Survivorship Analysis of Eighty Revised Hip Arthroplasties With the Impaction Grafting Technique Using Whole Femoral Head Allografts With the Articular Cartilage.

BACKGROUND: Acetabular impaction bone grafting aims to restore anatomy in hip revision surgery. This is an effective but expensive and time-consuming technique. Usually, the articular cartilage is removed from the femoral head allograft. We aimed to reproduce the same results retaining the cartilage of the allograft. METHODS: Eighty acetabular revisions using impacted morselized bone graft retaining the articular cartilage and a cemented cup were studied retrospectively. Six were lost during follow-up. The mean follow-up was 6.5 years (range 1-13). Clinical and radiological assessment was made using the Oxford Hip Score, Hodgkinson's criteria for socket loosening, and the Gie classification for evaluation of allograft incorporation. RESULTS: Sixty-three sockets (85.1%) were considered radiologically stable (type 0, 1, and 2 demarcations), 8 (10.8%) were radiologically loose (type 3), and 3 (4.1%) presented with migration. Fifty-one (68.9%) cases showed good trabecular remodeling (grade 3), 20 (27%) showed trabecular incorporation (grade 2), and 3 (4.1%) showed poor allograft incorporation. Mean preoperative hip score was 43 and postoperative score was 28. Six (8.1%) cases presented heterotopic ossification around the revised implants, 2 patients (2.7%) had periprosthetic fractures, and 4 (5.4%) had dislocations. The Kaplan-Meier survivorship at a mean of 6.5 years with revision of the cup for any reason was 95.9% (95% confidence interval 5.6-7.5). CONCLUSION: The mid-term results of our technique are promising. Particularly when the supply of fresh-frozen allografts and surgical time is limited, using whole femoral head with articular cartilage is both safe and effective.

Comparison of femoral stem alignment in primary total hip replacement by transtrochanteric and posterior approach.

BACKGROUND: In this study we have compared the femoral component alignment in primary cemented THR performed by a single surgeon using the same implant by trochanteric osteotomy and posterior approach in 50 consecutive cases. MATERIAL AND METHODS: The femoral component was compared in sagital and coronal planes on plane X-rays. The femoral stem position was classified as neutral, varus or valgus in the sagital plane. In the coronal plane the femoral stem was graded as neutral, stem pointing anteriorly or stems pointing posteriorly. Chi square test was used for the statistical significance of the findings. RESULTS: The number of stems in neutral position in AP radiograph (coronal plane) was 36 and 42 respectively in osteotomy and posterior approach. 6 stems were in varus/valgus angle of ≥5° in osteotomy group and 1 stem in the posterior approach group had a varus/valgus angle of ≥5° (p value 0.05). In the lateral radiograph (sagital plane) 45 and 43 stems respectively in osteotomy and posterior approach were in neutral position (p value 0.37). CONCLUSIONS: There is no statistically significant difference in the positioning of the femoral stem in the sagital plane by either trochanteric osteotomy or posterior approach to the hip. The positioning of the femoral stem in the coronal plane is better with the posterior approach as compared to trochanteric osteotomy

Extraction of Fractured Femoral Stem in Primary Cemented Hip Replacements: Surgical Technique using a Mole Wrench.

Extracting a fractured stem poses a technical challenge in revision surgery. A number of techniques have been described based on method of fixation (cemented or uncemented); location of the fracture; and composition of the stem alloy. These include the drilling and cortical window techniques. We describe our surgical removal of a proximally fractured cemented stem using a Mole wrench.

Rheumatoid forefoot reconstruction: 1st metatarsophalangeal fusion and excision arthroplasty of lesser metatarsal heads.

This is a retrospective review of 66 feet (mean follow-up of 3 years) in 43 patients with painful severe rheumatoid forefoot deformities. All were treated by arthrodesis of the first metatarsophalangeal (MTP) joint through a dorsomedial incision and excision of the lesser metatarsal heads through a separate plantar approach. The mean post-operative AOFAS scores were 65.94 (range: 32 to 82). The mean post-operative Foot Function Index (FFI) was 0.47 (range: 0.23 to 0.63). Eighty five percent (57/67 feet) reported excellent or good pain relief, improved cosmetic appearance, and improved footwear comfort. The mean hallux valgus angles improved from 39 degrees to 16 degrees and the intermetatarsal angle from 16 degrees to 8 degrees. Five feet had nonunion of the 1st MTP joint arthrodesis. There were five re-operations for non-union of the 1st MTP joint arthrodesis. The success of the operation as evidenced by this study depends upon attention to metatarsal length harmonisation, stabilisation of the 1st MTP joint and thereby even distribution of loading of the forefoot. The poor results in this study were as a result of a failure to secure the stability of the 1st MTP joint.

Intrarater and interrater reliability of the socket version marker in total hip replacement.

The aim of this study was to evaluate the intraobserver and interobserver variability in determining the socket version using the wire marker. 100 anteroposterior pelvis radiographs of cemented primary total hip replacements were reviewed by two orthopaedic consultants and registrars, twice. Intrarater and interrater reliability were assessed using Cohen's kappa. Intrarater kappas for junior doctors were 0.78 and 0.80, 0.73 and 0.62 for Consultants. Interrater kappas were 0.60 between the two Consultants and 0.63 between the two Junior Doctors. The kappas between Consultant A and Junior Doctor A was 0.61, between Consultant A and Junior Doctor B was 0.59, between Consultant B and Junior Doctor A was 0.53 and between Consultant B and Junior Doctor B was 0.46. Intrarater reliability was substantial for the two junior doctors and the two consultants. Interrater reliability was moderate-to-substantial between the two consultants, between the two junior doctors and between each pair of junior doctors/consultants.

Forearm Compartment Syndrome following Thrombolytic Therapy for Massive Pulmonary Embolism: A Case Report and Review of Literature.

Use of thrombolytic therapy in pulmonary embolism is restricted in cases of massive embolism. It achieves faster lysis of the thrombus than the conventional heparin therapy thus reducing the morbidity and mortality associated with PE. The compartment syndrome is a well-documented, potentially lethal complication of thrombolytic therapy and known to occur in the limbs involved for vascular lines or venepunctures. The compartment syndrome in a conscious and well-oriented patient is mainly diagnosed on clinical ground with its classical signs and symptoms like disproportionate pain, tense swollen limb and pain on passive stretch. However these findings may not be appropriately assessed in an unconscious patient and therefore the clinicians should have high index of suspicion in a patient with an acutely swollen tense limb. In such scenarios a prompt orthopaedic opinion should be considered. In this report, we present a case of acute compartment syndrome of the right forearm in a 78 years old male patient following repeated attempts to secure an arterial line for initiating the thrombolytic therapy for the management of massive pulmonary embolism. The patient underwent urgent surgical decompression of the forearm compartments and thus managed to save his limb.

Early results of whole femoral head allograft with articular cartilage for acetabular impaction grafting in revision hip replacements.

INTRODUCTION: Extensive bone loss associated with revision hip surgery is a significant orthopaedic challenge. Acetabular reconstruction with the use of impaction bone grafting and a cemented polyethylene cup is a reliable and durable technique in revision situations with cavitatory acetabular bone defects. Some use cancellous graft alone whilst others morselise the whole femoral head after removal of articular cartilage. This paper asks, if it really necessary to use pure cancellous graft? PATIENTS AND METHODS: Forty-two acetabular revisions using impacted morselized bone graft without removal of articular cartilage and a cemented cup were studied retrospectively. The mean follow-up was 3 years (range, 2-5.6 years). Clinical and radiographic assessment was made using the Oxford hip score, Hodgkinson's criteria (1988) for socket loosening and the Gie classification (1993) for evaluation of allograft consolidation and remodelling. RESULTS: Forty (95%) sockets were considered radiologically stable (type 0, 1, 2 demarcations) and two (5%) sockets were radiologically loose (Type 3 demarcation). There was no socket migration in our series. Twenty-seven(64%) cases showed good trabecular remodelling (grade 3). Twelve (29%) cases showed trabecular incorporation (grade 2). Only three (7%) cases showed poor allograft incorporation (grade 1). Average pre-operative Oxford hip score was 41 and postoperative hip score was 27. There have been no socket re-revisions (100% survival) at an average of 3 years. CONCLUSIONS: Early radiological and clinical survival results with retaining articular cartilage of femoral head allografts are similar and comparable to other major studies for acetabular impaction bone grafting in revisions. Minimal loss of allograft mass is 40% in obtaining pure cancellous graft. When there is a limited supply and demand of allograft, saving up to 40% of the material is a valuable and cost-effective use of scarce resources.