Treatment of periprosthetic femoral fractures after femoral revision using a long stem.

BACKGROUND: Periprosthetic femoral fractures are becoming increasingly common and are a major complication of total hip arthroplasty and hemiarthroplasty. The treatment of periprosthetic femoral fracture after femoral revision using a long stem is more complex and challenging. The purpose of this study was to identify the clinical and radiographical features of periprosthetic femoral fractures after revision using a long stem. METHODS: We report a retrospective review of the outcomes of treatment of 11 periprosthetic fractures after femoral revision using a long stem. Eleven female patients with a mean age of 79.2 years (70 to 91) were treated for a Vancouver type B1 fracture between 1998 and 2013. The mean numbers of previous surgeries were 3.1 (2 to 5). RESULTS: The average follow-up was 58.9 months (8 to 180). We found several important features that might influence the outcome of treatment for periprosthetic femoral fractures after femoral revision using a long stem: 1) all cases were classified as Vancouver type B1. 2) 6 patients (55%) had a transverse fracture around the tip of the long stem. 3) 7 patients (64%) had a history of previous fracture of the ipsilateral femur. The type B1 fractures were treated with open reduction and internal fixation in 9 hips, 6 of which were reinforced with bone grafts. Two other periprosthetic fractures were treated with femoral revision. One was revised because of stem breakage, and the other was a transverse fracture associated with poor bone quality, which received a femoral revision with a long stem and a plate. All fractures except one achieved primary union. This failed case had a bone defect at the fracture site, and revision surgery using a cementless long stem and allografts was successful. CONCLUSIONS: These findings suggest that most cases of type B1 fracture after revision using a long stem have been treated successfully with open reduction and internal fixation. However, a transverse fracture with very poor bone quality might be considered as a type B3 fracture, and femoral revision might be a treatment of choice.

Long-Term Outcome of Acetabular Reconstruction Using a Kerboull-Type Acetabular Reinforcement Device with Hydroxyapetite Granule and Structural Autograft for AAOS type II and III Acetabular Defects.

We evaluated the clinical results of the reconstruction of acetabular bone deficiency using hydroxyapatite (HA) granules and structural autografts supported by a Kerboull-type acetabular reinforcement device at a minimum of 10 years follow-up. Between 1993 and 2003, 40 consecutive THA revisions were performed in 37 patients with a mean age of 66.4 years. The mean follow-up period was 12.8 years. Radiologically, 5 hips failed, of which 2 were revised. The survival rate of the acetabular component at 10 years was 100% in type II defects and 94.9% in the type III defects, using acetabular revision for loosening as the end point. Acetabular reconstruction with HA granules, structural autografts and a Kerboull-type acetabular reinforcement device provided satisfactory clinical and radiological results at 12.8 years postoperatively.

Radiographic features of teriparatide-induced healing of femoral fractures.

Teriparatide is a drug that is used to increase bone remodeling, formation, and density for the treatment of osteoporosis. We present three cases of patients with a femoral insufficiency fracture. The patients were administered teripatatide in an attempt to treat severe osteoporosis and to enhance fracture healing. We found several radiographic features around the femoral fractures during the healing period. 1) Callus formation was found at a very early stage in the treatment. Teriparatide substantially increased the unusually abundant callus formation around the fracture site at 2 weeks. Moreover, this callus formation continued for 8 weeks and led to healing of the fracture. 2) Abundant callus formation was found circumferentially around the cortex with a 'cloud-like' appearance. 3) Remodeling of the teriparatide-induced callus formation was found to be part of the normal fracture healing process. After 1 year, normal remodeling was observed on plain radiographs. These findings indicate that teriparatide can be used as an adjuvant therapy in the management of femoral insufficiency fractures.

Total hip arthroplasty for Crowe IV hip without subtrochanteric shortening osteotomy -a long term follow up study.

BACKGROUND: Several authors reported encouraging results of total hip arthroplasty (THA) for Crowe IV hips performed using shortening osteotomy. However, few papers have documanted the results of THA for Crowe IV hips without shortening osteotomy. The aim of the present study was to assess the long term-results of cemented THAs for Crowe group IV hips performed without subtrochanteric shortening osteotomy. METHODS: We have assessed the long term results of 27 cemented total hip arthroplasty (THA) performed without subtrochanteric osteotomy for Crowe group IV hip. All THAs were performed via transtrochanteric approach. RESULTS: After a mean follow-up of 10.6 (6 to 17.9) years, 25 hips (92.6%) had survived without revision surgery and survivorship analysis gave a survival rate of 96.3% at 10 years with any revision surgery as the end point. Although mean limb lengthening was 3.2 (1.0 to 5.1) cm, no hips developed nerve palsy. Complications occurred in four hips, necessitating revision surgery in two. Among the four complications, three involved the greater trochanter, two of which occurred in cases where braided cables had been used to reattach the greater trochanter. CONCLUSIONS: Although we encountered four complications, including three trochanteric problems, our findings suggest that THA without subtrochanteric shortening osteotomy can provide satisfactory long-term results in patients with Crowe IV hip.

Cemented total hip arthroplasty with transverse subtrochanteric shortening osteotomy for Crowe group IV dislocated hip.

A consecutive series of 19 cemented total hip arthroplasties with transverse subtrochanteric shortening osteotomy was performed for Crowe group IV hip, with a mean follow-up of 38 (6-96) months. The osteotomy sites were covered with onlay grafts of the excised fragments. The conditions of the osteotomy sites were classified into 3 types according to the presence of a remaining gap and cement interposition within it. Three cases had a noticeable gap, and 2 of them showed cement interposition. All osteotomy sites became united involving the onlay grafts, with an average time to union of 4.9 (3-8) months. Our findings suggest that cemented total hip arthroplasty with subtrochanteric transverse osteotomy provides satisfactory short-term results without major complications for Crowe group IV hip.

[Myoclonus following spinal and epidural anesthesia--a case report].

We report a case of spinal myoclonus following cesarean section. The patient was a 34-year-old woman without history of neurologic disorders. In the operating room, after placement of an epidural catheter at T12-L1, bupivacaine 2.4 ml was administered intrathecally via a 25 G needle at L2-3. Epidural administration of ropivacaine (0.13%, 4 ml x hr(-1)) was started 72 min after spinal anesthesia. The intra- and postoperative courses were otherwise uneventful. The patient complained of involuntary jerky movements of her lower legs 195 min after the start of the spinal anesthesia. The sensory level was T12 and she could move her legs on command but could not stop her involuntary movements. The myoclonic movements ceased 150 min later without medication and did not reappear, despite restarting the epidural anesthesia with ropivacaine.

Total hip arthroplasty using Kerboull-type acetabular reinforcement device for rapidly destructive coxarthrosis.

We studied 20 primary cemented total hip arthroplasties performed using Kerboull-type acetabular reinforcement device for rapidly destructive coxarthrosis. The average patient age at the time of surgery was 68.3 (range, 60-77) years. The mean follow-up period was 6.3 years (3.8-11.8). The mean preoperative Japanese Orthopedic Association hip score was 38.1 (16-70) vs 85.2 (70-93) at the latest follow-up. The radiographic outcome in 20 hips showed no migration or aseptic loosening. A partial radiolucent line at the cement-bone interface was noted in 2 hips (10%), but no progression occurred. There were no major complications. No patient required repeated surgery. The use of Kerboull-type acetabular reinforcement device for rapidly destructive coxarthrosis provided satisfactory 3-year to 11-year clinical and radiographic results.