Endoscopic Sciatic Nerve Decompression After Fracture or Reconstructive Surgery of the Acetabulum in Comparison With Endoscopic Treatments in Idiopathic Deep Gluteal Syndrome.

OBJECTIVE: The purpose of this study was to assess the endoscopic findings of the sciatic nerve and clinical outcomes of major traumatic sciatic nerve neuropathies after fracture or reconstructive surgery of the acetabulum with idiopathic deep gluteal syndrome (DGS) groups. DESIGN: Retrospective review of patient reports. SETTING: Level I trauma center of a tertiary university hospital. PARTICIPANTS: The study included 70 patients who consecutively underwent endoscopic sciatic nerve decompression. Patients who had previous fractures or reconstructive surgeries of the acetabulum were categorized as the major trauma group, whereas those without major trauma were categorized as the idiopathic group (45 patients) after a minimum of 24-months of follow-up period. MAIN OUTCOME MEASURES: The results were evaluated using the modified Harris Hip Score (mHHS), Hip outcome, and 12-Item Short Form Health Survey scores, respectively. RESULTS: In the major trauma group, all patients with sensory symptoms showed some degree of relief after the endoscopic sciatic nerve release. None of the patients with complete foot drop demonstrated complete improvement. Three patients with motor weakness without foot drop showed complete improvement in motor function. The mean mHHS increased from 61.5 ± 13.4 to 84.1 ± 8.1 (P = 0.031). In the idiopathic DGS group, the mean mHHS increased from 73.8 ± 10.3 to 94.4 ± 5.3 (P = 0.003). The Benson outcomes rating in the major trauma group was statistically lower than that in the idiopathic DGS group. CONCLUSION: Endoscopic release of the sciatic nerve after fractures or reconstructive surgeries could provide some improvements without complications. However, more favorable outcomes were observed in the idiopathic DGS group.

Endoscopic resection of acetabular screw tip to decompress sciatic nerve following total hip arthroplasty.

BACKGROUND: Sciatic nerve injuries following total hip arthroplasty are disabling complications. Although degrees of injury are variable from neuropraxia to neurotmesis, mechanical irritation of sciatic nerve might be occurred by protruding hardware. This case shows endoscopic decompression for protruded acetabular screw irritating sciatic nerve, the techniques described herein may permit broader arthroscopic/endoscopic applications for management of complications after reconstructive hip surgery. CASE PRESENTATION: An 80-year-old man complained of severe pain and paresthesias following acetabular component revision surgery. Physical findings included right buttock pain with radiating pain to lower extremity. Radiographs and computed tomography imaging showed that the sharp end of protruded screw invaded greater sciatic foramen anterior to posterior and distal to proximal direction at sciatic notch level. A protruding tip of the acetabular screw at the sciatic notch was decompressed by use of techniques gained from experience performing endoscopic sciatic nerve decompression. The pre-operative pain and paresthesias resolved post-operatively after recovering from anesthesia. CONCLUSIONS: This case report describes the first documented endoscopic resection of the tip of the acetabular screw irritating sciatic nerve after total hip arthroplasty. If endoscopic resection of an offending acetabular screw can be performed in a safe and minimally invasive manner, one can envision a future expansion of the role of hip arthroscopic surgery in several complications management after total hip arthroplasty.

Alterations in Range of Motion and Clinical Outcomes After Femoroplasty in Asians.

INTRODUCTION: The restoration of range of motion after surgery in patients with femoroacetabular impingement syndrome is considered an important factor that improves clinical outcomes and determines the quality of life of patients, especially in the Asian population. METHODS: Arthroscopic femoroplasty was done in 109 Asian patients with cam impingement. The patients were retrospectively evaluated using range of motion and clinical outcomes (Harris Hip Score [HHS], visual analog scale score, Hip Outcome Score-Activity of Daily Living, and Hip Outcome Score-Sports subscales) between preoperative and postoperative conditions, with a follow-up period of >2 years. RESULTS: The increments of hip motion were an internal rotation of 10.1° (P < 0.05) at 3 postoperative months and an external rotation of 11.8° (P < 0.05) at approximately 6 postoperative months; both were maintained at 2 postoperative years. Mean clinical outcomes improved from 69.1 to 82.1 for HHS, from 6.0 to 2.1 for the visual analog scale score, and from 40.1 to 68.7 for the Hip Outcome Score-Sports Subscale at 6 postoperative months (P < 0.05) and were maintained at 2 years. Younger subjects (<45 years of age) displayed even greater improvements in the HHS and Hip Outcome Score-Activity of Daily Living/Sports Subscale than the other group (≥45 years of age) (P < 0.05). CONCLUSION: Patients who underwent arthroscopic femoroplasty showed improvements in internal rotation at 3 months postoperatively and external rotation at approximately 6 months postoperatively. In addition, younger age (<45 years and the restoration of rotational hip motion resulted in better clinical outcomes. LEVEL OF EVIDENCE: III a.

Effects of Titanium Mesh Surfaces-Coated with Hydroxyapatite/ß-Tricalcium Phosphate Nanotubes on Acetabular Bone Defects in Rabbits.

The management of severe acetabular bone defects in revision reconstructive orthopedic surgery is challenging. In this study, cyclic precalcification (CP) treatment was used on both nanotube-surface Ti-mesh and a bone graft substitute for the acetabular defect model, and its effects were assessed in vitro and in vivo. Nanotube-Ti mesh coated with hydroxyapatite/ß-tricalcium phosphate (HA/ß-TCP) was manufactured by an anodizing and a sintering method, respectively. An 8 mm diameter defect was created on each acetabulum of eight rabbits, then treated by grafting materials and covered by Ti meshes. At four and eight weeks, postoperatively, biopsies were performed for histomorphometric analyses. The newly-formed bone layers under cyclic precalcified anodized Ti (CP-AT) meshes were superior with regard to the mineralized area at both four and eight weeks, as compared with that under untreated Ti meshes. Active bone regeneration at 2-4 weeks was stronger than at 6-8 weeks, particularly with treated biphasic ceramic (p < 0.05). CP improved the bioactivity of Ti meshes and biphasic grafting materials. Moreover, the precalcified nanotubular Ti meshes could enhance early contact bone formation on the mesh and, therefore, may reduce the collapse of Ti meshes into the defect, increasing the sufficiency of acetabular reconstruction. Finally, cyclic precalcification did not affect bone regeneration by biphasic grafting materials in vivo.

Is there a clinical benefit of additional tension band wiring in plate fixation of the symphysis?

BACKGROUND: The purpose of this study was to determine whether additional tension band wiring in the plate for traumatic disruption of symphysis pubis has clinical benefits. Therefore, outcomes and complications were compared between a plate fixation group and a plate with tension band wiring group. METHODS: We retrospectively evaluated 64 consecutive patients who underwent open reduction and internal fixation of the symphysis pubis by using a plate alone (n = 39) or a plate with tension band wiring (n = 25). All the patients were followed up for a minimum of 24 months (mean, 34.4 months; range, 26-39 months). Demographic characteristics, outcomes, movement of the metal works, complications, revision surgery, and Majeed functional score were compared. RESULTS: Significant screw pullout was relatively significantly more frequently found in the plate fixation group than in the plate with tension band wiring group (P = 0.009). In terms of the overall rate of all-cause revision surgery, including significant loosening, symptomatic hardware, and patient-requested hardware removal during follow-up period, the plate with tension band wiring group showed a significantly lower rate. CONCLUSION: Tension band wiring in combination with a symphyseal plate showed better radiological outcomes, a lower incidence of hardware loosening, and a lower rate of revision surgery than plate fixation alone. This technique would have some potential advantages in terms of avoiding significant movement of plate, symptomatic hardware failure, and revision surgery.

Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: mean 2-year follow-up.

BACKGROUND: The purpose of this study is to assess the effectiveness of endoscopic sciatic nerve decompression and evaluated the differences of clinical results between atraumatic and traumatic groups. METHODS: Sixty consecutive patients. We retrospectively reviewed sixty consecutive patients without major trauma (45 hips) or with major trauma (15 hips) groups to compare the outcomes of endoscopic treatment.). The mean follow-up period was 24 ± 2.6 months (range, 24-38.4 months). RESULTS: The mean duration of symptoms was 14.1 months (range, 12 to 32 months). Compromising structures were piriformis muscle, fibrovascular bundles, and adhesion with scar tissues. The mean VAS score for pain decreased from 7.4 ± 1.5 to 2.6 ± 1.5 (P = .001). The mean mHHS increased from 81.7 ± 9.6 to 91.8 ± 7.6 (P = .003). Clinically, positive paresthesia and seated piriformis test were statistically significant to diagnosis sciatic entrapment syndrome. Paresthesia and sitting pain were significantly improved at the final follow-up (P = .002). More favorable outcome was observed a group without major trauma. No complication was observed. CONCLUSIONS: Endoscopic sciatic nerve decompression is a safe and effective procedure for the management of DGS. Patients with major trauma could have poor clinical outcome. Seated piriformis test, FADIR, and tenderness of sciatic notch are maybe useful guide for pre and postoperative evaluation of DGS.

Outcomes of polyethylene liner cementation into a fixed metal acetabular shell with minimum follow-up of 7 years.

Cementation of a polyethylene liner into the well-fixed shell is a convenient option for revision total hip arthroplasty. We retrospectively reviewed 45 patients who had liner cementation to investigate the risk factors which gave rise to major complications and reoperation. Patients were observed for a minimum of 7 years (range 7.8-14 years). Relevant risk factors (age, BMI, surgical approach, previous cup size and position, types of coated surface) were assessed with Cox regression analysis. The mean Harris Hip Score was improved from 62.5 (range 57-68) preoperatively to 87.1 (range 70-97). A total of 7 hips (15.5%) had acetabular component loosening that was treated with reoperation. Prevalence of acetabular component loosening was statistically significantly higher in hydroxyapatite-coated group (5 of 13) than in the Ti-coated group (2 of 32, p = 0.015). All recurrent dislocations occurred in patients treated with a posterior approach. Diameter of the previous metal shell of below 54 mm showed a lower 10-year survival rate than those greater than 54 mm in diameter. PE liner cementation in stable metal cup is a useful alternative option for carefully selected patients. Pre-existing HA-coated cups as well as small sized cups were indicative of poor outcomes.

Hip arthroscopy for femoroacetabular impingement: the changing nature and severity of associated complications over time.

PURPOSE: The aim of this study was to assess complications related to arthroscopy for femoroacetabular impingement (FAI) and how these complications have changed as we have gained more experience with this procedure. METHODS: The authors reviewed 200 hips (197 patients). The average patient age was 44.64 years and the mean follow-up time was 28.2 months. All patients underwent hip arthroscopy in the supine position. Clinically, Modified Harris Hip Scores (MHHS) and patient satisfaction with outcome were used. We divided complications into 3 groups: Group 1 related to traction, group 2 related to surgical technique or implant failure, and group 3 related to outcomes. RESULTS: Clinically, the MHHS improved from 69.96 (±6.10) to 80.45 (±7.00), and patient satisfaction with the achieved outcome increased to 8.87 (±0.76). The overall complication rate was 15% (30 of 200 hips). Group 1 consisted of 4 patients with pudendal neuropraxia and 2 patients with ankle joint pain (P = .013). Group 2 consisted of 2 patients with lateral femoral cutaneous neuropraxia, 2 patients with iatrogenic labral perforations, one patient with a labral tear, and 4 patients with femoral head scuffs. There were 4 incidents of instrument breakage. Furthermore, 3 suture anchors failed, a second-degree burn occurred in one patient, and there was incomplete reshaping in 5 hips (P = .045). Group 3 included one patient with a snapping sound and heterotopic ossification. Second-look arthroscopy was performed for 5 hips. All the complications outlined in groups 1 and 2 are related to the learning curve and have statistical significance (P < .05). CONCLUSIONS: Complications relating to hip arthroscopy took different forms during the early learning period, but overall complication rates decreased along the learning curve. Surgical technique-related complications such as problems with suture anchors and the reshaping of cam impingements were also considered during the later stage. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Internal fixation of femoral head fractures (Pipkin I) using hip arthroscopy.

A hip arthroscopy technique for the reduction and internal fixation of a displaced femoral head fracture is presented. Open treatment is often required for femoral head fractures. However, it is shown below how large fragments of a femoral head fracture-dislocation were reduced and internally fixated using hip arthroscopy. This was performed in the supine position using skeletal traction. The accessory distal anterior portal was used for internal fixation when a hip was positioned in abduction with external rotation. A satisfactory outcome was reported. Recovery was immediate and cosmetics were excellent. We conclude that hip arthroscopy is a valuable option for managing femoral head fracture-dislocations (Pipkin I).

Arthroscopic reduction and internal fixation of femoral head fractures.

Displaced femoral head fractures often require open reduction and internal fixation. This article describes 3 cases of displaced large-fragment femoral head fractures (OTA 31-C1.3) that were treated by arthroscopic reduction and internal fixation, which was accomplished using an anterolateral viewing portal, an anterior portal, and an accessory distal anterior working portal. By 3 months postoperatively, all 3 patients had returned to full function. Therefore, we conclude that an arthroscopic approach results in stable fixation and early joint motion, thereby effectively treating displaced femoral head fractures in a minimally invasive manner.

Hip Arthroscopic Management for Femoral Head Fractures and Posterior Acetabular Wall Fractures (Pipkin Type IV).

Femoral head fractures associated with acetabular fractures are usually treated by an open method. After a closed reduction of a hip dislocation, open reduction and internal fixation of acetabular fractures usually depend on the type of acetabular fracture. Acetabular fractures associated with femoral head fractures, torn labrums, or osteochondral fractures are often managed simultaneously by a posterior approach. The patient in this study was referred to us because of pain and limited motion after open reduction and internal fixation of an acetabular fracture. Postoperative computed tomography showed remnant osteochondral fragments located in the cotyloid fossa. Using hip arthroscopy, we found a torn labrum and multiple osteochondral fragments in the cotyloid fossa. The avulsed torn labrum was reattached with 2 anchors through the midanterior portal. Osteochondral fragments were curetted and removed. This article reviews the treatment of the torn labrum and multiple fragments after acetabular fracture reduction. The patient recovered immediately and had a satisfactory outcome. We conclude that hip arthroscopy is a valuable option for treating femoral head fracture dislocations associated with acetabular fractures.

Cementless bipolar hemiarthroplasty using a rectangular cross-section stem for unstable intertrochanteric fractures.

The purpose of this study was to compare the clinical and radiographic results for elderly patients sustaining unstable intertrochanteric fractures treated with an uncemented bipolar hemiarthroplasty using a double-tapered, rectangular cross-section stem. Thirty-seven patients (21 females, 16 males; mean age 73.5 years, range 65-88 years) who underwent bipolar hemiarthroplasty with a standard (double-tapered, rectangular cross-section) uncemented stem were followed up for a minimum of two years. At final follow-up, 27 patients (72.9%) had recovered their daily living ability (Barthel index), and 28 patients (75.6%) had recovered all walking ability at a community level (Koval's category).

The management of the displaced medial wall in complex acetabular fractures using plates and additional cerclage.

Reduction for displaced quadrilateral plates in complicated acetabular fractures is difficult and requires wide exposure. The purpose of this study is to assess the usefulness of the additional cable in this complicated fracture and to evaluate the potential danger of compressing the superior gluteal artery and nerve with cable application. We evaluated 31 hips (these included 25 hips with fractures of both columns, two posterior wall and column fractures, three anterior column and posterior hemitransverse fractures, and one high T-shaped fracture) with an average six-year follow-up. Clinical outcomes were evaluated using a modification of the Matta grading system and radiographic arthritic grades. We assessed the postoperative clinical outcomes in relation with other variables such as anatomical reduction, delayed operation, seagull sign, and femoral head injuries. We determined whether the superior gluteal artery and nerve were compressed by cerclage with the help of femoral angiography and EMG. Clinical outcomes were graded as very good to excellent for 18 patients, good for five, fair for three and poor for five. Preoperative femoral head injury (P = 0.011), a seagull sign (P = 0.001), poor reduction (P = 0.015), and delayed reduction (P = 0.05) were found to statistically influence clinical results. We found that there were no injuries to the superior gluteal artery and nerve in spite of using a cable. Cerclage methods can be useful for initial reduction of displaced medial plates in acetabular fractures. These methods reduce operation time and blood loss as compared with other methods.

Eleven-year follow-up of second-generation metal-on-metal total hip arthroplasty.

PURPOSE: To investigate the cause of failure in matte-surface cemented stems in second-generation metal-on- metal total hip arthroplasty (THA). METHODS: Records of 26 men and 11 women (39 hips) aged 29 to 72 years who underwent primary cementless THAs by a single surgeon using second-generation metal-on-metal prostheses and were followed up for a mean of 122 (range, 120-141) months were reviewed. Two types of femoral stems were used: a cementless Ti-alloy stem (n=21) and a matte-surface, iron-based alloy, cemented stem (n=18). Clinical outcomes were measured using the Harris hip score. Radiographs were assessed for stem loosening and osteolysis. Patient activity levels were graded. Surfaces of the retrieved femoral stems and periprosthetic tissue samples were examined. Metallic and cement particles were studied. Hypersensitivity to metal was tested. RESULTS: None of the cementless stems were revised; no osteolysis or stem loosening occurred. In contrast, 7 of 18 matte-surface cemented stems were revised owing to stem loosening or osteolysis. Periprosthetic tissues revealed abundant cement-related particles; 90% were zirconium oxides but a few were iron particles. Histological examination of periprosthetic tissues showed perivascular infiltration of lymphocytes and macrophages containing tiny foreign materials. Metal hypersensitivity was not associated with aseptic loosening. CONCLUSION: Metal-on-metal THA with cementless components could be recommended for young, active patients to prevent wear and osteolysis. The matte-surface cemented stem is more likely to fail owing to friction during the earlier stage and cement-related biological processes during the later stage.

A distal fluted, proximal modular femoral prosthesis in revision hip arthroplasty.

Most reports on the use of modular femoral stems during revision surgery have involved short follow-up periods. The authors evaluated the clinical and radiographic performance of 59 patients fitted with a distal fix modular stem. The average follow-up period was 8.2 years. Average Harris hip score was improved from 47 to 87.6. Of 19 patients with trochanteric osteotomy, 4 had a displaced greater trochanter. Re-revision was performed in 5 patients, and 3 of these were for subsidence (of these 3, subsidence was associated with dissociation of the coupling part in 1 and with osteotomy nonunion in other 2 [proximal component only]). Modular distally fixed femoral stems were found to offer intraoperative flexibility, but to suffer from subsidence and intraoperative greater trochanter and metaphyseal femoral fractures.

Management of periprosthetic femur fractures treated with distal fixation using a modular femoral stem using an anterolateral approach.

The authors retrospectively analyzed 27 hips with periprosthetic femoral fractures (types B2 and B3) treated with distal fixation using a modular, fluted, femoral stem. The average follow-up was 4.8 years. Most fractures (25 hips) were united (92.6%), and mean Harris Hip Score at follow-up was 84.7. Subsidence was noted in 2 patients within 6 months postoperatively, but despite the subsidence, one achieved union. One patient developed peroneal nerve palsy. Two hips were defined as failure: one nonunion associated with infection, and the other one had 10 mm more subsidence. No dislocation occurred in any of the patients. This technique has proven to be reliable in the treatment of difficult fractures in the acute stage, although concerns regarding the subsidence remain when using this femoral stem.

Ischemic optic neuropathy after hemiarthroplasty for femoral neck fracture.

Ischemic optic neuropathy due to hemorrhaging remote from visual pathway can occur after surgery. This complication is usually associated with a chronic bleeding disorder, such as gastrointestinal hemorrhage, diabetes, arteriosclerosis, and/or metal poisoning. There are many complications related to cemented hemiarthroplasty in patients who have a femoral neck fracture, such as dislocation, infection, leg length discrepancy, peroneal nerve palsy, and embolism. However, visual loss after this procedure has not previously been reported. In the case reported here, the operation time was short, and there was no massive hemorrhaging. Unilateral visual loss occurred within 3 days of an apparently safe and simple unilateral hemiarthroplasty of the hip.

Transverse subtrochanteric shortening osteotomy in primary total hip arthroplasty for patients with severe hip developmental dysplasia.

Twenty-four total hip arthroplasties were performed on patients with Crowe grade 3 or 4 hip dysplasia using subtrochanteric shortening osteotomy with 2 kinds of femoral stems. The average age of the patients was 44.8 years, and their average length of follow-up was 4.7 years. Acetabular reconstruction with structural autograft was used in 11 hips. Radiologically, hip centers were nearly normalized by a vertical height of 10.6-mm elevation and a horizontal length of 1.7 mm as compared with uninvolved sites. Three osteotomy nonunions required revisions with bone graft. One acetabular revision was performed for migration. One postoperative dislocation was managed successfully with closed reduction and an abduction brace. However, no neurologic complication was noticed. The Harris hip score improved from 35.6 to 81.7. A cementless modular distal fluted femoral stem is a useful device in these patients.

Management of periprosthetic femoral fractures.

We followed up 37 periprosthetic fractures to assess the factors related to the outcomes and the loosening of prostheses. The average union time is 3.1 months (range, 2-6.2 months). The most common types were fractures around the stem tip and displaced (89.1%). In our study, the loosening rate (32.4%) was low compared with other reports. These might be due to the cementless stem, but the difference was not significant (P>.05). After management of the fracture with a plate, we noted 5 complications: 2 nonunion and 3 refractures. The causes of these complications were related to screw in the level of the stem tip. Therefore, in the management of fractures with plates, we do not recommend using a screw in the area of the stem tip but rather using a cerclage proximally and bone graft. If stem was unstable or stability was uncertain, and the arthroplasty did not function well previously, revision with a distal fluted stem showed an early bony union.