Hip Hemiarthroplasty: The Misnomer of a Narrow Femoral Canal and the Cost Implications.

Objective Hemiarthroplasty has been identified as the treatment of choice for displaced intracapsular femoral neck fractures. A modular prosthesis is sometimes preferred for its sizing options in narrow femoral canals, despite its higher cost and no advantage in clinical outcomes. Thus, in this study, we investigated the factors affecting surgeons' choice of prosthesis, hypothesizing that modular hemiarthroplasty is overused for narrow femoral canals compared to monoblock hip hemiarthroplasty. Methods A retrospective study of a regional level 1 trauma center was conducted. Patients who had sustained femoral neck fractures from March 2013 to December 2016 were included in this study. Inclusion criterion was modular hemiarthroplasty for a narrow femoral canal. A matched group of patients who underwent monobloc hemiarthroplasty (MH) was created through randomization. The main outcome measurements were sex, age, Dorr classification, and femoral head size. We measured the protrusion of the greater trochanter beyond the level of the lateral femoral cortex postoperatively. Modular hemiarthroplasty patients were templated on radiographs using TraumaCad for Stryker Exeter Trauma Stem (ETS®). Results In total, 533 hemiarthroplasty procedures were performed, of which 27 were modular for a narrow femoral canal. The ratio of modular to monobloc was 1:18. Average head size was 46.7 mm ± 3.6 mm for monobloc and 44.07 ± 1.5 for modular (P= 0.001). There were four malaligned stems in the monobloc group versus 14 in the modular group (P= 0.008). Unsatisfactory lateralization was noted in 18 patients (7 mm ± 2.9 mm) in the modular group compared with 8 (4.7 mm ± 3.9 mm) in the monobloc group (P= 0.029). Dorr classification was A or B in 24 patients in the modular group and 18 in the monobloc group (P = 0.006). Templating revealed that modular was not required in 25 patients. Conclusions As per our findings, it was determined that patients with a narrow femoral canal intraoperatively should not receive modular hemiarthroplasty. This is especially true for female patients with small femoral head and narrow femoral canal dimensions (Dorr A and B). They would require extensive careful planning. Surgical techniques should be explored through education intraoperatively to achieve lateralization during femoral stem preparation. This may avoid prolonged anesthetic time and achieve potential cost savings.

The association between mode of delivery and developmental dysplasia of the hip in breech infants: a systematic review of 9 cohort studies.

Although developmental dysplasia of the hip (DDH) is a relatively common disorder, its aetiology remains elusive. The authors undertook a systematic review to determine whether there is an association between DDH and vaginal or caesarean delivery for singleton breech infants. The review focussed on cohort studies which provided risk estimates for DDH in breech-presenting infants, as a function of mode of delivery. Nine cohort studies with 35,139 infants were found. In the short-term, breech infants delivered through caesarean section had a significantly lower risk (13.5% less) for DDH: 5.95%, versus 6.88% (weighted values) in the vaginal delivery group (p = 0.008) {RR = 0.87 (95% CI 0.78-0.97)}. This might be mediated by the reduced stretch of the hip capsule, due to the absence of increased uterine pressure, which normally occurs in the active phase of labour. This pleads for the hypothesis that the mode of delivery is the critical factor promoting dislocation, not the breech presentation itself. Long-term data were not available, so that the overall effectiveness of caesarean section compared to vaginal delivery could not be established.

Post-radiotherapy vesicocutaneous fistula presenting as gas/fluid-filled groin swelling.

We report an interesting and rare case of a vesicocutaneous fistula, which was diagnosed only one year following radiotherapy. A 71 year old gentleman presented with a gangrenous swelling of his left thigh. A copius amount of urine was seen to be draining from the site after initial incision and drainage. Computed tomography with contrast confirmed the diagnosis of a vesicocutaneous fistula. Bilateral nephrostomies were inserted to aid spontaneous closure of the fistula. Previous case reports of vesicocutaneous fistulae involving radiotherapy have described the complication of a fistula occurring many years after the intervention.