Femoral stem revision through the direct anterior approach (DAA) remains technically demanding, particularly when standard exposure is insufficient for safe implant extraction. This article presents structured, anatomy-driven surgical techniques based on the interbundle concept.Three osteotomy strategies are described in detail: the trochanteric slide osteotomy (TSO), the anterior cortical window (ACoW) osteotomy, and the extended trochanteric osteotomy (ETO). Central to all techniques is the consistent identification of two neurovascular bundles distal to the lesser trochanter, which define a safe interbundle working zone, creating a ‘window of opportunity’.The TSO represents the simplest technique, preserving soft-tissue continuity while improving exposure. The ACoW provides minimally invasive, direct endomedullary access with minimal impact on postoperative rehabilitation. The ETO offers extensile exposure while maintaining soft-tissue integrity when performed within anatomical constraints.A thorough understanding of the interbundle anatomy allows surgeons to tailor the best osteotomy choice to the clinical scenario. Techniques can even be combined when deemed necessary, thereby expanding the versatility of the DAA in femoral revision hip arthroplasty.
Periprosthetic joint infection (PJI) remains a devastating complication of total hip arthroplasty (THA), and chronic PJI in the presence of a well-fixed femoral stem is particularly challenging because removal of an osseointegrated stem carries substantial morbidity. Partial two-stage exchange (P2-SE) with femoral stem retention, in which the acetabular components are removed and replaced with an antibiotic-cement functional spacer while the well-fixed stem is retained and debrided, has emerged as an alternative to complete one-stage or two-stage exchange. The direct anterior approach (DAA), although widely adopted for primary THA, has rarely been described for the management of PJI. This article reports three cases of chronic PJI managed by P2-SE performed entirely through the original anterior interval, together with a comprehensive review of the published outcomes of P2-SE. Two of the three patients achieved infection control and were pain-free and ambulatory at final follow-up with an antibiotic-loaded cemented acetabular construct (a polyethylene liner with a modular ceramic head in one, a dual-mobility construct in the other), and did not require second-stage reimplantation, while the third patient developed a recurrent infection after cessation of oral suppression and was subsequently converted to a formal two-stage exchange. The accompanying literature review demonstrates infection eradication rates of approximately 81 to 100% across predominantly Level IV series, with reported outcomes comparable to those of complete two-stage exchange. P2-SE through the DAA appears to be a reasonable option in carefully selected patients with a well-fixed femoral stem, although further prospective comparative investigation is warranted.
Background In recent years, negative pressure wound therapy (NPWT) has become increasingly employed in clinical practice for managing open extremity fractures, despite limited evidence, highlighting the need for an updated synthesis of evidence on this topic. This meta-analysis aims to assess the effectiveness of NPWT compared to standard wound dressings for open fracture wounds of the extremities. Methods The meta-analysis was registered with PROSPERO (ID: CRD420251148559). PubMed, EMBASE, Scopus, Cochrane, and Google Scholar were searched on April 12, 2025 for randomized controlled trials (RCTs) comparing NPWT with standard dressings in open fractures of the extremities. Primary outcomes were overall infection rates, deep infection rates, acute infection rates and length of hospital stay. Secondary outcomes included positive wound culture rate, and further interventions defined as graft repair, flap repair, or delayed wound closure. Data was pooled using random-effects models. The Cochrane Risk of Bias-2 Tool was implemented to assess risk of bias. Results 10 RCTs involving 1,171 patients were included. NPWT demonstrated no statistical reduction in overall or acute infection rate, length of hospital stay, or need for further interventions. NPWT significantly reduced deep infection rates (OR = 0.39, 95% CI 0.17–0.88) and positive wound culture rates (OR = 0.35, 95% CI 0.14–0.89), although these findings should be interpreted cautiously given the limited sample size and clinical heterogeneity. Overall risk of bias was low across most domains. Conclusion Compared to standard dressings, NPWT did not reduce overall or acute infection rates, length of hospital stay, and the need for further interventions. Heterogeneity was high for several outcomes and the certainty of evidence was very low for the majority of outcomes, highlighting the need for further high-quality studies. The current evidence does not demonstrate consistent superiority of either approach.
