Total Hip Arthroplasty for Secondary Coxarthrosis in Patients with Hereditary Multiple Exostoses: Minimum 5-Year Follow-up Results and Surgical Considerations

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.

Principles for Management of Periprosthetic Acetabular Fractures after Hip Arthroplasty

Periprosthetic acetabular fracture (PAF) is an uncommon complication following hip arthroplasty. However, as the number of people needing hip prostheses continues to rise, the absolute number of PAF is expected to increase as well. These fractures may occur either intraoperatively or postoperatively. Postoperative fractures can be caused by traumatic events or by pathologic conditions related to periacetabular osteolysis. The management of PAF usually depends on the degree of displacement and the stability of the acetabular component. While most of non-displaced fractures can be managed nonoperatively by protected weight bearing, displaced fractures with unstable implants require surgical intervention, which is often technically challenging. This review summarized the latest findings on the epidemiology, the diagnosis, the classification, and the treatment of PAF.

Modular Stems: Advantages and Current Role in Primary Total Hip Arthroplasty / 대한고관절학회지

Using modular femoral stems in total hip arthroplasty enables surgeons to make fine adjustments to individual joints and offers intraoperative flexibility. The concept of modularity has been developed in numerous shapes, resulting in a vast range of options. Among them, the greatest achievement has been made for prostheses with modular proximal sleeves. The use of these implants has resulted in excellent mid- to long-term results in a number of cases. Although the use of tapered stems with a broaching technique is gaining popularity in straightforward primary surgeries, modular femoral implants are still associated with a number of potential challenges (e.g., developmental dysplasia of the hip, infection sequelae, and skeletal dysplasia). Based on published results, it is advisable to consider it as an option for complicated cases where the proximal femur is severely deformed.

A FRAX Experience in Korea: Fracture Risk Probabilities with a Country-specific Versus a Surrogate Model

BACKGROUND: Recently, a Korean fracture-risk assessment tool (FRAX) model has become available, but large prospective cohort studies, which are needed to validate the model, are still lacking, and there has been little effort to evaluate its usefulness. This study evaluated the clinical usefulness of the FRAX model, a FRAX developed by the World Health Organization, in Korea. METHODS: In 405 postmenopausal women and 139 men with a proximal femoral fracture, 10-year predicted fracture probabilities calculated by the Korean FRAX model (a country-specific model) were compared with the probabilities calculated with a FRAX model for Japan, which has a similar ethnic background (surrogate model). RESULTS: The 10-year probabilities of major osteoporotic and hip fractures calculated by the Korean model were significantly lower than those calculated by the Japanese model in women and men. The fracture probabilities calculated by each model increased significantly with age in both sexes. In patients aged 70 or older, however, there was a significant difference between the two models. In addition, the Korean model led to lower probabilities for major osteoporotic fracture and hip fracture in women when BMD was excluded from the model than when it was included. CONCLUSIONS: The 10-year fracture probabilities calculated with FRAX models might differ between country-specific and surrogate models, and caution is needed when applying a surrogate model to a new population. A large prospective study is warranted to validate the country-specific Korean model in the general population.

Sinonasal Glomangiopericytoma Causing Oncogenic Osteomalacia

A 60-year-old woman suffered from recurrent femur neck fracture. Laboratory data showed serum hypophosphatemia, elevated alkaline phosphatase, normal serum calcium levels, and normal parathyroid hormone levels. Radiological examinations revealed a tumor in the right maxillary alveolar bone. The nasal cavity mass was removed, and the histological features were those of glomangiopericytoma. After removal of the tumor, some of the laboratory data normalized. Based on the clinical features, histopathological diagnosis and postoperative course of events, a diagnosis of glomangiopericytoma causing oncogenic osteomalacia was confirmed. We report a case of oncogenic osteomalacia caused by sinonasal glomangiopericytoma.

Prevention of Venous Thromboembolism in Hip Surgery Patients / 대한고관절학회지

The risk for venous thromboembolism (VTE) in total hip arthroplasty and hip fracture surgery is much higher than that of any other surgery. There is a general agreement that prevention of VTE in hip surgery patients is necessary due to concerns regarding symptomatic deep vein thrombosis or fatal pulmonary embolism. Optimal strategies for prevention of VTE include pharmacologic and mechanical approaches; however, the ideal prophylactic regimen has not been identified. Selection of a prophylactic regimen should be balanced between efficacy and safety. This article discusses the different prophylactic options available today for prevention of VTE in hip surgery patients.

On the Occasion of the Publication of the English Version of "Hip & Pelvis" / 대한고관절학회지

No abstract available.

Meta-analysis of the Incidence and Risk Factors for Squeaking after Primary Ceramic-on-ceramic Total Hip Arthroplasty in Asian Patients / 대한고관절학회지

PURPOSE: The purpose of this study was to assess the squeaking incidence and risk factors after primary ceramic-on-ceramic total hip arthroplasty (THA) in Asian patients using meta-analysis. MATERIALS AND METHODS: We performed a meta-analysis of published data on the squeaking incidence and risk factors from 2000 to 2013. Eight studies in Asians were analyzed for both squeaking incidence and risk factors and 25 studies in Western patients were analyzed for squeaking incidence. The data collected were: patient factors, surgical factors and implantation factors. RESULTS: The overall incidence of hip squeaking was 2.7% in Asians and 3.1% in Westerners. This difference was not statistically significant. The only significant risk factor was an increase in the acetabular cup abduction angle. Of the factors, the cup abduction angle was the only significant risk factor for the occurrence rate of squeaking, and the occurrence rate tended to increase with increasing angle. CONCLUSION: The incidence of squeaking in Asians after primary ceramic-on-ceramic THA is 2.7% and is similar to that in Westerners. The increased cup abduction angle is associated with squeaking; therefore, surgeons should be careful not to implant the cup at a too steep abduction angle.

Minimum Seven-year Follow-up of Cementless Total Hip Arthroplasty with the COREN Hip System / 대한고관절학회지

PURPOSE: We previously reported results of a mean 3.2-year follow-up of the COREN hip system, which is the first total hip prosthesis developed in Korea. The aim of this prospective study was to update the previous report with regard to the hip function and radiographic implant performance. MATERIALS AND METHODS: Between 2003 and 2004, a consecutive series of 68 primary, cementless, total hip prostheses (COREN) were implanted in 57 patients(68 hips) and followed up for a minimum of 7 years. Sixty-three of the 68 hips were available for clinical scoring and radiographic analysis. RESULTS: The mean Harris hip and WOMAC scores were improved from 48.1 and 54.7, preoperatively, to 96.4 and 22.1 at the final follow-up. The mean patient activity increased from 3.1, preoperatively, to 8.2 at the final follow-up. All hips showed stable bony ingrowth on the radiographs. No hips showed evidence of osteolysis or prosthesis loosening, and no revision was required during the follow-up. A Periprosthetic fracture (Vancouver type B1) was encountered in one hip 4.7 years after surgery, which was treated by reoperation. CONCLUSION: This study shows that the COREN hip system produces excellent mid-term results in cementless hip arthroplasty.

Treatment of Subtrochanteric Nonunion with a Blade Plate / 대한정형외과학회잡지

PURPOSE: Although nonunion is a relatively common complication in the management of subtrochanteric fractures, there are few studies regarding the treatment of nonunion. The purpose of this study was to evaluate clinical and radiological results for the treatment of subtrochanteric nonunions with a blade plate. MATERIALS AND METHODS: We retrospectively analyzed 16 cases of subtrochanteric nonunions that were treated with a blade plate between April 1997 and June 2008 and were followed for at least one year after the index operation. There were 8 males and 8 females with an average age of 58 years (range, 42-77 years). Outcome variables included the time to union, postoperative complications, Harris hip score, and the functional rating scale of Sanders. The average follow-up period was 26 months (range, 12-63 months). RESULTS: Union was achieved in 15 (94%) of 16 subtrochanteric nonunions after an average of 7 months (range, 4-11 months). One patient who did not reach union after the index operation underwent repeated surgery with a longer blade plate and bone graft, but this patient was eventually treated with total hip arthroplasty because of persistent nonunion and breakage of the blade plate. Two patients developed complications. One patient had bursitis around the greater trochanter and the other developed avascular necrosis of the femoral head. Of these, the patient with avascular necrosis of the femoral head was treated with total hip arthroplasty because of persistent hip pain 2 years after the index operation. At latest follow-up, the mean Harris hip score was 88 points (range, 36-100 points) and the functional rating scale of Sanders was good or excellent in 14 (88%) of 16 patients. CONCLUSION: The treatment of subtrochanteric nonunions with a blade plate is associated with a very high union rate and good clinical results.

Guideline for the Prophylaxis of Venous Thromboembolism in Hip Surgery Patients / 대한정형외과학회잡지

No abstract available.

Metal-on-Metal Bearing in Total Hip Arthroplasty

Metal-on-metal bearings have been reintroduced with the improved materials, design and manufacturing quality control as an alternative to the conventional metal-on-polyethylene articulation. The advantages of total hip arthroplasty using a metal-on-metal bearing include an extremely low wear rate, a very small risk of in vivo fracture and the use of a larger femoral head. These advantages have led to an increased use of metal-on-metal bearings for younger and more active patients with advanced hip disease. Concerns remain regarding the elevated levels of metal ions and their potential consequences such as metal hypersensitivity or potential carcinogenesis.

Modular Cementless Total Hip Arthroplasty with Subtrochanteric Shortening Osteotomy in Patients with High Hip Dislocation

PURPOSE: The purpose of this study was to report on the results of performing modular cementless total hip arthroplasty with a simultaneous subtrochanteric shortening osteotomy in patients with high hip dislocation. MATERIALS AND METHODS: We evaluated 23 patients (24 hips) with high hip dislocation and who had undergone total hip arthroplasty using a proximally modular cementless stem in combination with a subtrochanteric shortening osteotomy in order to place the acetabular cup at the level of the anatomic hip center between May 1996 and June 2008. There were 6 males and 17 females with a mean age of 44 years. The mean duration of follow-up was 5.6 years. RESULTS: The mean Harris hip score improved from 53 points preoperatively to 88 points at the time of final follow-up (P<0.001), and there were good or excellent results in 21 hips (87.5%). There was one instance of isolated loosening of the acetabular component. With the exception of one hip requiring revision surgery at 12 years postoperatively because of polyethylene wear and cup loosening, all the remaining components were well-fixed at the time of the last follow-up. A total of 4 hips (17%) had complications during follow-up; one dislocation, two transient femoral nerve palsies and one nonunion of the subtrochanteric osteotomy site. CONCLUSION: Modular cementless total hip arthroplasty with a subtrochanteric shortening osteotomy in patients with high hip dislocation was associated with excellent clinical outcomes while it minimized additional fixation of the osteotomy site.

Determination of an Applicable FRAX Model in Korean Women

We investigated which of the three FRAX fracture risk assessment tool models is most applicable to Korean women. For 306 postmenopausal women (mean age, 77 yr) with a hip fracture, fracture probabilities were calculated using FRAX models from Japan, Turkey and China. Data on bone mineral density (BMD) at the femoral neck were available for 103 patients. Significant differences existed among the models, independent of the inclusion of BMD in the calculation of fracture probabilities. The probabilities of both major osteoporotic fractures and hip fractures were significantly higher in the Japanese model than in the Turkish or Chinese models. In all of the models, the probabilities of a major osteoporotic fracture, but not of a hip fracture, decreased significantly if calculated without BMD values. By applying the Japanese model, the ten-year probabilities for major osteoporotic and hip fractures increased significantly with age. Our results suggest that the Japanese FRAX model might be the most appropriate for Korean women.

Short-Term Follow-up Results of Periacetabular Osteotomy for Hip Dysplasia

PURPOSE: To evaluate the clinical and radiologic results of periacetabular osteotomy for the treatment of hip dysplasia. MATERIALS AND METHODS: We performed a clinical and radiological assessment of 20 periacetabular osteotomies (19 patients), which had been followed up for > 1 year. The mean age of the patients at the time of surgery was 34.2 years (range, 18~50 years). The average follow-up period was 26.7 months (range, 12~85 months). The Harris hip score and range of motion were used for clinical evaluation. The radiologic measurements were evaluated using the acetabular angle, center-edge angle, acetabular depth, femoral head coverage, and medialization. RESULTS: The mean Harris hip score improved from 59.6 points to 96.4 points. The mean acetabular angle improved from 47.9 degrees to 26.4degrees. The mean center-edge angle increased from 14.2degreesto 41degrees. The acetabular depth increased from 176 to 242.7 The mean femoral head coverage increased from 63.3% to 95.4%. The following complications were noted: hematoma in 2 cases, temporary lateral femoral cutaneous nerve palsy in 3 cases, and superficial wound infection in 1 case. CONCLUSION: Periacetabular osteotomy is an effective surgical treatment for hip dysplasia.

Hip Arthroplasty Using Cementless Modular Femoral Stem for Displaced Femoral Neck Fracture in Patients More than 70 Years Old

Purpose: To evaluate the clinical and radiological results of hip arthroplasty using a cementless modular femoral stem in patients older than 70 years with a femoral neck fracture. Materials and Methods: From January 2002 to May 2005, 67 hip arthroplasty procedures (66 patients) using a cementless modular femoral stem for displaced femoral neck fractures in patients older than 70 years of age were evaluated. All the patients were followed up for more than 2 years. The mean age at surgery was 77 (70~92) years. There were 22 men and 44 women. The mean follow up period was 31 months (24~41). The clinical evaluation was performed by examining the perioperative Activities of Daily Living (ADL) and postoperative complications. The radiological evaluation for femoral stem loosening and osteolysis was performed using the serial postoperative radiographs. The radiological evaluation for leg length discrepancies was performed using the immediate postoperative radiograph. Results: In preoperative ADL, 31 cases (46%) were in grade 1, 21 (31.5%) in grade 2, 14 (21%) in grade 3, 1 (1.5%) in grade 4 and none in grade 5. A review of the postoperative ADL revealed 25 cases (37.5%) in grade 1, 18 (27%) in grade 2, 21 (31%) in grade 3, 3(4.5%) in grade 4 and none in grade 5. Postoperative restoration of the ADL was observed in 48 cases (71.5%). There were no significant complications. Radiographically, all cases showed stable bony fixation of the femoral stem with the exception of 1 case, who showed subsidence and a pedestal reaction. Postoperative leg length discrepancy was observed in 5 cases (7.5%) but was <1 cm in all cases. Conclusion: In elderly patients older than 70 years of age with a displaced femoral neck fracture, cementless hip arthroplasty using a modular femoral stem provides good initial stability and subsequent secure bony fixation with minimal complications.

Perioperative Risk of Hip Arthroplasty in Patients with Cirrhotic Liver Disease

We retrospectively reviewed the complete medical records of 30 patients with a diagnosis of liver cirrhosis who had undergone hip arthroplasty at three academic institutions between October 1994 and May 2001. There were 26 males and 4 females with a mean age of 60 yr at index operation. Surgical procedures included 17 primary total hip arthroplasties (THA), 8 bipolar hemiarthroplasties, and 5 revision THAs. According to the Child-Pugh scoring system, 19 cirrhotic patients were categorized as class A, 9 as class B, and 2 as class C. Eight (26.7%) of the 30 patients had one or more perioperative complications. Of these, wound infection was the most common, with a rate of 10% (3 of 30 hips). Other perioperative complications included surgical site bleeding, coagulopathy, encephalopathy, gastrointestinal bleeding, pneumonia, and arrhythmia. Death occurred in 2 (6.7%) of the 30 patients; both were Child-Pugh's C cirrhotics. A higher Child-Pugh score (p=0.0001) and a high level of creatinine (p=0.0499) were associated with significantly increased perioperative complications or death. Our findings suggest that surgeons should be vigilant about perioperative complications in patients with advanced cirrhotic liver disease who undergo hip arthroplasty, albeit the mortality rates are relatively low in less severe cirrhotics.

Comparison of the Gamma Nail and the Proximal Femoral Nail in the Treatment of Intertrochanteric Fracture

PURPOSE: We wanted to evaluate the results of fracture fixation with using Gamma nails and Proximal Femoral Nails (PFN) for treating intertrochanteric fractures. MATERIALS AND METHODS: From January 2003 to December 2005, we reviewed 77 patients who suffered with intertrochanteric fractures (35 cases of Gamma nails and 42 cases of PFNs). We evaluated the intraoperative blood loss, the operation time, the presence of stable reduction and the varus reduction rate, the union time, cutting-out, the screw head position, the status of the fracture reduction and the complications. The pre- and post-operative difference in the patients' ambulatory ability was also investigated. RESULTS: The mean operation time with using Gamma nails was shorter and the screw with using Gamma nails was located more centrally than that with using PFNs. The other factors were not statistically different. Cutting-out was not noted with Gamma nails, but 2 cases of cutting out were noted with using PFNs. 8 cases of proximal migration were noted with Gamma nails and 6 cases of lateral protrusion of the proximal pin were noted with using PFNs. CONCLUSION: The Gamma nail for which a single lag screw was inserted centrally had no case of cutting-out, which was in contrast to using PFNs for which two lag screws were used, although there was no statistically significant difference. In addition to this, the shorter operative time makes Gamma nails more appropriate for the operative treatment of femoral intertrochanteric fracture.

Cementless Total Hip Arthroplasty with Use of the COREN Hip System

PURPOSE: To report the results of a minimum three-year follow-up of cementless total hip arthroplasty using the COREN Hip System(R) (Corentec, Seoul, Korea), which is the first total hip prosthesis developed in Korea. MATERIALS & METHODS: A total of 57 patients (68 hips) who had undergone cementless total hip arthroplasty using the COREN Hip System(R) between July 2003 and March 2004 were analyzed clinically and radiographically after a minimum follow-up of three years after the index arthroplasty. RESULTS: The mean Harris hip score improved from 46 points preoperatively to 95 points at the one-year follow-up and to 99 points at the three-year follow-up. All the patients reported a good or excellent satisfaction with the results of surgery. All prostheses showed radiographic evidence of stable bony fixation, and no hips showed evidence of osteolysis or prosthesis loosening. During the follow-up period, there were no complications such as a deep infection, dislocation or ceramic fracture in any hip, and no revision surgery was required. CONCLUSION: The clinical and radiographic evaluations of Cementless total hip arthroplasty using the COREN Hip System(R) showed excellent outcomes after a minimum follow-up duration of three years.

The Usefulness of 3D Quantitative Analysis with Using MRI for Measuring Osteonecrosis of the Femoral Head

PURPOSE: We wanted to evaluate the usefulness of MRI 3D quantitative analysis for measuring osteonecrosis of the femoral head in comparison with MRI 2D quantitative analysis and quantitative analysis of the specimen. MATERIALS AND METHODS: For 3 months at our hospital, 14 femoral head specimens with osteonecrosis were obtained after total hip arthroplasty. The patients preoperative MRIs were retrospectively reviewed for quantitative analysis of the size of the necrosis. Each necrotic fraction of the femoral head was measured by 2D quantitative analysis with using mid-coronal and mid-sagittal MRIs, and by 3D quantitative analysis with using serial continuous coronal MRIs and 3D reconstruction software. The necrotic fraction of the specimen was physically measured by the fluid displacement method. The necrotic fraction according to MRI 2D or 3D quantitative analysis was compared with that of the specimen by using Spearman's correlation test. RESULTS: On the correlative analysis, the necrotic fraction by MRI 2D quantitative analysis and quantitative analysis of the specimen showed moderate correlation (r = 0.657); on the other hand, the necrotic fraction by MRI 3D quantitative analysis and quantitative analysis of the specimen demonstrated a strong correlation (r = 0.952) (p < 0.05). CONCLUSION: MRI 3D quantitative analysis was more accurate than 2D quantitative analysis using MRI for measuring osteonecrosis of the femoral head. Therefore, it may be useful for predicting the clinical outcome and deciding the proper treatment option.