Hip Resurfacing Arthroplasty after Failure of Tantalum Rod Insertion in Patients with Osteonecrosis of the Femoral Head / 대한고관절학회지

Purpose@#The purpose of this study was to examine the clinical outcomes and efficacy of hip resurfacing arthroplasty (HRA) in patients with osteonecrosis of the femoral head after the failure of porous tantalum rod insertion without rod removal. @*Materials and Methods@#Conversion to hip resurfacing arthroplasty was performed in 10 patients (11 hips) with a mean period of 14.9 months after the primary surgery. The mean follow-up period was 73.7 months. Analysis of pre and postoperative range of motion (ROM), University of California at Los Angeles (UCLA) activity score, modified Harris hip score, and visual analog scale (VAS) pain score was performed. Radiographic analysis of component loosening and osteolysis was performed. @*Results@#The postoperative ROM showed significant improvement (P<0.05), excluding flexion contracture. The modified Harris hip score showed improvement from 65.82 to 96.18, the UCLA score showed improvement from 4.18 to 8.00, and the VAS pain score was reduced from 6.09 to 1.80. All scores showed statistically significant improvement (P<0.05). No component loosening or osteolysis was detected by radiographic analysis. @*Conclusion@#Satisfactory results were obtained from conversion hip resurfacing arthroplasty after failure of porous tantalum rod insertion without rod removal. The findings of this study demonstrate the advantages of HRA, including no risk of trochanteric fracture and no bone loss around the tantalum rod. In addition, the remaining porous tantalum rod provided mechanical support, which reduced the potential risk of femoral neck fracture or loosening. This technique can be regarded as a favorable treatment option.

Acetabular Insufficiency Fracture Following Prolonged Alendronate Use and the Failure of Total Hip Arthroplasty in “Frozen” Bone: Two Cases Report / 대한고관절학회지

Atypical insufficiency fracture of the femur following prolonged bisphosphonate use is well described. Regardless of the cause, insufficiency fracture of the acetabulum is extremely rare, and no reports have described insufficiency fractures of the acetabulum that are associated with prolonged bisphosphonate use. This report demonstrates the possibility of insufficiency fracture at the acetabulum following long-term alendronate use and the necessity of particular care in managing insufficiency fractures in “frozen” bone. We describe two cases of insufficiency fracture of the acetabulum following 6 years of alendronate use. Given the patients' medical histories and bone biopsy findings, these insufficiency fractures were thought to be attributable to alendronate use. One case involved the left hip and the presence of pelvic fractures on the opposite side. The patient was treated using cementless total hip arthroplasty (THA), which failed 1 year after surgery. The hip was revised with a massive bone graft and a supportive wire mesh. The other case was managed via THA with a Ganz reinforcement ring due to concerns regarding the use of a cementless implant.

Dissociation of Polyethylene Liner of the Dual Mobility Acetabular Component after Closed Reduction of Dislocation: A Case Report / 대한고관절학회지

A dual mobility acetabular component has a structure that combines a polyethylene liner and a femoral head, unlike the general design of acetabular cups, making the dissociation of a polyethylene liner highly unlikely. In addition, it increases the range of motion and reduces the possibility of dislocations by increasing a jump distance. A fifty-one-year-old male who had received total hip arthroplasty with the dual mobility acetabular component visited a hospital for a posterior hip dislocation 10 weeks after the operation. At the emergency room, closed reduction was performed and the dislocation was reduced. However, plain imaging test revealed polyethylene liner dissociation after the closed reduction. Revision surgery was performed. We will report a rare case of early dislocation of the dual mobility acetabular component and dissociation of polyethylene liner accompanied with a literature review.

Amyloid Arthropathy of the Hip Joint Associated with Multiple Myeloma: A Case Report / 대한고관절학회지

Amyloidosis is a disease characterized by the deposition of non-soluble fibrous protein in multiple tissues with a number of possible causes. This protein deposition can occur in any tissue, yet is most commonly seen in kidneys, heart, and gastrointestinal tracts. However, invasion to bone tissues is not often reported. The deposition of amyloid proteins in bone tissues may result in joint pain and pathological fractures; it is important to elucidate the causes and detect early to determine prognosis and treat optimally. In the present case report, with relevant literature review, the authors report a case of total hip arthroplasty in an amyloidosis patient.

Osteochondroma Arising from Anterior Inferior Iliac Spine as a Cause of Snapping Hip

Snapping hip syndrome is a relatively common problem that can be easily managed with conservative treatment. This syndrome can be divided into external, internal and intra-articular types. Internal snapping hip syndrome is the rarest amongst these and its etiology is not well understood. We report a unique case of osteochondroma arising from the anterior inferior iliac spine (AIIS), which caused the internal snapping hip syndrome with hip pain and restriction of activity. This rare case of snapping hip syndrome from the AIIS was treated surgically and the symptoms completely disappeared after excision of the tumor.

Fracture of Fully-coated Femoral Stem after Primary Total Hip Arthroplasty for Nonunion of Intertrochanteric Fracture: A Case Report / 대한고관절학회지

Femoral stem fracture is an uncommon reason for the failure of total hip arthroplasty, with only 16 cases of fully coated stem fractures reported to date. Here we report a case in which a fully coated primary femoral stem fracture occurred after conversion to total hip arthroplasty for the non-union of an intertrochanteric fracture of the femur. Metallurgic evaluation of the etiology and mechanism revealed that the fracture was initiated by fatigue-related failure and completed by ductile failure on the posterior side of the fracture. Considering the recent trend of treating an intertrochanteric fracture with hip arthroplasty, possible stem failure should be considered, since most patients will have at least one of the known risk factors for stem fracture.

Periprosthetic Insufficiency Fracture around Radiographically Loose Cemented Stem: A Report of Two Cases / 대한고관절학회지

As the osteoporotic patient population grows, various periprosthetic fractures that cannot be classified appropriately can occur around the femur after hip arthroplasty. We experienced two cases of periprosthetic insufficiency fractures at subtrochanteric area of the femurs around radiographically loose cemented femoral stems. The ages of the patients were 75 years and 83 years. Both patients could not recall any history of trauma before the onset of pain. Both were treated non-operatively. Both healed uneventfully and did not recur after two years of follow up. When the osteoporotic patient with cemented stem showed sudden hip or thigh pain without a history of trauma, great attention should be focused to find this lesion.

Aspergillus Septic Arthritis of the Hip in an Immunocompetent Middle-aged Female with Undiagnosed Recurrent Pulmonary Aspergillosis / 대한고관절학회지

We present a case of Aspergillus septic hip arthritis in an immunocompetent patient with undiagnosed recurrent pulmonary aspergillosis who underwent arthroscopic surgery. Biopsy specimens of synovium revealed fungal hyphae, confirming Aspergillus infection. Aspergillus septic hip arthritis can occur in immunocompetent patients, and arthroscopy can be a noninvasive surgical option in these cases.

Does the Time of Postoperative Bisphosphonate Administration Affect the Bone Union in Osteoporotic Intertrochanteric Fracture of Femur? / 대한고관절학회지

PURPOSE: This study was designed to investigate the effect of bisphosphonate administration starting time on bone healing and to identify the best administration time following surgical treatment of osteoporotic intertrochanteric fractures. MATERIALS AND METHODS: Two hundreds and eighty four patients (284 hips; 52 males, 232 females) who underwent surgery following osteoporotic intertrochanteric fracture from December 2002 to December 2012 were retrospectively analyzed. The average follow-up period was 68.4 months. The patients were divided into three groups according to the time of bisphosphonate administration after operation: 1 week (group A; n=102), 1 month (group B; n=89), and 3 months (group C; n=93). Koval scores and change of Koval scores 1 year after operation were used for clinical evaluation. For radiologic evaluation, the time of callus appearance across the fracture line on sagittal and coronal radiographs and the time to absence of pain during hip motion was judged as the time of bone union. RESULTS: Koval scores one year after surgery for groups A, B, and C were 2.44, 2.36, and 2.43 (P=0.895), respectively. The mean time of union was 12.4, 11.9, and 12.3 weeks after operation in the three groups (P=0.883), respectively. There were zero cases of nonunion. There were 3, 5, and 7 cases of fixative displacement in the three groups, respectively, but the distribution showed no significant difference (P>0.472). CONCLUSION: The initiating time of bisphosphonate administration following surgery does not affect the clinical outcomes in patients with osteoporotic intertrochanteric fracture.

Clinical Implication of Diabetes Mellitus in Primary Total Hip Arthroplasty / 대한고관절학회지

PURPOSE: The purpose of this study was to investigate the effect of diabetes mellitus on primary total hip arthroplasty by comparing the clinical outcomes of patients diagnosed to have diabetes mellitus before the operation with those without diabetes. MATERIALS AND METHODS: A total 413 patients who underwent unilateral cementless total hip arthroplasty from June 2006 to May 2009 were recruited and divided into diabetic and non-diabetic groups. The comparative analysis between the two groups was made. We evaluated Harris hip score, postoperative complications such as wound problem, surgical site infection, other medical complication and length of stay in hospital as clinical parameters. Radiographic evaluations were also included to determine loosening, dislocation and osteolysis. RESULTS: Patients with diabetes had an increased incidence of orthopaedic complications including surgical site infection and mortality, but other medical complications were not increased in diabetic patients. All complications after primary total hip arthroplasty were associated with diabetes mellitus, but the degree of diabetes was not associated with complications. CONCLUSION: Diabetes mellitus increases incidence of orthopaedic complications, particularly deep infection, after cementless primary total hip arthroplasty.

Trigger Wrist

Triggering at the wrist during active flexion and extension of the fingers or wrists is very rare. It is caused by tumors, inflammation, and anomalous muscle belly. We report two cases of trigger wrist caused by synovial hypertrophy and fibroma of flexor tendon.

Acute Phase of Sero-negative Rheumatoid Arthritis Misdiagnosed as Pyogenic Arthritis: A Case Report / 대한고관절학회지

In cases of sero-negative rheumatoid arthritis (RA), no abnormal findings are observed on blood tests and its clinical course is favorable, compared to sero-positive RA. In the acute phase of sero-negative RA, infiltration of neutrophils may be the only pathologic finding on frozen section biopsy. Thus, it might be misdiagnosed as pyogenic arthritis. We report on a case of acute sero-negative RA misdiagnosed as pyogenic arthritis during hip surgery with review of the literature.

Hip Resurfacing Arthroplasty in Patients with Rheumatoid Arthritis

OBJECTIVE: This study analyzed the midterm results of hip resurfacing arthroplasty in patients with rheumatoid arthritis. METHODS: Between October of 2003 and September of 2008, 13 consecutive hips that were treated with hip resurfacing arthroplasty due to rheumatoid arthritis were analyzed. The average follow up period was 48.6 months and the mean age at the time of operation was 35.9 years old. The mean BMI at the operation was 23.2 kg/m2. The implanted prostheses were the Conserve Plus system in five hips, the Birmingham hip resurfacing system in four hips and the Durom system in four hips. The results were clinically evaluated with the Harris hip score, the UCLA activity score, hip or thigh pain, the limb length discrepancy and the range of motion. As radiological evaluation, we observed the patterns of bone remodeling and complications such as femoral neck fracture, loosening and osteolysis. RESULTS: The average Harris hip score improved from 62.2 to 98.9 at the final visit. The range of motion improved to 0degrees in flexion contracture, 118.1degrees in further flexion, 22.7degrees in internal rotation, 40.4degrees in external rotation, 28.8degrees in adduction and 38.1degrees in abduction, respectively. No patient complained of a limb length discrepancy and hip or thigh pain. Radiographically, impingement between the acetabular component and the femoral neck was observed in one case. However, radiographic findings such as osteolysis, radiolucency, wear and loosening were not observed. CONCLUSION: The midterm results of hip resurfacing arthroplasty in patients with rheumatoid arthritis were excellent. But long-term studies are needed to determine the survivorship and to evaluate the osteoporotic change, the metal ion level and their influence after hip resurfacing arthroplasty.

Technique and Early Results of Percutaneous Reduction of Sagittally Unstable Intertrochateric Fractures

BACKGROUND: This paper introduces a percutaneous reduction technique using one or two Steinman pin(s) to reduce sagittally unstable intertrochanteric fractures. METHODS: A fracture was defined as a sagittally unstable intertrochanteric fracture when posterior sagging of a distal fragment and flexion of the proximal fragment worsens after usual maneuvers for a closed reduction. Of 119 intertrochanteric fractures treated from June 2007 to December 2008, twenty-one hips showed sagittal instability. The sagittal displacement was reduced using a Steinmann pin as a joystick, and stabilized with a nail device. Nineteen hips were followed up for more than one year. The clinical and radiological results were reviewed in 19 hips and compared with those of the remaining cases. RESULTS: The demographics were similar in both groups. The mean anesthetic time did not differ. Although the pre-injury and final activity levels were significantly lower in the study group, the degree of recovery was the same. No clinical complications related to this technique were encountered. Radiologically, the reduction was good in all hips in both groups. Union was obtained in all cases without any time differences. CONCLUSIONS: This less invasive reduction technique is simple and safe to use for this type of difficult fracture.

Revision Total Hip Arthroplasty Using Acetabular Reinforcement Ring: Midterm Follow-up Result

PURPOSE: To evaluate the clinical and radiographic outcomes of the revision total hip arthroplasty using the acetabular reinforcement ring. MATERIALS AND METHODS: Thirty-six acetabular revisions were performed in 36 patients with use of the reinforcement ring and structural or morselized allograft, between 1997 and 2005, in thirty-six patients. According to the AAOS classification, thirty-four cases of acetabular defects were Ttype III, and two were Ttype IV. Mean follow-up period after surgery was 7.2 years. RESULTS: The mean Harris hip score was 92.3, which was significantly increased compared with the preoperative score. (p<0.001). There were five failures: a case of aseptic loosening of Muller ring, two cases of infection (5.4%) and two cases of hip dislocation (5.4%). Graft incorporation and bone remodeling occurred successfully in all hips, but in the case of aseptic loosening in which the ring fixation had been inadequate at the time of surgery. The success rate was 91.7% with a mean follow-up of 7.2 years, if the cases of revision or loosening of the component were classified into failure cases. CONCLUSION: Patients treated with acetabular revision with three kinds of reinforcement ring had reconstitution of periacetabular bone stock as well as good clinical and radiographic results. For the good results, the secure implant fixation during the surgery should be confirmed and we should completely understand the characters of the each kinds of reinforcement rings.

Computer-Assisted Total Hip Arthroplasty

Despite the overall satisfactory results of total hip arthroplasty, post-operative complications continue to occur. To minimize these problems, computer-assisted total hip arthroplasty using navigation or robot-assisted systems is being developed. A navigation system is defined as a system that locates a position in three-dimensional space and traces the target spot, and a robot-assisted system is defined as a system that performs operations automatically with mechanical robot arms based on prior preoperative planning. Computer-assisted surgeries have shown superior results to conventional methods in implant positioning, fixation, and accurate lower extremity alignment in the limited reports available. However, computer-assisted surgeries take longer compared to conventional methods. Due to the extra time needed, the risk of postoperative infection and blood loss is considered to be higher. Nevertheless, robot-assisted system is being developed for the field of hip arthroplasty, and thus its efficacy and accuracy needs to be further investigated. Since these methods have other advantages compared to conventional methods, they are the focus of much interest.

Isolated Polyethylene Liner Exchange in a Revision Total Hip Arthroplasty

PURPOSE: To analyze the results of isolated exchange of polyethylene (PE) liners for treatment of wear and osteolysis around a well-fixed Harris-Galante (HG) cementless acetabular cup. MATERIALS AND METHODS: Thirty-three PE liner changes were performed without the removal of stably ingrown implants (33 hips of 32 patients). They were able to be followed for a mean period of 92 months. Clinically, the Harris hip score (HHS), pain evaluation, and complications were evaluated. Radiologically, the annual wear rate and the size of the osteolytic lesions were measured before the operation and the latest follow-up. The bone graft incorporation scale and the development of new osleolytic lesions were checked during the final follow-up. RESULTS: HHS improved to 89.3 at last follow-up. The size of the osteolysis was significantly reduced postoperatively. Bone graft incorporation scales were Grade I in 9 and Grade II in 14 cases. New osteolytic lesions have not developed at latest follow-up. As a complication, one case of dissociation of a liner and a periprosthetic fracture were noted. Annual wear rates during the same period were significantly reduced. There was no sign of alteration in stability of the PE liner. CONCLUSION: Exchange of a PE liner without removal of stable implants can be a good option for the treatment of wear and osteolysis around a stable cementless THA implant, even if the system has a weak locking mechanism, such as the HG cup. In these cases, under certain states with a higher risk of early failure in the locking mechanism, it would be better to select other revision procedures such as cup revision or cemented polyethylene liner fixation.

Revision Total Hip Arthroplasty Using a Fully Porous-Coated Long Stem: a Minimum 5 Years Follow up

PURPOSE: We wanted to evaluate the mid-term results of revision total hip arthroplasty using a fully porous-coated long stem. MATERIALS AND METHODS: A retrospective series of 20 hips in 19 patients who underwent stem revision with a fully porous-coated long stem were evaluated at a mean follow-up of 64.6 months. The causes of revision were aseptic loosening, periprosthetic fracture and infected arthroplasty. Four kinds of implants had previously been used and an additional bone graft procedure had been done in 17 cases. The Harris hip scores, thigh pain, limping and ROM were reported. Radiological changes of the radiolucent signs, subsidence, loosening and the stress shielding signs were evaluated. RESULTS: The Harris hip score improved from an average of 56.5 to 91.9 and the ROMs were satisfactory. The only case with persistent thigh pain showed stable bony ingrowth. No signs of subsidence or loosening of the stem was found in all the cases. There were 2 cases of periprosthetic fracture. None of the patients experienced re-revision surgery. CONCLUSION: The mid-term results of revision hip arthroplasty using a fully porous coated long stem have demonstrated that it provides a reliable initial fixation with a propensity for stable longevity. It is relatively easy for the techniques, and there is the opportunity to restore the bone stock by bone-grafting procedures with diaphyseal fixation and bypassing a bone defect. Yet alternative techniques may be required for the femur with extensive diaphyseal bone loss. There are some concerns about the technique and the possibility of making a crack in the femur during the operation, which will cause thigh pain at the follow-up. So, only by employing great caution when performing this technique can successful results be guaranteed.

Cementless Total Hip Arthroplasty with Medial Wall Osteotomy for the Sequelae of Septic Arthritis of the Hip

BACKGROUND: We performed a retrospective study to evaluate the results of acetabular circumferential medial wall osteotomy, a procedure designed to provide secure fixation of a cementless hemispherical acetabular cup for the sequelae of septic arthritis of the hip. METHODS: We assessed 38 total hip arthroplasties (THAs) with circumferential acetabular medial wall osteotomies performed on patients with sequelae of septic arthritis of the hip between 1993 and 2000, who were followed up for > or = 3 years. The average follow-up period was 8.3 years (range, 3 to 12 years). The indication for this technique was poor acetabular cup coverage of < or = 70% on preoperative templating. In all cases, cementless hemispherical acetabular cups were fixed to the true acetabulum. Additional procedures included soft tissue release in 16 hips and femoral derotational and shortening osteotomies in 12 hips. We evaluated both clinical and radiological results. RESULTS: The Harris hip scores improved from 57 points preoperatively to 91 points postoperatively. Radiological analysis revealed no aseptic loosening or radiolucent lines around the acetabular cup. Stable bony fixation of the acetabular cup in the true acetabulum was seen in all cases. Acetabular osteolysis was demonstrated in 12 hips. Revision surgery was performed in 6 hips, but there were no complications related to acetabular circumferential medial wall osteotomy. CONCLUSIONS: Circumferential acetabular medial wall osteotomy can provide appropriate positioning and sufficient coverage of the acetabular cup and thus preserve the medial wall thickness in cementless THA without the need for additional bone grafting for the sequelae of septic arthritis of the hip.

Treatment of Infected Hip Arthroplasty with Antibiotic-Loaded Cement Spacers

PURPOSE: This study evaluated the effect of antibiotic-loaded cement spacers on the treatment of infected hip arthroplasty. MATERIALS AND METHODS: Twenty-one patients, twenty-one cases that experienced infection after total hip arthroplasty, were treated with two-stage arthroplasty using antibiotic-loaded cement spacers between July 1995 and March 2005. The average age was 56.3 years (range, 36~84 years). The follow-up period was 7.2 years (range, 3~11.4 years). The period from the first operation to diagnosis of infection was 28 months (range, 1~49 months). Preoperative culture, Tc 99m scan or Gallium scan, intraoperative culture and biopsy were performed for the evaluation of infection. We postoperatively evaluated clinical and radiological outcomes, blood analysis including serologic study, complete blood cell count, differential count, erythrocyte sedimentation rate and C-reactive protein. RESULTS: Of a total of 21cases, acetabular cup, femoral head and femoral stem were substituted in 10 cases (48%). Acetabular cup and femoral head were substituted in 11 cases (52%). Revision arthroplasty was performed in 19 cases, on average 11.9 months (range 2~31 months) after insertion of antibiotic-loaded cement spacers. Infection recurred in 1 case. In 18 cases, excluding the reinfected one, the average Harris hip score, 46.8 points (range, 35~72 points) preoperatively, improved to 89.5 points (range, 78~100 points) at last follow-up in the revision group. In 2 cases in which revision total hip arthroplasty was not performed, the Harris hip score was 53 points (range, 36~70 points) preoperatively, and 86 points (range,72~100 points) at last follow-up. CONCLUSION: The use of antibiotic-loaded cement spacers in two-stage arthroplasty is an effective method for management of infection, preserving joint function until performing revision arthroplasty. Preservation of the femoral stem should be considered in cases in which were fixed firmly and in cases which show no evidence of the spreading of infection to the distal part of the stem on Tc 99m scan or Gallium scan performed preoperatively.