Non-neoplastic indications and outcomes of the proximal and distal femur megaprosthesis: a critical review

Purpose@#Megaprosthesis or endoprosthetic replacement of the proximal and distal femur is a well-established modality for treatment of tumors. The indications for megaprosthesis have been expanded to the treatment of some non-neoplastic conditions of the knee and hip, with the severe bone loss associated with failed arthroplasty, communited fractures in the elderly with poor bone quality, and resistant non-union. Th aim of this study is to find out whether megaprosthesis of the knee and hip is successful in the treatment of non-neoplastic condtions. The study comprises a review of the indications, complications, and outcomes of megaprosthesis of the proximal and distal femur in non-neoplastic conditions of the knee and hip joints. @*Methods@#We extensively reviewed the literature on non-neoplastic indications for megaprosthesis of the proximal and distal femur after performing a detailed search of the Pubmed database using the medical subject heading (MeSH) terms ‘proximal femur replacement’ or ‘distal femur replacement’ and ‘hip or knee megaprosthesis.’ The data obtained after the structured search were entered into a Microsoft Excel spreadsheet. The frequency distribution of the demographic data, indications, complications, and outcome was calculated.Result: We included ten studies (seven proximal femur replacement and three distal femur replacement) of 245 proximal femur and 54 distal femur mega prostheses for treatment of non-neoplastic conditions. Bone loss in failed arthroplasty, either due to periprosthetic fracture or deep infection, was the most common indication for megaprosthesis. Dislocation was the most common complication after proximal femur megaprosthesis, and infection was the leading cause of complications after distal femur megaprosthesis. @*Conclusion@#Megaprosthesis for treatment of non-neoplastic conditions around the distal and proximal femur is a viable option for limb salvage, with an acceptable long-term outcome. Although the complications and survival rates of megaprosthesis in non-neoplastic conditions are inferior to a primary arthroplasty of the hip and knee but are comparable or better than the mega prosthetic replacement in the neoplastic conditions. Proximal femoral megaprosthesis has higher dislocation rates and requirement for revision compared to distal femoral megaprosthesis. However, the proximal femoral megaprosthesis has lower rates of infection, periprosthetic fractures, and soft tissue complications, as compared to distal femoral megaprosthetic replacement. Both associated with aseptic loosening but not statistically significant.

Windswept deformities of the knee are challenging to manage

Background@#Little has been published about TKA in windswept deformities of the knees where combined varus and valgus deformities present in the same patient. Windswept deformities present with unique problems and must be addressed as two halves of a complex entity. Through this review we aim to understand the interrelation between the deformities, examine outcomes following simultaneous bilateral total knee arthroplasty in windswept deformities, and develop an algorithm for the management of windswept deformities by total knee arthroplasty. @*Methods@#An extensive online literature search for the keywords yielded 31 articles on which we based our review.Articles were analyzed in context to our research questions and are presented in a tabular format for quick reference and a better perspective. @*Results@#The abnormal biomechanics and force moment of the knee cause progressive arthritis of the knee. The valgus deformity usually precedes a varus deformity on the contralateral knee in windswept deformities. Correct restoration of mechanical tibiofemoral angles by individualizing valgus correction angles have better outcomes after TKA. @*Conclusion@#A well-planned and judiciously executed simultaneous bilateral total knee replacement can offer distinct advantages to the patient and surgeon and provides optimum utilization of time and resources in the management of windswept knees.

Windswept deformities of the knee are challenging to manage

Background@#Little has been published about TKA in windswept deformities of the knees where combined varus and valgus deformities present in the same patient. Windswept deformities present with unique problems and must be addressed as two halves of a complex entity. Through this review we aim to understand the interrelation between the deformities, examine outcomes following simultaneous bilateral total knee arthroplasty in windswept deformities, and develop an algorithm for the management of windswept deformities by total knee arthroplasty. @*Methods@#An extensive online literature search for the keywords yielded 31 articles on which we based our review.Articles were analyzed in context to our research questions and are presented in a tabular format for quick reference and a better perspective. @*Results@#The abnormal biomechanics and force moment of the knee cause progressive arthritis of the knee. The valgus deformity usually precedes a varus deformity on the contralateral knee in windswept deformities. Correct restoration of mechanical tibiofemoral angles by individualizing valgus correction angles have better outcomes after TKA. @*Conclusion@#A well-planned and judiciously executed simultaneous bilateral total knee replacement can offer distinct advantages to the patient and surgeon and provides optimum utilization of time and resources in the management of windswept knees.

Challenges in Total Hip Replacement after McMurray’s Osteotomy: A Report of 3 Cases and Review of Literature

Background@#McMurray’s osteotomy of the hip was a popular surgery practiced for almost 5 decades for the management of the fractured neck of the femur and hip osteoarthritis since its first description in 1936. It is an oblique, medial displacement intertrochanteric osteotomy. In the long term, McMurray's osteotomy patients develop limb length discrepancy and secondary osteoarthritis due to the altered biomechanics of the hip and may require total hip replacement (THR). THR after the previous osteotomy is more challenging than that for unoperated hip joints due to severe distortion of the hip anatomy and soft-tissue contractures. These challenges are related to distorted bony anatomy, soft-tissue contractures, and the choice of implants. @*Methods@#Three patients with previous McMurray's osteotomy of the hip developed secondary osteoarthritis and underwent total hip replacement. We discussed specific challenges encountered during THR and techniques to deal with such problems. @*Results@#All patients had pain-free hip, with minimal residual shortening (average, 1.2 cm) at an average follow-up of 3.67 years (range, 1 to 6 years). The Harris hip score improved significantly postoperatively and no complications were encountered. @*Conclusions@#A detailed and careful preoperative planning, correct execution of surgical techniques, and postoperative rehabilitation are the keys to the successful management of these cases.

Virtual preoperative planning and 3D printing are valuable for the management of complex orthopaedic trauma / 中华创伤杂志(英文版)

Purpose:@#The technology of 3D printing (3DP) exists for quite some time, but it is still not utilized to its full potential in the field of orthopaedics and traumatology, such as underestimating its worth in virtual preoperative planning (VPP) and designing various models, templates, and jigs. It can be a significant tool in the reduction of surgical morbidity and better surgical outcome avoiding various associated complications.@*Methods:@#An observational study was done including 91 cases of complex trauma presented in our institution requiring operative fixation. Virtual preoperative planning and 3DP were used in the management of these fractures. Surgeons managing these cases were given a set of questionnaire and responses were recorded and assessed as a quantitative data.@*Results:@#In all the 91 cases, where VPP and 3DP were used, the surgeons were satisfied with the outcome which they got intraoperatively and postoperatively. Surgical time was reduced, with a better outcome. Three dimensional models of complex fracture were helpful in understanding the anatomy and sketching out the plans for optimum reduction and fixation. The average score of the questionnaire was 4.5, out of a maximum of 6, suggesting a positive role of 3DP in orthopaedics.@*Conclusion:@#3DP is useful in complex trauma management by accurate reduction and placement of implants, reduction of surgical time and with a better outcome. Although there is an initial learning curve to understand and execute the VPP and 3DP, these become easier with practice and experience.

Outcome of distal end clavicle fractures treated with locking plates / 中华创伤杂志(英文版)

<p><b>PURPOSE</b>Fractures of the lateral end of the clavicle are relatively uncommon. These fractures are unstable due to the various deforming forces which act on the fragments as well as the small distal fracture fragment. At most times the deforming forces are not taken into consideration, and the fracture is not fixed securely. In this study, we assessed a fixation technique using the precontoured locking plates to find out whether it provided a stable fixation with good functional outcome.</p><p><b>METHODS</b>Totally, 32 patients with lateral end clavicle fracture (Neer's Type II) were included in the study. After the informed consent and preoperative investigations were obtained, open reduction and internal fixation was done using a 3.5 mm precontoured superior locking plate with lateral extension under general anesthesia. Postoperative X-rays were done on day 1 and every 6 weeks after operation, until radiological union was achieved. The postoperative pain was assessed using Visual Analogue Scale (VAS) on postoperative days 1, 2 and 10. Postoperatively arm pouch sling was given for 2 weeks followed by active mobilization. Patients were asked to do their daily routine work and avoid lifting heavy weights. The functional outcome was assessed at the end of 2nd and 6th months with the help of Disabilities of the Arm, Shoulder and Hand (DASH) scoring.</p><p><b>RESULTS</b>There were no intraoperative complications in the procedure. The mean VAS score on postoperative day 1 was found to be 5 which decreased to 3 on day 2 and 0 on day 10. The mean DASH score was calculated as 11.63 at the end of postoperative month 2 and then 4.6 at the end of month 6. There was one case of malunion in whom the overhead abduction was restricted but was not painful and was managed conservatively.</p><p><b>CONCLUSION</b>The precontoured locking plates with lateral extension may be a good method to fix the fractures of the lateral end clavicle, which provide a stable fixation with good functional outcome with very few instances of stiffness and decreased range of motion of the shoulder with the hook plates and failure of fixation in screw and K-wire fixations. It may well be the answer to the fixation questions of the lateral clavicle fractures, although larger comparative studies between the surgical treatment methods are required to confirm the same.</p>

Bilateral segmental pelvic and femoral fractures in a young female: A rare case report / 中华创伤杂志(英文版)

The management of multiple complicated injured patients remains a great challenge despite advance- ments in modern medical care. We present a rare case of bilateral unstable pelvic fractures associated with bilateral segmental femoral shaft fractures.We have proposed a mechanism of such complex injury pattern and discussed the plan of management. We believe that a timely and aggressive surgical intervention to fix all the major fractures soon after medically stabilizing the patient helped our patient to overcome these serious and lethal injuries. It is necessary to establish an optimal protocol for management of such complex fractures by conducting prospective and multicentric studies in the future.

Dislocation of a constrained total knee arthroplasty with patellar tendon rupture after trivial trauma / 中华创伤杂志(英文版)

Constrained total knee prostheses are used in knees with severe deformities and insufficiency of collaterals to provide stable and mobile knees. Dislocation after constrained knee prosthesis is an extremely rare and dreaded complication. When dislocation is associated with patellar tendon rupture, the management includes restoration of the extensor apparatus along with a stable knee. Repair of the patellar tendon is challenging due to poor soft tissue coverage in the area and a bulky repair can put tension on the wound closure. Ideal method of restoration of the extensor apparatus is a matter of debate. There are various modalities used ranging from primary end-to-end repair, augmentation by medial gastrocnemius flap, semitendinosus and synthetic implants and allograft tendoachilles. We report a rare case of a posterior dislocation of a constrained total knee arthroplasty in association with patellar tendon rupture due to a minor fall after a few weeks of surgery. The first episode was managed by reposition of the dislocation and V-Y plasty of the quadriceps and primary repair. The second episode of dislocation with re-rupture needed augmentation by semitendinosus along with the insertion of the thicker insert. The management of this complex problem along with the review of literature is discussed in this case report.

Anterior cruciate ligament reconstruction in a 75 years old man: a case report with review of literature / 中华创伤杂志(英文版)

Anterior cruciate ligament (ACL) reconstruction is usually recommended for young patients. Several recent articles have however reported comparable outcomes of ACL reconstruction between youth and patients in fourth or fifth age group. But in the literature there are not many reports about ACL reconstruction in patients over 70 years old. We report a case of a successful arthroscopic ACL reconstruction (using single bundle quadrupled hamstring graft) in an active 75-year-old medical practitioner. Successful outcome after ACL reconstruction can be achieved in selected older patients; chronological age is no barrier.

Periprosthetic subtrochanteric femoral fracture in a megaprosthesis of the knee / 中华创伤杂志(英文版)

We report a rare case of periprosthetic posttraumatic fracture of subtrochanteric region of femur after a megaprosthesis of the knee, done for resistant nonunion of distal femur with secondary osteoarthrosis in a 51 years old man. Treatment with a locking femoral plate was able to achieve primary union with a good result.

A Galeazzi-variant type fracture-dislocation in adults / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>Fracture of either radius or ulna with a dislocation either at the proximal or distal radioulnar joint (DRUJ) is not a common injury and is inherently unstable. Here we report a case series, with both-bone forearm fractures associated with dislocation of DRUJ, as a Galeazzi-variant type fracture-dislocation, and try to analyze this injury pattern.</p><p><b>METHODS</b>The study was based on 6 patients having Galeazzi-variant type fracture-dislocation of different age (20 to 45 years). All fractures were closed type. Two fractures involved the same level and three fractures were at different levels of radius and ulna shaft. After thorough examination and investigations they were treated with limited contact dynamic compression plate without additional fixation for DRUJ.</p><p><b>RESULTS</b>All cases were followed up for 24 weeks. The maximum incidence occurred in age group between 31 and 40 years. All the fractures of both radius and ulna were united in average time of 12 weeks. Range of motion of wrist and elbow, supination and pronation at final follow-up were normal. There was no subsequent re-subluxation or dislocation of the DRUJ in any of the cases.</p><p><b>CONCLUSION</b>Galeazzi variant in adult is a new undescribed pattern of forearm with wrist injury. Stable open reduction and internal fixation of both-bone forearm fractures is mandatory, followed by 3 to 4 weeks of immobilization in a cast for the healing of disrupted DRUJ.</p>

Scapular dislocation from trivial trauma: a rare case / 中华创伤杂志(英文版)

Dislocation of the scapula between the ribs and into the thoracic cage is a very rare event. Scapulothoracic dissociation though has been reported, usually occurs after a severe injury and is often associated with other serious injuries like brachial plexus or chest injury, etc. Ainscow has described a rare type that may occur due to slight violence with a pre-existing condition. Cases of isolated scapular dislocation after minor trauma have not been reported frequently in the literature. It is a distinct clinical entity and needs to be differentiated from other similar conditions. Here, we present a case of painless scapular dislocation associated with trivial trauma followed by spontaneous reduction in a 10 years old girl. The patient had a recurrence of the dislocation before presenting to us. But she did not have any pre-existing condition for scapular dislocation.

Spontaneous fracture of the femoral neck in preexisting avascular necrosis of femoral head in sickle cell disease / 中华创伤杂志(英文版)

The presence of anterior hip dislocation along with contralateral posterior hip dislocation in the absence of other major traumas is a distinctly rare injury pattern. We report such a case, along with a review of previous cases. A 40-year-old male patient after motorcycle skidding had posterior dislocation of the left hip and anterior dislocation of the right one without other associated injuries. The patient underwent successful closed reduction of both hips. The clinical course and follow-up assessment of the patient was uneventful.

Nonunion of coronal shear fracture of femoral condyle / 中华创伤杂志(英文版)

Isolated coronal fractures of femoral condyle are rare in adults and nonunion of Hoffa fracture is reported only a few times in the literature. We analyzed six cases of nonunion of Hoffa fractures over a period of three years. Three patients were treated conservatively and three patients had fixation failures. Delay of presentation was 2 months to one year. Treatment protocol consisted of open reduction, excision of pseudoarthrosis, bone grafting and internal fixation along with knee arthrolysis. Union was achieved in all patients at mean 16 weeks. The treatment of nonunion of Hoffa fractures requires careful preoperative planning and meticulous surgical technique. The literature regarding the controversies in fracture management and surgical technique are reviewed.