Dual offset metaphyseal-filling stems in primary total hip arthroplasty in dysplastic hips after a minimum follow-up of ten years.

PURPOSE: The aim of this study was to assess the long-term performance of tapered one-third proximally coated stems in dysplastic hips. METHODS: This study included 135 dysplasia patients (150 hips) who underwent a total hip arthroplasty and had a minimum follow-up of ten years. Single design tapered stems were used in all patients. There were 112 women (83%) and 23 men (17%) with a mean age of 45 years (23 to 72) at the time of surgery. The mean follow-up was 14.7 years (10 to 16.8). For clinical evaluation, the Harris Hip Score and Merle D'Aubigne scale were used pre-operatively and at the final follow-up. Implant survival was calculated using Kaplan-Meier survivorship analysis, with failure defined as a component revision for any reason. RESULTS: Overall, one stem was revised for a deep infection. There were no other femoral stem revisions secondary to loosening, wear, periprosthetic fracture, or instability. Radiographic evaluation showed excellent stem osteointegration in all cases. Kaplan-Meier survivorship, with stem revision for any reason as the end point, was 98% at 14 years (95% confidence interval 92.5 to 99.8). CONCLUSION: This study demonstrates that a dual offset tapered stem achieved excellent survivorship and stability, as well as good clinical outcome scores with minimal thigh pain and stress shielding in patients with arthritis and developmental dysplasia of the hip; a dual offset tapered stem may be a suitable option for primary total hip arthroplasty in this group.

Dual-mobility bearings for patients with abductor-trochanteric complex insufficiency.

INTRODUCTION: The purpose of this study was to summarise the performance of dual-mobility cup systems for revision total hip arthroplasty in patients with abductor-trochanteric complex deficiency. METHODS: We prospectively followed 17 patients (20 hips) with a mean age of 64.5 years (range 33-89 years) who underwent acetabular reconstruction with dual-mobility cups for aseptic loosening in 12 hips, infection treatment as second or single stage in 6 hips, and instability in 2 hips. All of the patients had abductor insufficiency. We evaluated the clinical Harris Hip scores (HHS) and radiographs for migration, loosening, and osteolysis. The survival of the components was calculated according to Kaplan-Meier survivorship analysis, and failure was defined as any dislocation, acetabular component or total hip revision for any reason. RESULTS: The mean duration of follow-up was 38.1 months (range 24-98 months). There were 2 (12.5%) revisions for cemented cup migration after 11 months and 19 months respectively. There were no dislocations. At the last follow-up, the mean HHS increased from 42 points preoperatively to 86 points. The cumulative survival rate of the dual-mobility cup system was 93% (95% confidence interval 88-98.7%) at 5 years, with any revision as the end point. CONCLUSION: Dual-mobility cups may provide excellent stability in patients with abductor-trochanteric complex insufficiency.

Long-term retrospective study on the placement of the cementless acetabular cup and clinical outcomes in patients undergoing femoral head autografting for hip dysplasia and total hip arthroplasty.

BACKGROUND: Placement of acetabular cup in the dysplastic hip is a challenging procedure. Using bulk femoral head autograft to increase the bony coverage of the cup is one of the techniques, which have been described. The impact of cup position on cup and autograft survival is a controversial issue. We aimed to determine whether the position of cementless acetabular cup used in conjunction with femoral head autograft in dysplastic hips affected the autograft-host incorporation with its final radiographic appearance and the cup survivorship into the second decade. METHODS: Thirty-eight dysplastic hips with varying Crowe types in 31 patients (30 women and one man) were included. The mean age was 47 years (range, 29-64 years) and the mean follow-up was 20.3 years (range, 14.8-25.9 years). The initial postoperative and final radiographs were evaluated. The survival rate of the cups was analysed using Kaplan-Meier statistics and the log-rank test. Multivariate analysis was used to evaluate the effect of variables (Crowe type, radiographic initial host bone coverage over the cup and position of the cup) on survivorship. RESULTS: The acetabular cups were positioned anatomical in 27/38 hips according to Ranawat measurement technique. Trabecular bridging at graft-host interface was seen in all cases at an average 22.1 months. Neither acetabular cup position nor initial host bone coverage over acetabular cup less than 50% had any significant effect on either cup survival or final radiographic appearance of the graft. The 20-year cup survival rate without aseptic revision was 66% (95 CI, 52%-84%). No revision was performed due to graft resorption. CONCLUSION: Twenty-year survival rate of the cementless cup combination with femoral head autograft showed no significant differences whether it was placed at high or anatomic hip centre. The final radiographic appearance of the autograft was not affected from either the cup location or the initial radiographic horizontal host bone coverage.

Total hip arthroplasty with step-cut subtrochanteric femoral shortening osteotomy in high riding hip dislocated patients with previous femoral osteotomy.

BACKGROUND: To evaluate the long-term clinical and radiological outcomes of cementless total hip arthroplasty (THA) in high riding hip dislocated patients with previous proximal femoral osteotomy. METHODS: Twenty-one consecutive patients with a mean age forty-two years were treated with cementless THA Step-cut subtrochanteric femoral osteotomy was performed in all twenty-eight hips. Metal on polyethylene (MoP) and ceramic on ceramic (CoC) bearings were used in two different consecutive time periods. The mean follow-up time was twelve years. Harris hip score, limb length discrepancy, complications, union status of the osteotomy, survivorship of constructs were the criteria for evaluation. RESULTS: The mean Harris hip score improved from 39.5 to 88.7 points. The mean limb length discrepancy in unilateral cases decreased from 54.5 mm to 12.3 mm. The mean amount of femoral shortening was 37 mm. The mean union time was 3.5 months and there were no delayed union and non-union. There were three cup and two femoral revisions due to osteolysis in patients who had MoP. There was only one femoral revision in patients who had CoC. The Kaplan Meier survivorship with an end point of any revision of the stem and the acetabular component was 94% (95% CI, 75%-98%) and 92% (95% CI, 74%-99%) at ten years respectively. CONCLUSIONS: Total hip arthroplasty with subtrochanteric step-cut femoral shortening is a successful technique to improve the hip functions and reconstruct limb length discrepancy in young patients with proximal femoral deformities.

The cementless fibre mesh coated anatomic femoral stem: 12 to 23 years clinical and radiological outcome study.

INTRODUCTION: The aim of this study was to assess the long-term clinical and radiographic results, and possible reasons for failure of two versions of the cementless fibre-metal coated anatomical femoral component. METHODS: 99 patients (119 hips) were evaluated at an average of 16.7 years (range, 12 to 23 years) following primary THA. Developmental dysplasia of the hip (DDH) was the most common pathology (n = 37 hips). Structural femoral head autografts were used to increase cup coverage in 23 hips. Vertical and horizontal migration of acetabular and femoral components and osteolysis around the components were assessed using conventional radiolography. For clinical evaluation, the Harris Hip Score and Merle D'Aubigne scale were used preoperatively and at final follow up. Implant survival was calculated according to the Kaplan-Meier survivorship analysis and failure was defined as component's revision for any reason. RESULTS: The cumulative survival rate of the anatomical femoral stem was 64.2% at 19.8 years, with a worst-case scenario of 41%. The cumulative survival rate of the total hip arthroplasty was 51% at 19.8 years, with a worse case scenario of 38%. The mean preoperative Harris Hip Score of 42 points improved to 88 postoperatively. The mean preoperative Merle D'Aubigne functional score of 3.5 improved to 5.2 points at the time of final follow-up. In 36 hips (41.6%) osteolysis was found in Gruen zone 1, proximal to the ingrowth surface. CONCLUSIONS: The cementless fibre-metal coated anatomical femoral component showed favourable long-term clinical and radiological results. Proximal coating seems to protect bone implant interface from wear debris induced osteolysis during the second decade.

Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected?

Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5-2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.

Mid-term result of ceramic bearings in total hip arthroplasty.

PURPOSE: The purpose of this study was to evaluate our clinical experience with ceramic-on-ceramic cementless total hip arthroplasty (THA) and complications after an average follow-up of more than eight years. METHODS: From January 2001 to December 2008, 540 THA with ceramic-on-ceramic bearings were performed in 448 patients (92 bilateral, 54 of which were operated simultaneously) with a mean age 49.9 years (range 18-84) by a senior surgeon. Pre-operative aetiological reasons were developmental dysplasia of the hip (DDH) in 205 hips, degenerative arthritis in 157 hips, avascular necrosis in 51 hips, rheumatoid diseases in 40 hips, posttraumatic arthritis in 40 hips, other reasons in 25 hips and revision surgery in 22 hips. Patients were evaluated with Harris hip score (HSS), and radiological findings of acetabular and femoral component loosening or osteolysis with ceramic bearing related complications like squeaking, liner and head fractures were recorded. RESULT: The average duration of follow-up time was 8.2 years (range, five to 13.2). The main Harris hip score increased from 42.4 points preoperatively to 94.9 points at the time of last follow-up. We had one fracture of the ceramic head, 11 clicking and four squeaking; one of them was revised because of terrible squeaking due to acetabular liner fracture, the other three were seldom audible from the outside and followed conservatively. We did not observed loosening or osteolysis due to ceramic bearings at the time of the final follow-up. CONCLUSION: Our study has demonstrated that ceramic-on-ceramic bearings can be used safely in different etiological problems. Incidences of noisy hips are becoming less frequent.

Medical photography: principles for orthopedics.

BACKGROUND: Medical photography is used clinically for patient evaluation, treatment decisions, and scientific documentation. Although standards for medical photography exist in many branches of medicine, we have not encountered such criteria in publications in the area of orthopedics. PURPOSE: This study aims to (1) assess the quality of medical images used in an orthopedic publication and (2) to propose standards for medical photography in this area. METHODS: Clinical photographs were reviewed from all issues of a journal published between the years 2008 and 2012. A quality of clinical images was developed based on the criteria published for the specialties of dermatology and cosmetic surgery. All images were reviewed on the appropriateness of background, patient preparation, and technique. RESULTS: In this study, only 44.9% of clinical images in an orthopedic publication adhered to the proposed conventions. CONCLUSIONS: Standards have not been established for medical photography in orthopedics as in other specialty areas. Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. We propose that formal conventions for clinical images should be established.

Simple electrodiagnostic method for Morton neuroma.

INTRODUCTION: We describe a simple and quickly applied electrodiagnostic method for confirming the diagnosis of interdigital neuropathy caused by Morton neuroma (MN). METHODS: Interdigital nerves II-III and III-IV were stimulated with surface electrodes simultaneously touching the lateral side of 1 toe and the medial side of the other. Recording was also made with surface electrodes. The results of 20 normal controls and 14 patients with MN were evaluated. RESULTS: The amplitude and peak latency values elicited in the patients as well as the interside differences revealed an acceptable abnormality rate between 57.1% and 71.4%. CONCLUSIONS: Although the most popular and effective method of MN diagnosis is clinical evaluation supported by imaging, electrophysiological studies can, in selected patients, provide valuable information.

Regional migratory osteoporosis and transient osteoporosis of the hip: are they all the same?

We hypothesized that regional migratory osteoporosis (RMO) and transient osteoporosis of the hip (TOH) terms describe a common disease process. Therefore, based on our patient, we aimed to review the pathogenesis, diagnosis, and treatment of both diseases. The patient was a pregnant woman in her third trimester with sacral insufficiency fracture, which was shortly followed by migratory arthralgia of both hips and ankles in a proximal to distal direction. She was operated (core decompression) for both hips and ankles, and she was symptom free at 17th month. RMO and TOH have an unclear etiology, share the similar course, and bear a self-limiting nature. Both disorders may be the same clinical entity with a common pathogenesis. Probably, many of RMO patients were labeled as TOH, and therefore, RMO has been underrepresented. In conclusion, we think that both RMO and TOH describe a common disease process. Either the diagnosis is RMO or TOH, the management will be the same. Finally, the conservative treatment protocol is a better treatment modality and must be obeyed even in resistant cases.

Ten- to 15-year clinical and radiographic results for a compression molded monoblock elliptical acetabular component.

The aim of this study was to report the long-term results from a previously published midterm follow-up of a titanium monoblock, elliptical acetabular component. A total of 258 primary total hip arthroplasties (212 patients) with a monoblock, acetabular component were followed up for a mean period of 11.1 years (10-15). Average yearly wear rate was 0.08 mm/y (0.0009-0.32). Acetabular radiolucencies were present in 6 hips (2.4%); all were nonprogressive and present in acetabular zone I. Acetabular osteolysis was present in 5 patients (5 hips, 1.9%); all cups were stable. Four acetabular components were revised, 3 because of recurrent instability. No acetabular components were revised for polyethylene wear or dissociation, acetabular osteolysis, loosening, or deep infection. This monoblock design demonstrates excellent long-term survival and low rate of osteolysis.

Guillain-barré syndrome mimicking nerve injury after total hip arthroplasty.

BACKGROUND: Guillain-Barré syndrome (GBS) is a rare, acute, inflammatory demyelinating polyneuropathy with a presentation of progressive ascending motor weakness of the extremities, which may extend to the respiratory muscles and require mechanical support. CASE DESCRIPTION: This case describes a healthy male who developed GBS 1 week following otherwise an uncomplicated bilateral total hip arthroplasty surgery. The diagnosis was made based on physical exam significant for bilateral lower extremity weakness and diffuse arreflexia, and confirmed by nerve conduction studies. There were no effects on respiratory function, and the patient underwent a gradual recovery, with near complete return of motor function by 10 weeks following surgery and no functional deficits at 1 year following surgery. Functional activity levels are maintained 4 years postoperatively. LITERATURE REVIEW: A literature review is presented. While GBS has been described in the literature following several different forms of surgery and anesthesia, cases after orthopedic surgery are exceedingly rare. PURPOSES AND CLINICAL RELEVANCE: This case demonstrates that GBS may occur following orthopedic, including total joint arthroplasty, surgery. The presentation of GBS can be variable, but the hallmarks are areflexia and diffuse ascending weakness, with or without sensory symptoms. Rapid diagnosis and treatment are critical for preventing disability and life-threatening sequelae.

Acetabular component revision in total hip arthroplasty. Part I: cementless shells.

Magnitude and location of acetabular bone defects dictate the type of reconstruction required. For the majority of reconstructions, a porous-coated hemispheric shell secured to host bone with multiple screws is the implant of choice. This reconstruction is feasible provided at least 50% of the implant contacts host bone. When such contact is not possible, and there is adequate medial and peripheral bone, techniques using alternative uncemented implants can be used for acetabular reconstruction. An uncemented cup can be placed at a "high hip center." Alternatively, the acetabular cavity can be progressively reamed to accommodate extra-large cups. Oblong cups, which take advantage of the oval-shaped cavity resulting from many failed acetabular components, can also be used. The success of these cementless techniques depends on the degree and location of bone loss and on the presence of pelvic discontinuity.

Acetabular component revision in total hip arthroplasty. Part II: management of major bone loss and pelvic discontinuity.

Use of structural bone graft and/or reconstruction cage devices in acetabular revisions with major bone loss has the advantages of providing a stable construct at the anatomical hip center of rotation and, theoretically, reconstituting bone stock. When the structural graft supports more than 50% of the acetabular component, a reconstruction cage device spanning ilium to ischium should be used to protect the graft and provide structural stability. Recent introduction of trabecular metal cups and augments and custom triflanged acetabular components has increased the potential for biological fixation and long-term stability of revision constructs. Longer follow-up of these reconstructions is needed. Revisions with pelvic discontinuity and major bone loss have a high failure rate and require techniques either to reduce and plate the discontinuity or to distract the discontinuity to achieve long-term stability.

Wear is reduced in THA performed with highly cross-linked polyethylene.

UNLABELLED: Highly cross-linked polyethylene (HCLPE) has been used extensively to decrease osteolysis and related implant failure in THA. We compared the wear rate of HCLPE and noncross-linked conventional PE (CPE) liners and the rate of radiographic calcar resorption and osteolysis in young patients (35-60 years of age) who underwent THA by one surgeon. Thirty-four patients (41 THAs) who received a hybrid THA using a HCLPE liner were match-paired for age, gender, body mass index, and diagnosis with a group of patients who underwent THA with identical implants but with a CPE liner. The minimum followup was 4 years (average, 5.3; range, 4-8 years). Using the Livermore measurement technique, the averages of total wear of the HCLPE and CPE liners were 0.01 mm (range, -0.23-0.4) and 0.64 mm (range, 0-1.7), respectively. The average annual wear was less for the HCLPE than the noncross-linked PE (0.002 mm, range, -0.05-0.1 versus 0.12 mm, range, 0-0.29, respectively). Four hips in the HCLPE group and 23 in the CPE group had calcar resorption measuring averages of 2.5 mm (range, 2-3) and 7.5 mm (range, 1.8-23.8), respectively. Periprosthetic osteolysis occurred in two and eight hips in the HCLPE and CPE groups, respectively. Longer followup is needed to determine if these findings will result in improved implant survivorship. LEVEL OF EVIDENCE: Level III, therapeutic study.

Aspirin decreases the prevalence and severity of heterotopic ossification after 1-stage bilateral total hip arthroplasty for osteoarthrosis.

Heterotopic ossification (HO) is a frequent complication after total hip arthroplasty (THA). We retrospectively evaluated the prevalence and severity of HO in patients with osteoarthrosis who underwent 1-stage bilateral THA (OSBTHA) and compared those who received aspirin with those who received Coumadin for postoperative chemothromboprophylaxis. The aspirin group consisted of 66 patients (132 hips), with a mean age of 64 years (SD, 8.5). The Coumadin group consisted of 67 patients (134 hips), with a mean age of 60 years (SD, 10.2). Overall, HO was detected in 124 hips (46.6%). There were 43 hips (32.5%) with HO in the aspirin group and 81 (60.4%) in the Coumadin group (P < .00005). Aspirin significantly decreases the prevalence and severity of HO in comparison to Coumadin after OSBTHA.

Reconstruction of the failed acetabular component using cemented shells and impaction grafting in revision hip arthroplasty.

Cemented revision techniques have been used with variable success in the reconstruction of the failed acetabular component. Diminished cement-bone interlock secondary to diminished cancellous bone quality and quantity may contribute to the observed high rates of aseptic loosening of this construct in the revision setting. Nevertheless, this technique may still be an option in the elderly patient with limited function or life expectancy. Impaction bone grafting in conjunction with cemented acetabular cups has been reported to result in good midterm results. The reconstruction is challenging and tedious and requires meticulous execution for success. When performed well, impaction grafting can result in survivorship rates equaling those seen using cementless hemispheric cups with the additional advantage of increasing acetabular bone stock.