The Evolution of Computer-Assisted Total Hip Arthroplasty and Relevant Applications / 대한고관절학회지

In total hip arthroplasty (THA), the accurate positioning of implants is the key to achieve a good clinical outcome. Computer-assisted orthopaedic surgery (CAOS) has been developed for more accurate positioning of implants during the THA. There are passive, semi-active, and active systems in CAOS for THA. Navigation is a passive system that only provides information and guidance to the surgeon. There are 3 types of navigation: imageless navigation, computed tomography (CT)-based navigation, and fluoroscopy-based navigation. In imageless navigation system, a new method of registration without the need to register the anterior pelvic plane was introduced. CT-based navigation can be efficiently used for pelvic plane reference, the functional pelvic plane in supine which adjusts anterior pelvic plane sagittal tilt for targeting the cup orientation. Robot-assisted system can be either active or semi-active. The active robotic system performs the preparation for implant positioning as programmed preoperatively. It has been used for only femoral implant cavity preparation. Recently, program for cup positioning was additionally developed. Alternatively, for ease of surgeon acceptance, semi-active robot systems are developed. It was initially applied only for cup positioning. However, with the development of enhanced femoral workflows, this system can now be used to position both cup and stem. Though there have been substantial advancements in computer-assisted THA, its use can still be controversial at present due to the steep learning curve, intraoperative technical issues, high cost and etc. However, in the future, CAOS will certainly enable the surgeon to operate more accurately and lead to improved outcomes in THA as the technology continues to evolve rapidly.

Acute Delayed or Late Infection of Revision Total Hip Arthroplasty Treated with Debridement/Antibiotic-loaded Cement Beads and Retention of the Prosthesis / 대한고관절학회지

PURPOSE: The treatment of infected revision total hip arthroplasty (THA) is very challenging due to retained revision prosthesis, poor bone stock and soft tissue condition derived from previous revision surgeries, and comorbidities. The purpose of this study was to investigate the effectiveness and short-term outcomes of aggressive debridement and use of antibiotic-loaded cement beads with retention of the prosthesis for acute delayed or late infection of revision THAs. MATERIALS AND METHODS: Ten consecutive patients with symptoms or signs of less than one-week evolution and well-fixed prostheses, were treated with this procedure and a postoperative course of organism-specific antibiotics for a minimum of 6 weeks. All hips presented with acute delayed or late infection of revision THAs. Patients with a mean age of 68.1 years (range, 59-78 years) underwent an average of 1.9 previous revision THAs (1-4) before the index surgery. The minimal follow-up was 2 years with a mean of 46.2 months (range, 24-64 months). RESULTS: There were 8 cures (80.0%) and 2 failures with no mortality during the study period. The 2 failures involved the same and resistant bacteria implicated in the primary infection (methicillin-resistant Staphylococcus aureus and Prevotella oralis, respectively). The mean Harris hip score was 65.2 (range, 26-83) and the mean visual analogue scale was 2.6 (range, 1-4) at final follow-up. CONCLUSION: With a favorable success rate and no mortality, our procedure may be considered a safe and effective alternative for the treatment of acute delayed or late infection of revision THAs with well-fixed prostheses.

Future Bearing Surfaces in Total Hip Arthroplasty

One of the most important issues in the modern total hip arthroplasty (THA) is the bearing surface. Extensive research on bearing surfaces is being conducted to seek an ideal bearing surface for THA. The ideal bearing surface for THA should have superior wear characteristics and should be durable, bio-inert, cost-effective, and easy to implant. However, bearing surfaces that are currently being implemented do not completely fulfill these requirements, especially for young individuals for whom implant longevity is paramount. Even though various new bearing surfaces have been investigated, research is still ongoing, and only short-term results have been reported from clinical trials. Future bearing surfaces can be developed in the following ways: (1) change in design, (2) further improvement of polyethylene, (3) surface modification of the metal, (4) improvement in the ceramic, and (5) use of alternative, new materials. One way to reduce wear and impingement in THA is to make changes in its design by using a large femoral head, a monobloc metal shell with preassembled ceramic liner, dual mobility cups, a combination of different bearing surfaces, etc. Polyethylene has improved over time with the development of highly crosslinked polyethylene. Further improvements can be made by reinforcing it with vitamin E or multiwalled carbon nanotubes and by performing a surface modification with a biomembrane. Surface modifications with titanium nitride or titanium niobium nitride are implemented to try to improve the metal bearings. The advance to the fourth generation ceramics has shown relatively promising results, even in young patients. Nevertheless, further improvement is required to reduce fragility and squeaking. Alternative materials like diamond coatings on surfaces, carbon based composite materials, oxidized zirconium, silicon nitride, and sapphire are being sought. However, long-term studies are necessary to confirm the efficacy of these surfaces after enhancements have been made with regard to fixation technique and implant quality.

Analysis of the Fixation Failure in Intertrochanteric Hip Fractures Treated with Hip Nailing

PURPOSE: To analyze the patterns of and risk factors for fixation failure after hip nailing in intertrochanteric (IT) hip fractures. MATERIALS AND METHODS: Fourteen patients who sustained a fixation failure after hip nailing for IT hip fractures were enrolled in this study. The mean age at the index surgery was 74.5 years and the mean time to the fixation failure was 6.6 weeks. All of the serial radiographs up to the fixation failure and pre-operative 3-D computed tomography were analyzed. RESULTS: According to AO classification, there were 7 stable fractures and 7 unstable ones. Of the total of 14 cases, 10 showed a comminution of the greater trochanter tip and incomplete anatomical reduction of the medial and anterior cortex at the fracture site. Of the 10 cases with appropriate position of the lag screw within the femoral head, 9 showed a high pertrochanteric fracture (HPF) pattern. The mechanism of the fixation failure was rotation of the femoral head in 7 of 9 cases with HPF and varus collapse of the proximal fragment in 4 of the other 5 cases. CONCLUSION: The HPF pattern, the comminution of the greater trochanter tip, and incomplete reduction of the medial and anterior cortex may be additional risk factors of fixation failure after treating IT hip fractures with hip nailing in.

The Tribological and Lubrication Responses of a Cobalt-Chromium Femoral Head in Total Hip Arthroplasty

PURPOSE: This study aimed at investigating the role of albumin as a boundary lubricant in the lubrication of the Co-Cr femoral head of artificial hip implants by measuring the tribological parameters of the Co-Cr femoral head with Atomic Force Microscope (AFM) techniques. MATERIALS AND METHODS: Samples were prepared from the main wear region of a Co-Cr femoral head from revision hip surgery. Two types of solutions were prepared as lubricants: PBS (Phosphate Buffered Saline) as a control solution and BSA (Bovine Serum Albumin) as a lubricant at concentrations of 10, 20, 30 and 40 mg/ml in PBS solution. RESULTS: There were statistically significant differences in the frictional coefficients (micron) of a Co-Cr head between the PBS control and all the concentrations of BSA (10, 20, 30, 40 mg/ml) (P<0.001). Similarly, there were statistically significant differences for the micron between the BSA concentrations of 10, 20, 30 and 40 mg/m for all the cases except between the BSA of 30 and 40 mg/ml (P<0.01). CONCLUSION: There exists a maximum protein concentration of BSA to play a role as an effective boundary lubricant through adsorption on the surface of Co-Cr femoral head.

Bipolar Hemiarthroplasty for Hip Fractures in Patients Aged over 90 Years: The Factors Influencing the Postoperative Mortality

PURPOSE: We wanted to evaluate the factors that influence the one-year mortality rate after bipolar hemiarthroplasty in elderly patients over 90 years of age and who had hip fractures. MATERIALS AND METHODS: In this retrospective study, we enrolled 42 cases (29 females and 12 males) that were treated by bipolar hemiarthroplasty for hip fractures between April 1999 and April 2008. The mean age was 94 (range: 90~101) years. We compared such variables as age, gender, BMD (bone mineral density), the ASA (American Society of Anesthesiologists) score, the type of fracture, the operation time, the type of anesthesia, the length of the ICU (intensive care unit) care, the length of hospitalization, operative delay and the postoperative ambulatory capability between the one-year mortality group and the control group (alive over a minimum of 1-year), and we investigated the risk factors related to one-year mortality. RESULTS: The one-year mortality rate was 32%. There were significant relationships between the postoperative one-year mortality and the ASA score, the length of the ICU care, operative delay and the postoperative ambulatory capability. The one-year mortality rate in the trochanteric fracture group was significantly higher than that in the neck fracture group. However, there were no relationships between the one-year mortality and age, gender, BMD, the length of operation, the type of anesthesia and the length of the hospitalization. CONCLUSION: The preoperative ASA score was significantly higher in the one-year mortality group among the elderly patients over 90 years of age and who were treated with bipolar hemiarthroplasty for hip fractures. The length of the ICU care, operative delay and the postoperative ambulatory capability were significantly associated with one-year mortality, and so all of these should be considered as postoperative prognostic factors.

Affection of Wnt/beta-catenin in Titanium Particles Challenged Osteoblasts / 대한정형외과연구학회지

PURPOSE: The intracellular mechanisms that lead to periprosthetic osteolysis including impaired bone forming activity of osteoblast remain incompletely characterized. To determine the possibility that Ti-particles play a role to regulate Wnt/beta-catenin signaling pathway in impaired osteogenesis, we analyzed the stability of beta-catenin and the transcriptional changes of regulators for Wnt/beta-catenin signaling pathway in MC3T3-E1 osteoblast cells. MATERIALS AND METHODS: Ti-particles were prepared by sterilizing and counted on the microscopy. Transcriptional changes of OPG, RANKL, LRP5, LRP6, DKK1 and sFRP2 were determined by real-time RTPCR. Protein level of beta-catenin and GSK3beta was detected using Western blotting and immunofluorescence staining. RESULTS: After 4 hours of treatment of Ti-particles, OPG/RANKL mRNA ratio was significantly decreased. And also, decreased protein levels of beta-catenin and phospho-GSK3beta were detected. Using immunofluorescence stain, it was confirmed that Ti-particles suppressed nucleus staining of beta-catenin induced by Wnt3a conditioned medium. The results of real-time RT-PCR showed reduced level of LRP5 and LRP6 transcripts, and induced level of DKK1 and sFRP2 transcripts by challenging of Ti-particles CONCLUSION: Our report suggests that Ti-particles may play a crucial role in the regulation of Wnt/beta-catenin signaling pathway in osteoblast through the transcriptional changes of membrane receptors and extracellular inhibitors for Wnt.

Obturator Internus Pyomyositis: A Case Report

Pyomyositis is a primary bacterial infection of skeletal muscle and this is on the increase worldwide among children as well as young adults. We report herein on a case of a 29-year-old male with pyomyositis of the obturator internus. The fact that pyomyositis predominantly affects the muscles of the lower limb and it is confined to the obturator internus muscle has been poorly recognized. CT with an enhancement was an accurate imaging modality to image the obturator internus muscle and to ascertain the diagnosis for this case. The patient was managed with antibiotics and surgical intervention was not necessary. Pyomyositis of the obturator internus muscle needs to be differentiated from septic arthritis of the hip. The present study reports the clinical signs and treatments of pyomyostis and we review the relevant literature.

Hypothermia During Total Hip Arthroplasty with Combined Spinal-epidural Anesthesia

In operations of the lower extremities in elderly patients, regional anesthesia is preferred over general anesthesia because regional anesthesia is associated with less deep vein thromboses, pulmonary emboli, bleeding, transfusion volume, and can better control post-operative pain. During surgery, a drop in core temperature frequently occurs. In elderly patients, temperature control and compensatory abilities are physiologically impaired. During induction of regional anesthesia, such as spinal anesthesia, elderly patients often do not complain of coldness, despite the decrease in the core temperature. Also, problems associated with hypothermia can easily be overlooked because anesthesiologists are less concerned about measuring the body temperature of patients than they are during induction of general anesthesia. Because perioperative hypothermia can cause various complications, such as infection, bleeding, cardiac injury, and shivering, closer attention is necessary. We report a case of hypothermia that developed during total hip arthroplasty under combined spinal-epidural anesthesia.

The Harris-Galante-II Acetabular Componentin Cementless Total Hip Arthroplasty : Average Ten-year Follow-up Results / 대한정형외과학회잡지

PURPOSE: To evaluate the average ten-year follow-up results of 98 total hip arthroplasties using Harris-Galante-II porous-coated acetabular components. MATERIALS AND METHODS: Ninety-eight hips were evaluated. The mean age of the patients was 45 years, and the mean follow-up was 121 months. The clinical and radiographic findings including the wear of the polyethylene liner were evaluated. The endurance of the acetabular component was analyzed using the Kaplan-Meier method. RESULTS: Retroacetabular osteolysis, dissociation of the PE liner and aseptic loosening of the acetabular component was observed in 25 hips (25.5%), 9 hips (9.2%), and 1 hip (1.0%), respectively. The average rate of liner wear was 0.16 mm/year. Twenty acetabular components (20.4%) were revised, and the survival probability of the acetabular components at 10 years was 87% (95% confidence limits, 83-90%). CONCLUSION: In this long-term follow-up study, the revision rate of Harris-Galante-II acetabular component was relatively high, and was associated with locking mechanism failure and retroacetabular osteolysis. However, the rarity of aseptic loosening suggests that excellent long-term fixation could be achieved with the surface treatment of a fiber-metal porous coating.

Degenerative Change of Femoral Head Cartilage in the Elderly with Hip Fracture / 대한정형외과학회잡지

PURPOSE: To evaluate the incidence, grade and extent of the degenerative changes in the femoral head articular cartilage in the elderly with hip fracture through gross, histological and immunohistochemical studies. MATERIALS AND METHODS: The study examined 30 femoral heads obtained from patients over 65 years with no arthrosis by radiograph, who had undertaken bipolar hemiarthroplasty due to hip fracture. The mean age of patients was 79.7 years and the study examined three weight bearing zones (anterior, middle and posterior) and one non-weight bearing zone (inferior) of each femoral head. RESULTS: The gross findings showed significant correlation with the Mankin grade for each zone (p<0.05). Twenty four cases (80%) showed mild degeneration according to the Mankin grade and the others moderate. The mean Mankin score at each zone of all femoral heads was 5 points, which indicated mild degeneration. No significant difference was found between the weight bearing zone and the non-weight bearing zone (p=0.75). The distribution of type II collagen antibody stainabilities mainly showed normal or mild degeneration (93.3%). CONCLUSION: Degeneration of the articular cartilage of the femoral heads in the elderly with hip fracture and no arthrosis by radiograph was mostly mild, and showed generalized changes regardless of the zone.

Influences of Particles on Pro-inflammatory Signalings in Pre-osteoclasts / 대한정형외과연구학회지

PURPOSE: To evaluate the roles of macrophages and their influences on the signal transduction in the periprosthetic osteolysis, the pro-inflammatory signals were analyzed in particles-stimulated macrophages. MATERIALS AND METHODS: Raw 264.7 cell line derived from mice macrophages was used as pre-osteoclasts. To increase the stimulatory effects, the particles were composed of PMMA and polyethylene. Under the similar conditions as osteoclast differentiation, we examined the effect of particles on the pro-inflammatory signals in macrophage: the production of TNF-alpha, the activity of MAPKs (mitogen-activated phosphorylation kinase), the expression of I-kappaB (Inhibitory (B) and the production of H2O2 and nitric oxide. RESULTS: The particles stimulated the secretion of TNF-alpha and increased the phosphorylation of p38 and ERK in course of time. The concentration of H2O2 was increased; however the nitric oxide formation was not increased by particle treatment. In addition, the production of H2O2 was synergistically increased by suboptimal stimulation with PMA (phorbol 12-myristate 13-acetate). Expressions of I-kappaB were inhibited by particles. CONCLUSION: The particles may stimulate the activation of MAPKs, the production of TNF-alpha, reactive oxygen species (ROS) and the activation of NF-kappaB in the pre-osteoclasts. We speculate that particles may mediate the pro-inflammatory signal cascade by the activation of NF-kappaB through ROS in pre-osteoclasts, rather than reactive nitrogen species (RNS). Therefore we suggest that the macrophages in inflammatory osteolysis may have the characteristics of pre-osteoclast as well as pro-inflammatory cell. Further researches should be recommended.

Cementless Zweymuller Stem for the Treatment of the Hip Fracture in Patients Older than 80 with Severe Osteoporosis: Case Control Study with Cemented Stem

PURPOSE: We tried to evaluate the usefulness of the cementless Zweymuller stem for treating hip fracture in those patients older than 80 years with severe osteoporosis. MATERIALS AND METHODS: Thirty cases were treated with bipolar hemiarthroplasty with a cementless Zweymuller stem and they served as group I (the study group), and 30 cases treated with a cemented stem served as group II (the control group). We performed a comparative study between the two groups. RESULTS: The admission period (days) was 24.6+/-10.7 and 32.8+/-16.8 (p=0.047) for the 2 groups, respectively, and the average operation time (minutes) was 75.8+/-17.6 and 89.2+/-28.1 (p=0.024), respectively; the total blood loss (ml) was 457.2 and 548.3 (p=0.035) in group I and II, respectively. The incidence of staying in the intensive care unit (ICU) and the average time to start postoperative ambulation showed no significant differences between the two groups. Pulmonary embolism occurred in 1 case in group I and in 4 cases in group II, and intraoperative fracture of calcar occurred in 2 cases of group I. There was no case of position change of the femoral stem at 1 year postoperatively in both groups. CONCLUSION: The cementless Zweymuller stem, inserted by press fit in the patients who are older than 80 years and who have hip fracture with severe osteoporosis showed clinically better results as compared with the cemented stem.

Bone Ingrowth into Harris-Galante Porous-coated Acetabular Cup Retrieved during Revision

Purpose: To investigate the extent of bone ingrowth into the porous-coated acetabular cups as well as the factors that correlated with bone ingrowth in total hip arthroplasty. Materials and Methods: Thirty six Harris-Galante porous-coated acetabular cups that were retrieved through revision surgery were examined in this study. Acetabular cups retrieved due to infection or severely destroyed cups (ed note: severe what?) were excluded. The extent of bone ingrowth into the acetabular cups was grossly measured, and its correlation with the variables including age, gender, weight, height, the duration of fixation, size, number of screws, inclination and anteversion was statistically analyzed. Results: The mean proportion of bone ingrowth was 52.9 21.9%(2~90%) and less than 30% in three cups(8.3%). The pattern and the location of bone ingrowth were not consistent. There was no correlation between the extent of bone ingrowth and age, gender, weight, height, the duration of fixation, cup size, number of screws, size, inclination and anteversion. Conclusion: Harris-Galante porous-coated acetabular cups showed satisfactory bone ingrowth regardless of the variables associated with the demographic or surgical conditions. Surface treatments with a fiber-metal porouscoating appears to be suitable for cementless acetabular cups in terms of the long term results.

Effect of Erythromycin on Pro-inflammatory Signalings by Particles

Purpose: In periprosthetic osteolysis, cytokines, which are secreted from macrophages by the stimulation of particles, up-regulate the signaling for osteoclast activation through RANKL (Receptor activator of Nuclear Factor Kappa-B Ligand). This study compared the reaction to the particles and RANKL in the macrophages by examining the changes in the pro-inflammatory signals. In addition, because erythromycin has an anti-inflammatory effect, the effect of erythromycin on the pro-inflammatory signals by particles and RANKL was also analyzed to clarify the mechanism for the anti-resorptive effect with particles. Materials and Methods: The Raw 264.7 cell line (murine macrophage cell line) was used for these experiments. The particles were made from PMMA (poly-methyl-meth-acrylate) and UHMWPE (ultra high molecular weight polyethylene) to enhance their stimulatory effects. Under the same culture conditions used for macrophages, the cells were treated with either particles or RANKL. The differences in the production of TNF-α, activities of MAP kinase, I-κB and reactive oxygen species (ROS) between the particle and RANKL treated macrophages were examined. The influence of erythromycin on these models was also observed. Results: Erythromycin inhibited ERK and p38 phosphorylation in both models, and suppressed the increase in H2O2 production in the particle-treated macrophages. However, erythromycin inhibited neither the production of TNF- in both models nor the production of H2O2 in the RANKL-treated macrophages. In addition, erythromycin reversed the suppression of I-κB by the particles. Conclusion: For the response of macrophages, erythromycin mainly suppresses the particle induced ROS and NF-κB activation compared with RANKL-induced osteoclastogenesis signaling. Erythromycin might suppress particle-induced osteolysis through these anti-inflammatory effects. Therefore, further studies on the downstream signals of osteoclastogenesis will be needed.

Problems of Anterior External Fixation in Unstable Pelvic Ring Injury

PURPOSE: To determine the problems of anterior external fixators in unstable pelvic ring injuries. MATERIALS AND METHODS: We reviewed 25 patients with an unstable pelvic ring injuries who had been treated with only anterior external fixator over one year follow-up. By Tile's classification, type B 14, type C 11 and the radiological results were evaluated preoperation, postoperation and bone union state. The clinical evaluation was done in termas of the residual pain, discrepency in limb length, rotational deformities, gait disturbance, neurologic deficiency. RESULTS: In 25 patients with an unstable pelvic ring injuries, 18 (72%) patients were reducted and 3 (17%) patients of 25 were reduction failure at last follow up, they were all Tile type C. The residual pain was graded normal 3, mild 11, moderate 10, severe 1 respectively. The cases with discrepency in limb length and gait disturbance were 6 (all type C), 10 (type B 3, type C 7) respectively. The complication were 4 pin site infection, 3 pressure sore and 1 pyogenic hip arthritis. CONCLUSION: Our results indicate that anterior external fixator should be limited to vitally unstable patients in acute resuscitative phase and cases without vertical displacement.

Pyogenic Infection of Deep Joint after Major Burn Injury / 대한정형외과학회잡지

PURPOSE: To report the clinical findings and the results of treatment on hematogenous pyogenic arthritis after major burn injury. MATERIALS AND METHODS: A retrospective analysis was made of 11, 797 major burn injury patients from January 1996 to June 2004. Severity of burn by involved body surface area, time of diagnosis, and laboratory findings were analyzed. Direct spread of infection from injured skin to superficial joint was excluded. RESULTS: Hematogenous infection was complicated in 26 joints of 22 patients (0.19% of overall cases). The mean age was 43.6 years, and mean follow-up was 46 months. The body surface area of burn injury was averaged 34.7%. The common involved area was hip in 10 patients, spine and shoulder in five patients, respectively. From the time of injury, average interval to development of symptom was 4.1 weeks, and to establish the diagnosis was 6.3 weeks. The most common isolated pathogen was Methicillin-resistant Staphylococcus aureus. A total of 22 joints underwent surgical treatment. The clinical results of the patients were poor in 72% due to recurrent infection and persistent pain. CONCLUSION: The results of this study suggest that major burn injury may be an important risk factor of hematogenous pyogenic arthritis. Careful clinical suspicion should be important for early diagnosis and treatment.

Roles of Distal Centralizer in Cemented Total Hip Arthroplasty / 대한정형외과학회잡지

PURPOSE: This study was performed to find out the influencing factors on cement mantle thickness in cemented total hip arthroplasty. MATERIALS AND METHODS: Eighty patients were randomly enrolled who received total hip arthroplasty with the third generation cementing technique. Four types of femoral prosthesis (20 patients in each type) were used: Centralign (Zimmer, Warsaw, IN), Precision (Howmedica, Rutherford, NJ), Omnifit (Osteonics, Allendale, NJ), and Elite Plus (Depuy, Warsaw, IN). Size of femoral prosthesis, diameter of stem tip, shape and size of centralizer, and the condition of cement mantle on the radiograph were analyzed. RESULTS: Between the two groups of same or above C1 (> or =C1; A, B, and C1, n=69) and C2 (n=11) by Barrack classification, there was no difference in age, sex, underlying disease, size of applied stem, Dorr ratio, and the distance between stem tip and plug. The difference of distal diameter between centralizer and stem was less than 2 mm in 18 patients, and same or above 2 mm in 62 patients. C2 was more frequently observed in patients with the diameter difference or =2 mm (22.2% vs. 11.3%). However, C2 developed in all types of femoral stems, irrespective of their shapes, even the diameter difference was > or =2 mm. CONCLUSION: The diameter of distal centralizing device should be at least 2 mm larger than that of stem tip for an optimal cement mantle thickness. In addition, centralizers investigated in this study should be carefully used, and more improved shape of centralizer is required for the successful cement mantle formation.

Value of Preoperative Bone Scan in Evaluation of Femur Shaft Fracture

PURPOSE: To evaluate the availability of bone scan as a preoperative study by analyzing patients who developed ipsilateral femoral neck fractures during intramedullary nailing for femoral shaft fractures. MATERIALS AND METHODS: Among 28 patients who conducted preoperative bone scan before performing intramedullary nailing for femoral shaft fractures, three patients developed femoral neck fractures during the operation. We analyzed retrospectively the result of bone scan including clinical and radiological findings of three patients. RESULTS: Among 28 patients, 7 showed hot uptake in femoral neck area compared to the unaffected side in preoperative bone scan; All 3 patients who developed femoral neck fractures during the operaion showed hot uptakein the area. Among 7 patients who showed hot uptake, there were no abnormalities in plain radiograph and computerized tomography of femoral neck area. CONCLUSION: The risk of femoral neck fracture should be considered during the intramedullary nailing for femoral shaft fracture, if there was hot uptake in femoral neck area in preoperative bone scan.

The Risk Factors Associated with Alcohol-induced Osteonecrosis of the Femoral Head / 대한정형외과학회잡지

PURPOSE: To assess the relationship between the osteonecrosis of the femoral head (ONFH) and the patterns of alcohol intake and evaluate the risk factors associated with alcohol-induced ONFH using an epidemiologic study. MATERIALS AND METHODS: The study examined 250 patients (333 hips) with ONFH, who were diagnosed based on the findings after a total hip arthroplasty. Among them, 169 patients who were not associated with the specific etiologic factors except for a history of alcohol were selected in the case group. These patients were compared with the 338 controls, which were matched for gender, age, occupation and education. The patterns of alcohol intake, cigarette smoking, the level of the liver function test and body mass index were statistically assessed in relation to the development of ONFH. RESULTS: The incidence of alcohol-induced ONFH was 42.8% in all ONFH patients. The average duration of alcohol ingestion was 8.1 years. The average quantity of alcohol per day, per week and drink-years were 84.8 g, 328.6 g and 4, 330 respectively. The elevated relative odds were observed for 1) frequent drinkers (>4/week), 2) the amount of intake per day >90 g, 3) the amount of alcohol intake per week >300 g, 4)drink-year >6, 000, 5) the patients had not consumed food with their drinks. A increased risk was found for smokers (>20 cigarettes/day), patients with an increased serum transaminase level and body mass index < or =25. CONCLUSION: Chronic alcohol intake showed significant dose-response relation in the development of ONFH. The Increased amount of alcohol per day was a more significant risk factor than the total duration of alcohol intake. The pattern of alcohol consumption is one of the risk factors associated with the development of alcohol induced ONFH.