Bilateral Universal Exeter™ Femoral Stem Fracture.

INTRODUCTION: Total hip arthroplasty(THA) in dysplastic hips involves technical difficulties due to impaired anatomy. Specially designed implants are needed for dysplastic hips. Usage of these implants with appropriate material and design features reduces the pain in this group of patients and increases the standard of life. Improper implant selection causes various complications. The presented case is about a 62-year-old female patient who was operated bilaterally for coxarthrosis secondary to developmental hip dysplasia. She had minimal complaints during her last outpatient follow-up. Radiographs revealed a fracture of the simultaneous bilateral femoral stem. CASE REPORT: Seventeen years ago, a 45-year-old lady was admitted to our hospital due to coxarthrosis secondary to developmental hip dysplasia. In six months interval, she underwent bilateral THA with Exeter™ Universal Hip system.She had re-operated on her 3rd year because of right femoral stem fracture.Since then, she has beenexamined at the outpatient clinic regularly on1-year-based intervals. There was no trauma or obvious activity experienced. Radiographs of the pelvis and bilateral femur were obtained, andit was demonstrated that both femoral stems were broken. Both fractured stems were removed by extended femoral osteotomy via a lateral approach.Intraoperative examination revealedthat the right acetabular component was well-fixed, but there was a loosening of the left acetabularcomponent. The acetabular revision was performed to the left side. Echelon cementless revision hip system (Smith and Nephew) was used for the right and left sides. The patient was stood-up on the first post-operative day and weight-bearing was permitted as much as tolerated. At the end of 6 weeks, full weight bearing was permitted. She was returned to her routine daily life activities after 4 months. CONCLUSION: After the acquisition of Howmedica by Stryker in 1998, the taper in the Exeter stem was modified, and a new Exeter V40 stem concept was introduced in 2001, but still in literature, we could comeacross stem fracture cases. We may not eliminate all prosthetic fractures, but we may reduce them as low as possible by doing appropriate cementing, placing the stem in proper alignment and for us, the most important one is pre-operative templating. Spending some time in front of X-rays and choosing the appropriate size of a stem is the most helpful step while eliminating the prosthetic fractures.

Short-term results of the management of severe bone defects in primary TKA with cement and K-wires.

OBJECTIVE: The aim of this study was to evaluate the results of cement and kirschner wire augmentation in the management of bone defects in primary TKA. METHODS: Twenty-four patients (10 male, 14 female; mean age: 66 years) with uncontained unilateral medial tibial articular bone defect who underwent TKA between 2010 and 2014 were included in this study. The average follow up time was 33.7 months. Patients were divided to two groups according to the size of the bone defect (Group 1: <20 mm, Group 2: >20 mm). The tibial defect was reconstructed by using cement and K-wires. We used posterior stabilized prosthesis with no tibial stem extension. RESULTS: The preoperative and postoperative lower extremity mechanical axis in Group I was in a mean varus of 15° and mean varus of 3°, respectively (p < 0.001). The preoperative and postoperative lower extremity mechanical axis in Group 2 was in a mean varus of 20° and mean varus of 3° respectively in Group II (p < 0.001). None of the patients neither suffered from failure of K-wires nor loosening. CONCLUSION: The use of cement and K-wires augmentation appears to be a simple and cost-effective treatment option for the tibial bone defects in primary TKA. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Intensive supervision of rehabilitation programme improves balance and functionality in the short term after bilateral total knee arthroplasty.

PURPOSE: To evaluate the short-term results of the rehabilitation programme with two different supervision on balance and functionality after simultaneously bilateral total knee arthroplasty (SBTKA) in patients with osteoarthritis and to compare the results with those of healthy individuals. METHODS: This study was a single-blind randomized controlled study. Two exercise groups who underwent primary bilateral total knee arthroplasty (Group 1, n = 20 and Group 2, n = 20) and a control group of healthy individuals (Group 3, n = 20) included in the study. Group 1 applied exercise programme with intensive supervision of the physiotherapist for a period of 1 month (2 days/1 week). Group 2 performed exercise programme under the control of same physiotherapist twice monthly (1 day/2 weeks), and the patients were checked every week by telephone interview. Pre-operative and post-operative blind evaluations were made at first and second month. Static balance with single leg stance test, dynamic balance with timed get up & go (TGUG), functionality with walking cadence, stair climbing test (SCT) and Western Ontario McMaster Universities (WOMAC) index were assessed. RESULTS: Group 1 improved statistically significantly better in terms of SLST (p = 0.0 (right), p = 0.0 (left)) and WOMAC function (p = 0.0) at first month, and SLST (p = 0.0), TGUG (p = 0.0), SCT (p = 0.0), WOMAC pain (p = 0.0), stiffness (p = 0.0) and function (p = 0.0) at second month. In Group 1, TGUG, walking cadence, SCT, WOMAC pain, stiffness and function results reached the levels of healthy individuals at second month, and SLST was better for two legs as compared to healthy individuals. In Group 2, cadence results were similar to healthy individuals at second month. CONCLUSIONS: The osteoarthritis patients who had the applied rehabilitation programme after SBTKA with intensive supervision of the physiotherapist for 1 month have obtained more improvements in balance and functional parameters, and it was demonstrated that their performances approached the healthy control group values. As a clinical relevance of our study, intensive supervision of rehabilitation programme should be provided to the patients after SBTKA surgery to accomplish early balance and functional improvements.

The midterm and long-term effects of acetabular roof ring and Burch-Schneider anti-protusio cages in acetabular revisions for patients with acetabular bone deficiency.

OBJECTIVE: The purpose of this study was to investigate the mid-term and long-term effects of the acetabular roof ring (ARR) and Burch-Schneider anti-protrusio cage (BSAPC) in acetabular revision for patients with acetabular bone deficiency and acetabular component loosening. METHODS: Between 1988 and 2007, ARR revisions were performed in 51 patients (25 women; average age: 46.9 years) and BSAPC in 18 patients (16 women; average age: 62.1 years). Grafts were used in all revisions. The patients were evaluated retrospectively. The bone defects were classified according to the classification of the American Academy of Orthopaedic Surgeons (AAOS). Harris Hip Score (HHS) was used for clinical evaluation. Radiolucent lines, implant sizes, osseointegration, and heterotopic ossification in the 3 regions defined by DeLee and Charnley were evaluated radiologically. RESULTS: The success rate of ARR revisions after an average follow-up of 8.93±4.10 years (range: 4-23 years) was 87.9%, and the cumulative survival rate at year 10 postoperatively was 91%. Average HHS score increased to 83.70±8.98 postoperatively, from 40.10±2.49 preoperatively (p<0.01). The success rate of BSAPC revisions after an average follow-up of 7.06±2.39 years (range: 4-12 years) was 83.3%, and the cumulative survival rate was 78%. Average HHS score increased from 42.55 preoperatively to 73.86 postoperatively (p<0.01). All failures of ARR revisions occurred in type 3 defects (p<0.05). In 40 of the 47 patients in which an allograft was used, osseointegration occurred. No statistically significant difference was found between the increase in HHS scores of patients who underwent femoral component revision with acetabular revision and those who did not (p=0.06). Patients who underwent more than 1 revision had statistically significantly higher failure rates in comparison to patients undergoing revision for the first time (p=0.008). CONCLUSION: The mid-term and long-term results of the use of ARR and BSAPC with allografts in bone deficient acetabular revisions are satisfactory. The implants facilitate graft osseointegration, increase the bone stock, and make future revisions easier. ARR should be preferred in type 1 and type 2 acetabular bone defects, while BSAPC should be preferred in type 3 and 4 defects.

Patients' preoperative perspectives concerning the decision to undergo total knee arthroplasty and comparison of their clinical assessments.

[Purpose] The aims of our study were, 1. to assess pain, limitation of movement ability, and functionality in osteoarthritis patients scheduled to undergo total knee arthroplasty, 2. to determine if pain (Group 1) or function loss (Group 2) has a greater influence on the decision of patients to have surgery, and 3. to compare results between Group 1 and Group 2. [Subject and Methods] Fifty-five osteoarthritis patients classified as grades 3 and 4 according to the Kellgren-Lawrence system of classification were evaluated for preoperative pain intensity with the Visual Analogue Scale, knee flexion/extension range of movement with a clinical goniometer, and function with the Western Ontario and McMaster Universities Osteoarthritis Index. Patients were examined to reveal their reasons regarding the decision to undergo total knee arthroplasty (pain or function loss). [Results] The Visual Analog Scale scores at rest and during activity were 5.62 and 7.42, the knee flexion range of movement and extension limitation were 93.17° and -7.04°, and the Western Ontario and McMaster Universities Osteoarthritis Index value was 82.09. Regarding the decision to undergo surgery, 47.3% (n=26) of the knees were in Group 1, and 52.7% were in Group 2; the two groups were not significantly different. There were also no significant differences between the groups in Visual Analog Scale score during activity, the Western Ontario and McMaster Universities Osteoarthritis Index value, and knee flexion range of movement and extension limitation. The only statistically significant difference was found in the Visual Analog Scale score at rest in Group 1, which was significantly higher than that in Group 2. [Conclusion] Our results showed that osteoarthritis patients decided to undergo surgery only if all of the parameters were impaired significantly. Both pain and function loss have a similar impact on a patient's decision to undergo surgery. We observed no significant difference in clinical and self-reported outcomes between patients who decided to undergo surgery due to pain or function loss.