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Background@#Incomplete fractures are assumed to occur in the intertrochanteric area as fractures at other sites, but reports of incomplete intertrochanteric fractures (IIFs) are rare. In 1999, Schultz et al. defined isolated greater trochanter fractures (GTFs) as IIFs when intertrochanteric extension is observed on magnetic resonance (MR) images. On multiplanar reformation computed tomography (MPR CT) images acquired for further study of apparently isolated GTFs, we noted incomplete cortical breakage in the intertrochanteric area. We then found that the fracture line was incomplete on plain radiographs in some intertrochanteric fractures. We evaluated IIFs and apparently isolated GTFs using MPR CT and analyzed the fracture patterns of IIFs that were confirmed using MPR CT. @*Methods@#Between February 2006 and June 2019, 36 cases of IIF were detected using MPR CT in 36 patients. They were 17 women and 19 men with a mean age of 74.7 years (range, 26–94 years). Plain radiographs and MPR CT images were evaluated by two experienced orthopedic surgeons. In addition, MR imaging was performed in 5 cases. @*Results@#Plain radiographs showed no evidence of fracture in 2 cases, isolated GTF in 7 cases, and IIF in 27 cases. In all cases, incomplete cortical breakage in the intertrochanteric area was confirmed on MPR CT images. Cortical breakage was located in the anterior portion of the intertrochanteric area, whereas the posterior portion remained intact in all cases. The detection rate of cortical breakage was higher on coronal or sagittal images than that on axial images. On MR images of 5 cases, intertrochanteric extensions were found in the medullary space. All extensions originated in the greater trochanter area and extended anteriorly in the axial plane and inferomedially in the coronal plane. On the T1-weighted mid-coronal image, the extension reached or passed the midline in 3 cases, and cortical breakage was detected in only 2 cases. @*Conclusions@#In all cases of IIF, cortical breakage was detected in the anterior portion of the proximal femur, leaving the posterior cortex intact. This finding is notably different from that of intertrochanteric extension (from posterior to anterior) detected on MR images of isolated GTFs.
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Background@#The current trend of using short femoral stems in total hip arthroplasty (THA) is associated with angular deviation of the femoral stem towards the native femoral axis. The purpose of this study was to compare the difference in stem tilt angle between two different stems with a similar design except for the stem length. @*Methods@#This is a retrospective review of 66 patients who underwent primary THA between April 2012 and May 2016, using a trans-gluteal direct lateral approach by a single surgeon. We evaluated the femoral stem tilt angle in both the coronal and sagittal planes and performed multivariate logistic regression analysis to evaluate possible risk factors. We also simulated the range of motion (ROM) of the hip joint using three-dimensional computer-aided design software (SolidWorks, 2016) to examine the clinical significance of femoral stem tilt. @*Results@#The mean coronal tilt angle was 1.8° ± 1.0° in the conventional stem group and 1.6° ± 1.1° in the short stem group, showing no statistically significant difference between the groups (p = 0.570). However, the mean sagittal tilt angle was 4.0° ± 2.0° in the conventional stem group and 7.8° ± 2.0° in the short stem group (p < 0.001). The stem type and stem length had a linear correlation with the sagittal tilt angle (p < 0.001) in multivariate regression analysis. A simulated hip ROM demonstrated a 3.8° decrease in extension in proportion to a 3.8° increase in the mean sagittal stem tilt angle of the short femoral stem. @*Conclusions@#Anterior femoral stem tilting in the sagittal plane was prominent when the shorter stem was used, and anterior tilting was responsible for decreased ROM in hip extension.
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Purpose@#This study evaluated the clinical results and implant safety of a newly developed implant, Trochanteric Fixation Nail-Advanced (TFNA; DePuy Synthes), in the treatment of proximal femur fractures. @*Materials and Methods@#This was a retrospective cohort study of 26 patients diagnosed with proximal femur fracture and treated surgically with TFNA. The patients’ demographic data, surgical data, radiologic findings, and functional outcomes, including complications, were evaluated. @*Results@#The mean age of the patients was 71.2 years (95% confidence interval [CI], 68.2-74.2); 65.4% were female. The mean Carlson comorbidity index score was 5.4, and the mean Koval grade before fracture was 2.1. Fracture classification included four cases of AO/OTA 31.A1, nine cases of A2, six cases of A3, and seven cases of 32A including six cases of atypical femoral fractures. The mean operating time was 53.3 minutes (95% CI, 43.6-63.1). There were no early postoperative complications, such as postoperative infection, deep vein thrombosis, pulmonary embolism, or in-hospital death, except one case of pneumonia. The mean Koval score at the postoperative six-month follow-up was 2.9. EuroQol-5 Dimension (EQ-5D) increased from 0.05 to 0.54 after three months and 0.72 at six months postoperatively. Bone union was observed in all cases with a mean union time of 12.9 weeks. No implant failure occurred, and no cases required secondary revision surgery. @*Conclusion@#A new intramedullary nail system, TFNA, showed excellent outcomes and safety in the surgical treatment of proximal femur fractures.
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This study aimed to analyze the epidemiologic characteristics of patients who underwent hip arthroplasty using the Korean nationwide database and investigate the recent trends in implant fixation methods and bearing surface selection. We aimed to compare clinical characteristics and differences with the results from the registry of other western countries. We analyzed the data collected by the Health Insurance Review and Assessment Service database of Korea from 2007 to 2011 and the Main Surgery Statistical Yearbook from 2014 to 2018, published by the National Health Insurance Service. The number and rate of patients who underwent hip joint arthroplasty per 10,000 persons have been steadily increasing since 2007. There was a big difference in mean age and preoperative diagnosis of patients between the bipolar hemiarthroplasty and total hip arthroplasty groups. Most patients underwent surgery using a cementless biological fixation method, and the cemented fixation method was selectively used for a small portion of old aged osteoporotic patients. In relation to the use of bearing surfaces, the registry data showed that ceramic-ceramic bearings were used at an overwhelmingly high rate (81%) in Korea compared to other countries. The reason was attributable to various factors, such as patient’s age or economic status, differences in the health insurance system between countries, and recently reported complications, such as ceramic fracture or noise.
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Background@#Hereditary multiple exostoses (HME) is an autosomal dominant disorder. The lesion in the proximal femoral metaphysis can bring about hip dysplasia and subsequent degenerative arthritis. Due to its rare prevalence, there have been a few case reports of total hip arthroplasty (THA) for osteoarthritis secondary to HME. The aim of this study was to report mid- to long-term outcomes of THA in HME patients and discuss special considerations that should be taken into account during surgery. @*Methods@#We retrospectively evaluated the clinical and radiological results of THA for osteoarthritis secondary to HME in 11 hips of 9 patients after a minimum follow-up of 5 years (mean, 9.9 years). There were 3 men (3 hips) and 6 women (8 hips), with a mean age of 53.6 years (range, 46.8–58 years) at the index surgery in this study. Harris hip score (HHS) was used for clinical outcome assessment, and radiologically, implant stability, radiolucent lines, liner wear, and any sign of osteolysis or implant loosening were evaluated. Postoperative complications including infection, deep vein thrombosis, and dislocations were also investigated. @*Results@#Cemented stems and cementless cups with the conventional polyethylene liner were used in bilateral hips of a single patient. In the other cases, cementless implants were used with ceramic-on-ceramic bearings. The mean HHS improved from 34.8 preoperatively to 92.5 postoperatively. Polyethylene liner wear and osteolysis were observed in 1 patient with cemented stems. Radiolucent lines were observed in 2 different cases. However, the femoral stems remained stable. There were no surgery-related complications except heterotopic ossification during follow-up. @*Conclusions@#Despite the several surgical considerations, the mid- to long-term clinical and radiological outcomes of THA in HME patients were satisfactory. The abnormal, wide mediolateral diameter of the proximal metaphysis should be considered in selecting and inserting the stem with adequate anteversion. Leg length discrepancy was also common, so teleradiographs should be obtained before surgery. Intraoperative leg length evaluation might be difficult due to the morphologic changes in the proximal femur after mass excision and individual bone length differences.
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In the surgical treatment of acetabular fractures, the anterior approach is used widely for anterior column fractures with or without posterior column fractures. This paper reviews the anterior approach for the anatomical reduction and rigid fixation of acetabular fractures: traditional ilioinguinal approach, modified Stoppa approach, and new Pararectal approach.
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AcetabulumABSTRACT
PURPOSE: The purpose of this study was to evaluate the clinical outcome of arthroscopic treatment for recalcitrant external snapping hip. MATERIALS AND METHODS: Between September 2011 and June 2013, we evaluated 7 patients (10 cases) with snapping hip who were refractory to conservative treatments for at least 3 months. Two patients (4 cases) were impossible to adduct both knees in 90degreesof hip flexion. Surgery was done in lateral decubitus position, under spinal anesthesia. We made 2 arthroscopic portals to operate the patients, and used cross-cutting with flap resection technique to treat the lesion. We performed additional gluteal sling release in those 2 patients (4 cases) with adduction difficulty. Average follow-up length was 19 months (range, 12-33 months). Clinical improvement was evaluated with visual analog scale (VAS), modified Harris hip score (mHHS), and also investigated for presence of limping or other complications as well. RESULTS: The VAS decreased from 6.8 (range, 6-9) preoperatively to 0.2 (range, 0-2) postoperatively, and the mHHS improved from 68.2 to 94.8 after surgery. None of the patients complained of post-operative wound problem or surgical complications. CONCLUSION: The clinical outcome of arthroscopic treatment for recalcitrant external snapping hip was encouraging and all patients were also satisfied with the cosmetic results.