic society reports; a systematic narrative literature review conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA), searching PubMed, MEDLINE, Embase and the Web of Science Core Collection from inception to June 2025 without language restriction; and semi-structured interviews with practising orthopaedic surgeons across multiple continents. Results: Thirty-one registries were identified, but only seven reported data specific to the anterior approach. Adoption varied internationally, with reported DAA useage ranging from approximately 1 to 2% in the United Kingdom to 41% in the Netherlands and 53.7% in Switzerland, while surgeon surveys reported the uptake in the United States of America is 56.2%. Variation reflected differences in healthcare infrastructure, training pathways, registry participation, institutional preference and equipment access. Conclusions: Global DAA adoption is highly uneven, and registry capture is inconsistent and incomplete. Standardised, complete registry data and a dedicated global survey of arthroplasty practice are needed to clarify uptake and inform clinical practice and healthcare policy.
The son of a nuclear submarine’s first captain, Professor Justin Cobb grew up with no home port, learning as a boy to fix his position in Channel fog from the Morse signature of radio beacons. His father’s question — “Do you know where you are?” — became a lifelong pursuit: carrying the frame of reference into theatre, guiding the surgeon’s hand with imaging and the robot, sparing the joint rather than sacrificing it. And measuring, always, to stay humble.
Development of a ligament balance-based technology for total knee arthroplasty
Background: Although total knee arthroplasty (TKA) yields implant survival rates of 90–95% at ten years, up to 25% of patients remain dissatisfied, particularly with regard to functional outcomes. Whereas considerable effort has been devoted to implant design and bony resection accuracy, soft tissue management has historically relied on subjective, surgeon-dependent techniques. This paper presents the rationale, design and validation of a ligament balance-based technology (Newton, Exactech, Gainesville, FL, USA) developed to objectively measure intra-articular gaps under a controlled distraction force throughout the full arc of flexion and to inform intra-operative femoral resection planning. Methods: The Newton distractor combines two antagonistic mechanical actuators delivering a constant intra-articular distraction force (90 N per compartment) and integrates with a computer-assisted surgery platform (AdvitaGPS, Blue-Ortho, Meylan, France) to acquire alignment, sizing and gap data. The system was assessed through a stepwise programme comprising bench testing of force constancy, cadaveric studies of inter- and intra-rater reliability and of targeted balance achievement, evaluation of the surgeon learning curve using cumulative sum (CUSUM) analysis on 450 cases, comparison of planned versus achieved balance in 273 procedures, and a clinical comparison of 100 Newton-instrumented TKAs versus 100 control TKAs performed with a conventional tensioner. Results: Bench testing confirmed maintenance of a near-constant distraction force regardless of gap, implant size or batch. Inter- and intra-rater reliability of gap acquisition were superior with the instrumented method (mean intraclass correlation coefficient 0.72 and 0.66) compared with the manual method (0.35 and 0.41). Junior surgeons in particular achieved improved medio-lateral balance. The mean learning curve was 6.4 ± 2.8 cases. Achieved balance closely matched the surgical plan (unsigned differential 1–2 mm). Clinically, the Newton group demonstrated significantly greater improvements in Knee Society Scores and shorter hospital stays than the control group. Conclusions: This integrated ligament balance-based technology provides reproducible intra-operative measurements, a short learning curve and improved early clinical outcomes, supporting personalised TKA planning and offering a foundation for future artificial intelligence-driven developments.
A practical cookbook for state-of-the-art phenotyping
Total knee arthroplasty (TKA) has historically pursued a uniform neutral mechanical axis, an approach justified by early implant constraints but increasingly challenged by evidence that neutral alignment is not the constitutional norm. The recognition that meaningful personalisation requires prior systematic characterisation of the individual knee has driven the emergence of phenotyping as a structured framework integrating morphology, alignment, laxity, and kinematics. This article provides a practical, stepwise cookbook for state-of-the-art knee phenotyping in TKA, intended to guide surgeons through the application of currently available classifications within a coherent decision-making sequence. Step 1 addresses the bony Functional Knee Phenotype (B-FKP), describing how to measure the hip-knee-ankle angle, femoral mechanical angle, and tibial mechanical angle from weight-bearing long-leg radiographs to derive the two-dimensional phenotype, and how to extend the classification to a three-compartment model incorporating the posterior condylar angle and anterior trochlear angle when CT imaging is available. The phenotype obtained then informs the choice between mechanical, kinematic, functional, or fully personalised alignment strategies. Step 2 introduces the laxity Functional Knee Phenotype (L-FKP), explaining how standardised intraoperative varus and valgus stress testing at full extension and 90° of flexion, performed after dialling in patient-specific bony parameters on robotic platforms, generates a nine-group matrix that directly links laxity patterns to a structured management algorithm of bony cut adjustment, soft-tissue release, and constraint escalation. Step 3 presents the Dynamic Alignment of the Knee (DyAK) classification, which captures coronal alignment across the functional arc and addresses the limitations of static measurements, given that fewer than 15% of knees maintain consistent alignment throughout range of motion. Together, these layered phenotypes provide a reproducible framework in which alignment philosophies become tools matched to individual anatomy rather than competing doctrines, supporting safer and more personalised reconstruction.
Hip arthroscopy - separating the evidence from the hype and why we need it
Hip arthroscopy has evolved from a marginal, technically demanding procedure performed by a handful of pioneers into a consolidated component of contemporary hip preservation surgery. This editorial, written ahead of the forthcoming ESSKA Congress in Prague, offers a personal and historical perspective on that journey, drawing on more than two decades of clinical experience and active involvement within ESSKA’s Hip Arthroscopy Committee, now expanded into the European Hip Preservation Associates (EHPA) section. The author retraces the difficult early years of hip arthroscopy at the turn of the millennium, when published evidence was scarce, casuistry limited, indications poorly understood, and procedures essentially confined to loose body removal and labral debridement, the latter associated with disappointing mid-term outcomes. The article highlights the conceptual turning point represented by Reinhold Ganz’s definition of femoroacetabular impingement syndrome (FAIS), which transformed hip conservative surgery from the mid-2000s onwards, and the seminal contributions of Sampson, Kelly and Philippon to arthroscopic cam osteoplasty, labral suture and treatment of FAIS in athletes. The initial scepticism of senior hip surgeons, who occasionally dismissed cam osteoplasty as mere “osteophyte surgery”, is also addressed. The current state of the art is then reviewed, emphasising the broad therapeutic armamentarium now available through the arthroscope: postless hip distraction, femoral and acetabular osteoplasty (including correction of coxa profunda), labral and capsular repair or reconstruction, removal of loose bodies and benign bone tumours, management of aggressive synovitis of the acetabular fossa, gluteal tendon repair, psoas tenotomy, and ligamentum teres reconstruction. The author argues that, although hip arthroscopy remains demanding, time-consuming and reserved for adequately trained surgeons with a long learning curve, it now delivers reproducible benefits with an acceptable complication profile. The piece is intended for orthopaedic surgeons, trainees and researchers seeking historical context, a clear understanding of why hip arthroscopy is needed, and an appreciation of why its full potential has not yet been reached.
Distal femoral osteotomy in degenerative knee disease: indications, planning, techniques and complications
Distal femoral osteotomy (DFO) is an established joint-preserving procedure that occupies a clearly defined, though under-utilised, place in the surgical management of unicompartmental degenerative knee disease of femoral origin. By correcting the deformity at its anatomical site, DFO restores a satisfactory mechanical axis without inducing the excessive joint-line obliquity that may follow an isolated tibial correction. The aim of this review is to provide the practising surgeon with a structured overview of the current indications, preoperative planning, operative techniques and complications associated with DFO. The ideal candidate is a relatively young and active patient with mild lateral or medial femorotibial osteoarthritis, an extra-articular deformity of femoral origin, and an abnormal mechanical Lateral Distal Femoral Angle (mLDFA <85° in genu valgum, >90° in genu varum). Preoperative assessment must combine a bipedal weight-bearing full-length lower-limb radiograph with adequate dynamic and axial views; computed tomography or EOS imaging is recommended when a multiplanar component is suspected or when patient-specific cutting guides are envisaged. Planning aims for moderate overcorrection in varus and restoration to a normal mechanical axis in valgus, while keeping the mLDFA within the physiological range. The principal techniques—medial closing-wedge and lateral opening-wedge osteotomy for genu valgum, and lateral closing-wedge (favoured) and medial opening-wedge osteotomy for genu varum—are described step by step, with emphasis on the biplanar cut, the position and protection of the hinge, and reliable fixation with a locking compression plate. Postoperative management is dictated by the chosen technique, with earlier weight-bearing permitted after closing-wedge procedures. The most relevant complications—correction errors, hinge fracture, delayed union and non-union, vascular injury, stiffness and hardware-related discomfort—are reviewed, together with practical strategies for their prevention and management. Patient-specific cutting guides currently appear to be the most promising adjunct for improving reproducibility and meeting the demanding operative requirements of DFO.
At sixteen, this son of Tortosa dreamed of Cousteau’s ocean depths; a surgeon uncle decided otherwise. Professor Joan Carles Monllau has made the knee an entire territory of his own, rejecting American-style narrow specialisation to operate on everything, from meniscus to prosthesis. Outgoing ESSKA President, he openly admits past mistakes, champions passion as the only compass, and views robotics with rare clarity. A conversation with a demanding craftsman.
Minimally invasive and percutaneous surgery of hallux valgus: what has been abandoned, retained or modified after 20 years?
Hallux valgus remains the leading reason for consultation in forefoot pathology, and its surgical management has been profoundly transformed over the past two decades by the advent of minimally invasive and percutaneous techniques. More than 150 operative procedures had already been described by the mid-2000s, yet the question of which approach best serves the patient continues to generate debate. This article offers a critical synthesis of the current practice of the TALUS group — a French-speaking collective of foot and ankle surgeons — in the light of twenty years of evolution, with the aim of clarifying what has been abandoned, retained or modified in everyday forefoot surgery. The reflection draws on the members’ pooled experience, a review of the pertinent literature, and the educational activity of the GRECMIP / MIFAS learned society, from which the hybrid minimally invasive chevron and subsequent fully percutaneous procedures such as the MICA have emerged. The authors review the radioclinical keys to operative decision-making, including the intermetatarsal and hallux valgus angles, the distal articular angles (DMAA/TASA), cuneometatarsal mobility, the metatarsal formula, joint congruence, head pronation and patient-related factors. They then examine, technique by technique, the fate of the Isham–Reverdin procedure (now largely abandoned), the scarf osteotomy (progressively relinquished in favour of the chevron or of fixed bipolar and Lapidus procedures), the minimally invasive and percutaneous chevron (which has become the workhorse of the group), the bevelled (“biseau”) osteotomy, basal osteotomies and arthrodeses. Points that remain debated — Akin fixation, sesamoid repositioning, correction of metatarsal pronation, shortening of the first ray, one-stage versus two-stage management and indications for arthrodesis — are discussed in turn. A decision-making algorithm is proposed according to the severity of the deformity (mild, moderate, severe/XXL). The article will be of value to foot and ankle surgeons, trainees and general orthopaedic surgeons seeking a pragmatic, experience-based framework for selecting among the ever-expanding armamentarium of first-ray procedures.
Use of the Wilmington portal and knotless wire anchors for successful arthroscopic posterior Bankart repair
Posterior shoulder instability is a relatively uncommon condition, accounting for between 2 and 10% of all cases of shoulder instability, and predominantly affecting young men. Recurrent posterior subluxation is the most frequently encountered pattern, and a posterior labral tear is the principal structural lesion, identified in approximately half of all cases. When conservative management fails and in the absence of significant glenoid bone loss, arthroscopic posterior Bankart repair is the procedure of choice. Nevertheless, the technique is demanding: adequate visualisation of the posterior aspect of the joint and correct orientation of the working portal for anchor placement both represent recognised operative challenges. This technical note describes a reproducible, step-by-step arthroscopic approach that addresses these difficulties. The patient is positioned in the beach-chair position without traction, and three portals are employed: a standard posterior soft-spot portal, an antero-supero-lateral (ASL) viewing portal, and a posterolateral Wilmington portal placed 1 cm distal and 1 cm anterior to the posterolateral acromial border, affording a 45° angle of approach to the posterior glenoid rim. After transfer of the arthroscope to the ASL portal to optimise visualisation, the capsulolabral complex is mobilised with a curved elevator and the glenoid rim is prepared with a bone rasp and curette, avoiding thermal energy. A minimum of three knotless self-locking FiberTak® 1.8 wire anchors are then inserted through the Wilmington portal from inferior to superior, spaced 5 to 8 mm apart, with the posterior soft-spot portal reserved for suture shuttle relay and retrieval. Postoperative management comprises four weeks of sling immobilisation, hydrotherapy-based rehabilitation from the third week, and return to sport between four and six months. The combination of an ASL viewing portal, a Wilmington working portal and knotless wire anchors facilitates accurate anchor positioning, minimises iatrogenic cartilage injury, simplifies suture management, and renders the procedure more reproducible. This article will be of practical value to shoulder and arthroscopic surgeons seeking a clear, optimised operative strategy for posterior Bankart repair.
Medial unicompartmental knee arthroplasty: short-term outcomes of a prospective continuous series (SOFCOT–SFHG 2025 symposium)
Medial unicompartmental knee arthroplasty (UKA) is an appealing option for disabling medial femorotibial osteoarthritis, with reported clinical outcomes superior to those of total knee arthroplasty. Renewed interest in the procedure, driven by new technologies, appears to be broadening the classical Kozinn selection criteria. This study, conducted under the auspices of the SFHG and reported at the SOFCOT 2025 Symposium, aimed to describe current patient selection, to evaluate clinical and radiological outcomes, and to analyse the potential influence of robotics, navigation, and patient-specific instrumentation (PSI). Methods: Ten centres prospectively enrolled 487 consecutive medial UKAs between September 2023 and July 2024, with data collected via the RENACOT registry. Selection criteria, preoperative functional and radiological parameters, operative technique, fixation mode, and one-year outcomes were analysed. Conventional instrumentation was used in 35% of cases, navigation in 5%, PSI in 10%, and robotic assistance in 50%. Results: Only 61% of patients met the classical Kozinn criteria; 29% were “borderline” and 10% presented with at least one potential contraindication. At one year, 88.7% of patients reported improvement, with preoperative functional status identified as the principal prognostic factor. BMI showed a moderate negative correlation with functional outcome, whereas age, sex, comorbidities, and preoperative radiological parameters had no significant influence. The mean postoperative hip-knee-ankle angle was 176.5°, with a mean varus correction of 3.3°. Positioning-assistance technologies did not yield superior implant positioning compared with conventional instrumentation, although conventional techniques appeared less effective at reducing an excessive preoperative tibial slope. The one-year revision rate was 3.37%, and 6.74% of patients experienced unexplained pain. Female sex, vascular comorbidity, and cemented fixation were statistically associated with failure. Conclusions: Patient selection for medial UKA is evolving beyond the classical Kozinn criteria, and short-term outcomes are encouraging. Longer follow-up is required to assess the impact of broadened indications and the value of positioning-assistance technologies.
Variations in acetabular offset between preoperative planning (mediCAD®) and postoperative radiographic measurement: a neglected source of error influencing global offset restitution after THA
The restoration of global offset after total hip arthroplasty (THA) is correlated with functional outcomes and patient satisfaction. While preoperative planning is widely used to guide implant size and positioning, most studies focus on femoral offset, with limited attention paid to acetabular offset despite anatomical variability and the absence of reliable intraoperative landmarks during acetabular reaming. We hypothesised that variations in global offset observed after THA could be primarily linked to variations in acetabular offset relative to its initial planning. Methods: This retrospective study analysed prospectively collected data from patients who underwent primary THA performed by a single surgeon between January 2023 and November 2024, with 2D preoperative planning using mediCAD® software. After application of strict radiographic quality criteria, 43 patients were included. All received a Hueter-Gaine approach, an uncemented short stem, and a press-fit cup with a ceramic-on-ceramic bearing. Acetabular, femoral, and global offsets were measured on preoperative plans and postoperative radiographs by two independent senior surgeons, using two validated methods adapted to the radiographic field available. Intra- and inter-observer reproducibility was assessed using intraclass correlation coefficients, and relationships between offset variations were explored by bivariate analyses and multiple linear regression, including Shapley value analysis. Results: Intraclass correlation coefficients were good to excellent, confirming the reliability of the measurement methods. Significant correlations were observed between planned and postoperative global (r = 0.62), femoral (r = 0.60), and acetabular (r = 0.35) offsets. Variation in acetabular offset correlated strongly with variation in global offset (r = 0.74, p < 0.0001), as did variation in femoral offset (r = 0.68, p < 0.0001). Multiple linear regression showed that acetabular and femoral offset variations contributed equally (50% each) to global offset variation, with no correlation between them. Conclusion: Acetabular implant positioning influences postoperative global offset to an equivalent degree as the femoral stem. This finding should encourage surgeons to pay increased attention to acetabular implant placement and its preoperative planning during THA.
What factors influence the return to physical and sporting activity following hip arthroplasty in the young patient? Results of the symposium
Total hip replacement (THR) is increasingly performed in younger, more active patients who have high functional demand and sporting ambitions. Published evidence remains sparse, and numerous questions regarding implant choice, rehabilitation, return to sport, and long-term outcomes leave considerable room for individual practice variation. Following two earlier SOFCOT symposia (1997 and 2004), the present symposium, conducted under the auspices of the SFHG, sought to analyse current practice and outcomes of hip arthroplasty in the young patient. Methods: A non-inferiority, non-randomised, observational, multicentre study was conducted combining three data sources: a questionnaire distributed to SOFCOT/SFHG members (231 respondents); a prospective cohort of 513 patients across 12 centres (mean age 42 years); and a retrospective cohort of 475 patients across 10 centres (mean age 42 years; mean follow-up 11 years). Four bearing couples were compared: hip resurfacing arthroplasty (HRA), ceramic-on-ceramic hard-on-hard fixed-bearing (HHFB), hard-on-soft fixed-bearing (HSFB), and dual-mobility (DM) implants. Clinical outcomes included the UCLA activity score, FJS, and SHV scores; the minimum clinically important difference (MCID) for UCLA was set at 2 points. Results: Primary osteoarthritis (36%), avascular necrosis (13%), developmental dysplasia (12%), and femoroacetabular impingement (10%) were the leading aetiologies. The posterior approach predominated (74% prospectively). Day-case management reached 14%, exceeding the national average. Return to sport was effective at six months, with a mean UCLA gain of +2.3 points irrespective of prosthesis type (p = 0.209), reaching the MCID. Between three and six months, 76% of patients returned to the same occupation. The reoperation rate was 1.75% prospectively; 11-year survivorship was 93.7%, with no significant difference between bearing couples (HHFB 96.3%, HSFB 94.6%, DM 92.3%, HRA 92.2%). Conclusion: Hip arthroplasty in the young patient allows reliable return to sporting and professional activity by six months, with satisfactory mid-term survivorship and no demonstrable superiority of any bearing couple. Patient counselling should nonetheless acknowledge a non-negligible complication rate.
From schoolboy innovation to pioneering hip surgery, Richard Field’s journey exemplifies creative problem-solving and entrepreneurial spirit. This London and Cambridge-trained orthopaedic surgeon has combined research excellence with political activism, innovating strategies to reduce NHS waiting times, developing innovative implants and new surgical techniques. His transition from computing entrepreneur to anterior approach enthusiast demonstrates an insatiable curiosity and determination to challenge conventions, always seeking elegant solutions to complex orthopaedic problems.
Osteotaxis: a novel technique for the treatment of acetabular fractures
Acetabular fractures account for 3% of all fractures and typically result from high-energy trauma. Their management remains challenging owing to the complex three-dimensional anatomy of the acetabulum and the frequent association with other injuries. Conservative treatment entails prolonged hospitalisation and decubitus-related complications, whereas open surgical reduction is technically demanding and carries risks including heterotopic ossification, nerve injury and infection. During the COVID-19 pandemic, the need to shorten hospital stays and limit bed occupancy prompted the development of a novel percutaneous technique, termed Rahmi osteotaxis, for the treatment of displaced acetabular fractures. Methods: We report a prospective series of twenty patients (fourteen men and six women; mean age 57 years) operated on for acetabular fractures in the Orthopaedic-Traumatology Department of Ibn Rochd University Hospital, Casablanca, over a five-year period. Fractures were classified according to Judet and Letournel, with six simple transverse and fourteen complex fractures, predominantly both-column patterns. The technique employs a Hoffmann-type external fixator with six pins placed percutaneously in the supra-acetabular, femoral neck and subtrochanteric regions, producing vector traction that achieves instantaneous and stable reduction under fluoroscopic control. Reduction quality was assessed using Matta’s criteria and the Duquennoy and Senegas classification; functional outcome was evaluated with the Postel and Merle d’Aubigné score. Results: Mean operative time was 20 minutes with minimal blood loss. Reduction was satisfactory in sixteen cases and unsatisfactory in four. Vertical congruence was perfect in 60% and good in 40% of cases. All patients were discharged on the second postoperative day. The fixator was removed at six weeks, with full weight-bearing allowed from the third month. At a mean follow-up of four years, functional results were good in 80% of cases. One case of secondary coxarthrosis required total hip arthroplasty; no pin-site infection, deep vein thrombosis or secondary displacement occurred. Conclusion: Rahmi osteotaxis is a safe, reproducible alternative to conservative treatment of displaced acetabular fractures, particularly valuable when major surgery is contraindicated or in damage-control settings.
Simon Duplay, scapulohumeral periarthritis, and stiff shoulder
In 1872, Simon-Emmanuel Duplay (1836–1924), surgeon of the Paris hospitals and professor of surgical clinical medicine, published a monograph describing a chronic shoulder condition which he named scapulohumeral periarthritis (SHP). Working at a time when no imaging modality was available — X-rays would not be discovered until 1895 — Duplay relied exclusively on clinical observation, examination under chloroform anaesthesia, and post-mortem dissection to characterise a distinctive clinical picture: restriction of shoulder movement, particularly abduction, accompanied by pain only on mobilisation, without deformity or swelling of the joint. A pivotal post-mortem examination performed on a patient who had undergone manipulation under anaesthesia allowed him to demonstrate that the glenohumeral joint itself was intact, and that stiffness arose from extra-articular lesions — thickening of the subacromial bursa and fibrous adhesions between the humeral head, the coracoacromial arch, and the deep surface of the deltoid. In 1897, in his Cliniques Chirurgicales de l’Hôtel-Dieu, he confirmed and extended these findings, acknowledging that SHP was not invariably post-traumatic. This article retraces Duplay’s clinical and anatomical reasoning, his therapeutic proposals — massage, assisted mobilisation, hydrotherapy, electrical stimulation, and, when necessary, forcible manipulation under anaesthesia — and the legacy of his work through subsequent authors: Meyer and Pasteur on the long head of the biceps, Codman and his concept of frozen shoulder, Neviaser’s description of adhesive capsulitis, Steinbrocker’s shoulder-hand syndrome, the French rheumatological school’s fourfold classification by de Sèze, and the modern primary/secondary dichotomy following Lundberg. By tracing the evolution from a single eponymous entity to today’s nosological framework, the article situates Duplay as the pioneer of the vast and still incompletely understood domain of shoulder stiffness, and offers orthopaedic surgeons, rheumatologists, and medical historians a useful perspective on the conceptual foundations underpinning current practice.
Acromioclavicular joint dislocations: 20 years of experience
Acromioclavicular joint dislocations (ACJDs) remain one of the most debated entities in shoulder trauma surgery, with persistent controversies surrounding indications, timing, and choice of fixation. This article draws on twenty years of clinical and surgical experience to provide a critical, narrative overview of the evolution of ACJD management, with emphasis on the rationale underpinning current practice and on the unresolved questions that continue to shape the field. The discussion addresses, in turn, the refinement of surgical indications beyond the traditional Rockwood-based algorithm, integrating functional, aesthetic, and psychosocial dimensions, as well as the increasing demand generated by the “active elderly” population. The debate between early and delayed surgery is explored, including the technical consequences of chronicity, the impact of cutaneous lesions, and the role of supplementary graft procedures such as the Weaver–Dunn-type reconstruction in chronic presentations. The evolution of surgical techniques is then reviewed, from historically popular but now largely abandoned methods — Kirschner wires, tension-band wiring, transcoracoclavicular screws, hook plates, and subcoracoid cerclage — to the advent of arthroscopic endobutton ligament reconstruction. Reported complication rates of 20 to 40% with early arthroscopic constructs are analysed, together with their principal mechanisms of failure: malposition of transosseous tunnels, progressive tunnel widening, implant migration, coracoid and clavicular fractures, and residual horizontal instability. Recent optimisations are detailed, including the use of smaller-diameter drills, anatomically guided tunnel positioning, and a dedicated posterior offset clavicular guide. The rationale for bidimensional (vertical and horizontal) stabilisation is developed, reflecting current understanding of rotatory acromioclavicular instability. The authors’ present technique — combining arthroscopic coracoclavicular adjustable-loop fixation with a mini-open horizontal acromioclavicular anchor construct — is described step by step, along with postoperative rehabilitation. Ongoing SOFEC multicentre research and emerging avenues such as intraoperative three-dimensional imaging are outlined. This overview will be of interest to shoulder and upper-limb surgeons seeking a pragmatic, experience-based perspective on the contemporary management of ACJDs.
The first physician in his family, Professor Abdeljabbar Messoudi recounts a journey guided by humanism and tenacious determination. From his beginnings as a general practitioner in Dakhla to his brilliant academic career in Casablanca, his passion for orthopaedic surgery has never waned. As the dynamic president of SMACOT, he is now dedicated to the transmission of knowledge and the international growth of Moroccan orthopaedics, with pragmatism and a compelling conviction.
Bimalleolar equivalent fractures: should the medial approach be systematic?
Bimalleolar equivalent fractures combine a suprasyndesmotic lateral malleolar fracture with a deltoid ligament (DL) lesion, which often goes unnoticed. Failure to recognise such lesions may lead to an irreducible ankle due to tibialis posterior tendon interposition, as well as medial instability and long-term arthrosis. The diagnostic and therapeutic management of the DL remains controversial. The aim of this study was to clarify the features of this lesion, review diagnostic modalities, and propose an approach to surgical management of the DL. Methods: Twenty-three patients with a bimalleolar equivalent fracture were treated surgically between January 2018 and December 2024 in the Orthopaedic Traumatology Department of the Ibn Rochd University Hospital Centre in Casablanca. The mean age was 24.1 years (range 21 to 47), with a sex ratio of 2.83. All patients underwent a systematic primary medial approach for exploration and repair of the medial ligamentous structures. A dynamic valgus stress test under fluoroscopy was performed in patients with a preoperative medial clear space (MCS) greater than 5 mm. Outcomes were assessed using the EFAS score and a visual analogue scale for pain. Results: DL lesions were identified in 13 patients (56.5%), including 11 complete ruptures and two strains. Incarceration of the tibialis posterior tendon was noted in three cases. All ruptures were associated with medial ecchymosis. After lateral osteosynthesis, DL repair was performed using resorbable sutures. At a mean follow-up of 3.1 years, ankle function was rated very good in 78.2% of patients, with a mean VAS of 1.5. Two patients developed medial impingement syndrome, but no medial instability was observed. Conclusion: A systematic medial approach is not warranted in all bimalleolar equivalent fractures, but remains mandatory when clinical signs (medial ecchymosis, oedema) and radiological findings (MCS greater than 5 mm, with or without stress test) suggest DL injury. Early repair prevents medial instability and long-term arthrosis.
Implant allergy and total knee arthroplasty. What is the first-line management? Therapeutic options and outcomes
Background: Total knee arthroplasty (TKA) is a frequent procedure, yet persistent postoperative pain remains a significant cause for revision. Metal hypersensitivity, a type IV delayed immune reaction mediated by T-lymphocytes, is a controversial etiologic factor implicated in approximately 0.6% to 1% of TKA revisions. Objective: This article reviews the pathophysiological mechanisms of implant-related allergy, evaluates current diagnostic modalities, and analyzes clinical outcomes of hypoallergenic prosthetic alternatives in primary and revision settings. Key Points: Metal sensitization prevalence is estimated at 10% to 15% in the general population, increasing to 60% in cases of implant failure. Common haptens include nickel, cobalt, and chromium. Diagnosis relies on cutaneous patch testing and the lymphocyte transformation test (LTT), though both exhibit limitations in specificity and clinical correlation. Management of confirmed allergy involves hypoallergenic implants utilizing titanium nitride (TiN), zirconium nitride (ZrN), or ceramicized components like Oxinium. Prospective studies indicate that functional outcomes and ten-year survival rates for hypoallergenic implants in primary TKA are comparable to standard cobalt-chromium prostheses. However, registry data from the United Kingdom and Australia demonstrate higher cumulative revision rates for hypoallergenic designs, particularly in younger patient cohorts. In revision surgery for suspected allergy, outcomes are heterogeneous, with some series showing improved range of motion and pain relief following the use of coated implants. Conclusion: While hypoallergenic prostheses are viable for patients with confirmed symptomatic metal allergy, their routine use is not supported by registry data showing inferior long-term survivorship compared to standard implants. Diagnosis requires systematic exclusion of infection and mechanical loosening.
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Weil osteotomy of the first metatarsal in the management of grade 1 to 3 hallux rigidus: a retrospective cohort of 113 cases with a mean follow-up of four years
Background: Hallux rigidus is a prevalent degenerative condition of the first metatarsophalangeal joint. While arthrodesis is the established surgical standard for advanced stages, it significantly alters gait kinematics. Joint-preserving procedures, such as the Weil distal oblique shortening osteotomy, offer potential alternatives for maintaining motion, yet their efficacy across different radiographic grades and their impact on load distribution remain subjects of clinical investigation. Objective: This study evaluates the long-term clinical, functional, and radiological outcomes of the Weil first metatarsal osteotomy for the treatment of Coughlin and Shurnas Grade 1, 2, and 3 hallux rigidus. Key Points: A retrospective analysis of 87 feet (72 patients) with a mean follow-up of 51 months demonstrated a significant increase in mean AOFAS scores from 54.2 to 92.2 (p < 0.001). Mean dorsiflexion improved by 9°, while plantar flexion remained stable. Radiological analysis showed a mean metatarsal shortening ratio of 9.6%. Postoperative transfer metatarsalgia occurred in 17.2% of cases at six months, resolving in most patients through conservative management; only 4.6% reported persistent symptoms at final follow-up. No significant correlations were found between clinical outcomes and preoperative metatarsal index, Coughlin grade, or the degree of metatarsal shortening. The subjective satisfaction rate was 95.4%, and no patients required secondary arthrodesis. Conclusion: The Weil distal oblique osteotomy is an effective joint-preserving intervention for Grade 1 to 3 hallux rigidus. It provides significant pain relief and functional improvement with a low rate of persistent complications, regardless of the preoperative radiographic severity or metatarsal length.
The limits of implant retention in prosthetic joint infection
Background: Prosthetic joint infection (PJI) represents a significant complication in lower limb arthroplasty, compromising joint function and patient outcomes. The development of bacterial biofilms on prosthetic surfaces creates a protective environment against host immunity and antimicrobial therapy, typically becoming established within two weeks. Consequently, identifying the specific clinical conditions and temporal windows that permit implant retention is critical to avoid treatment failure and subsequent functional morbidity. Objective: This article aims to define the indications for implant retention in acute PJI and to describe a standardized surgical protocol, termed SYLAC (Synovectomy, Lavage, and Change of modular components), to optimize clinical outcomes. Key Points: Successful debridement, antibiotics, and implant retention (DAIR) requires adherence to a strict temporal window: three weeks from symptom onset or four weeks postoperatively. Contraindications include documented bacteremia, extensive soft tissue compromise, and high risk as determined by KLICC (>4) or CRIME-80 (>3) scores. The SYLAC protocol emphasizes radical synovectomy and the mandatory exchange of all modular components. Irrigation involves synergistic use of hydrogen peroxide and povidone-iodine, followed by six liters of pulsatile lavage. Postoperative management includes a three-month antibiotic regimen and structured laboratory monitoring. Failure to adhere to these selection criteria or surgical steps increases the risk of chronic infection and the need for radical explantation. Conclusion: Utilizing a structured decision-making algorithm and a standardized surgical technique allows for a cure rate of approximately 75% in appropriately selected PJI cases. Rigorous patient selection and meticulous surgical execution are essential to preserve prosthetic function and minimize long-term sequelae.
One-stage revision arthroplasty for infected total hip replacement: principles and outcomes
Background: Periprosthetic joint infection (PJI) of the hip is a significant complication traditionally managed via two-stage revision. While one-stage revision has gained traction due to reduced healthcare costs and the avoidance of multiple surgeries, its implementation requires strict surgical rigor and multidisciplinary coordination to ensure outcomes comparable to two-stage protocols. Objective: This article aims to define the prerequisites, pathophysiological rationale, and technical principles of one-stage revision arthroplasty for chronic hip PJI, while evaluating its clinical indications and success rates. Key Points: Successful management relies on a multidisciplinary team involving infectious disease specialists, microbiologists, and orthopedic surgeons. Pre-operative joint aspiration is essential, demonstrating 88% concordance with intra-operative cultures. The surgical procedure necessitates radical debridement of all infected soft tissue and complete removal of implants and cement, often requiring extended femoral osteotomies. Reconstruction utilizes modular revision implants, dual-mobility components, or structural allografts to address bone loss. Post-operative antibiotic therapy is typically administered for six to twelve weeks. Clinical data from a prospective cohort of 157 chronic PJI cases treated with one-stage revision showed a 95% infection-free survival rate at five years, even in cases involving resistant organisms or sinus tracts. Conclusion: One-stage revision arthroplasty is an effective strategy for the majority of hip PJI cases. By achieving high infection eradication rates and superior functional outcomes compared to two-stage procedures, it serves as a primary treatment option when managed within specialized referral centers.
Pierre Barouk’s trajectory reflects a deliberate balance between heritage and professional autonomy. Having witnessed the introduction of the SCARF osteotomy firsthand, he refined his expertise through rigorous training in Lille before establishing an independent practice in Bordeaux. Now presiding over the AFCP, Barouk emphasizes clinical pragmatism and the necessity of peer-to-peer knowledge transfer. His focus on long-term surgical outcomes and the sustainability of ankle arthroplasty underscores a commitment to advancing the specialty through collective evidence and technical precision.
Arun Mullaji is a famous knee surgeons in India and very active in Europe. He is one of the founding members of the Indian Hip and Knee Surgery Society and the past president of the Asia Pacific Arthroplasty Society.
Copyright (c) 2020 Mentors in Orthopedics
A pictorial and systematic approach to varus deformity
Background: Varus deformity is the most prevalent malalignment in total knee arthroplasty (TKA), ranging from mild, passively correctable cases to recalcitrant deformities. Traditional correction often involves extensive soft tissue release, yet controversy remains regarding the optimal sequence and necessity of releasing the superficial medial collateral ligament (MCL). Objective: This article describes a systematic approach to achieving coronal alignment and gap balancing in varus TKA without superficial MCL release, utilizing computer navigation and specific osteotomy techniques. Key Points: The methodology is based on the premise that the superficial MCL is often tented by osteophytes rather than contracted. Preoperative and intraoperative assessments must identify extra-articular deformities (EAD) and hindfoot valgus, which influence the weight-bearing axis. Following bone resections perpendicular to the mechanical axes, three clinical scenarios guide soft tissue management. Symmetrical gaps require no further release. If the extension gap is tight medially but the flexion gap is symmetrical, a posteromedial capsular release or a sliding medial condylar osteotomy is indicated. If both gaps are tight medially, a reduction osteotomy of the posteromedial tibial flare is performed, followed by semimembranosus release or corrective metaphyseal osteotomy if EAD is present. Conclusion: Precise alignment and ligamentous balance in severe varus deformity can be achieved by addressing bone morphology and posteromedial structures. This systematic protocol prioritizes preservation of the superficial MCL and utilizes intra-articular or extra-articular osteotomies to manage complex deformities without requiring constrained implants.
Hip arthroscopy on the orthopaedic table: Technique, tips and tricks to avoid potential complications
Background: Hip arthroscopy has evolved significantly since 1931, with expanding indications for intra-articular and extra-articular pathologies. The procedure involves a demanding learning curve and specialized instrumentation, while training is often limited by the scarcity of anatomical specimens and specialized centers. Objective: This article provides a comprehensive review of hip arthroscopy, detailing surgical anatomy, clinical indications, potential complications, and standardized technical approaches for accessing the various arthroscopic compartments. Key Points: The hip is categorized into central, peripheral, peritrochanteric, and posterior compartments. Accessing the central compartment requires approximately 1 cm of joint distraction under fluoroscopic guidance, typically performed in the supine position. Standard portals—anterolateral, anterior, and posterolateral—must be established within safe zones to avoid neurovascular structures like the femoral and sciatic nerves. Complication rates currently range from 0.5% to 7.9%, primarily involving traction-related neuropraxia, iatrogenic chondral injury, and fluid extravasation. For the peripheral compartment, traction is released and the hip flexed to 20°–45° to visualize the femoral head-neck junction. Peritrochanteric access enables management of extra-articular conditions, including gluteus medius tears and bursitis. Technical success relies on precise portal placement and sequential exploration of the joint spaces. Conclusion: Hip arthroscopy is a technically complex procedure requiring precise anatomical knowledge and adherence to safety protocols. Standardized portal placement and careful patient selection are essential to minimize complications and optimize outcomes in the management of coxofemoral pathology.
Medial unicompartimental knee arthroplasty : Indications and limits
Background: Medial unicompartmental knee arthroplasty (UKA) serves as an intermediary surgical intervention between osteotomy and total knee arthroplasty (TKA). Despite historical concerns regarding failure rates and restrictive selection criteria established in 1989, advancements in tribology and surgical technique have improved clinical outcomes to levels comparable with TKA. Objective: This article evaluates the evolution of indications and contraindications for medial UKA, examining the impact of patient factors and surgeon experience on long-term implant survivorship. Key Points: Modern evidence suggests that traditional contraindications, including age under 60, obesity, and asymptomatic patellofemoral chondrosis, do not significantly compromise outcomes. While inflammatory arthritis remains a definitive contraindication, ACL deficiency may be managed successfully in specific older populations. Optimal results are strongly correlated with surgical volume, specifically when UKA constitutes 20–50% of a surgeon's total knee replacement caseload. Technical precision is critical, as axial alignment must avoid overcorrection to prevent lateral compartment degeneration or undercorrection leading to polyethylene wear. The Unicompartmental Indication Score (UIS) provides a contemporary framework for patient selection, with scores exceeding 25 predicting superior clinical satisfaction. Conclusion: Medial UKA is a highly effective treatment for localized osteoarthritis when performed with meticulous technique. Success depends less on strict adherence to historical age or weight limits and more on the surgeon’s proficiency and the relative proportion of UKA procedures within their clinical practice.