Clinical outcome of Bioball universal adapter in revision hip arthroplasty.

Background: Removal of a well-fixed uncemented femoral component in revision hip arthroplasty is challenging. A modular head-neck adapter provides an option to optimise the femoral offset and anteversion, avoiding the need for femoral stem revision. Aim: To present the clinical results following revision arthroplasty with the Bioball head-neck adapter in the elderly American Society of Anaesthesiologists (ASA) Grade II, III & IV patients. Materials and methods: A retrospective review of our database was performed, and all patients classed as ASA grades II, III, & IV treated with the Bioball Universal Adapter (BUA) for 10 years were included. The indication for revision, stem retention, type of adapter, and head size were identified. Patients were contacted by a research nurse to assess the Forgotten Joint Score (FJS), the Oxford Hip Score (OHS), and any symptoms of instability at a minimum of one year post revision surgery. Results: Our study included 47 patients. 5 (10.6%) were ASA II, 19 (40.4%) were ASA III and 23 (49%) were ASA IV. The mean age was 74 years. The mean follow up was 52 months ± 28.4 SD. The median FJS was 86 ± 11.6 SD. The median OHS was 43 ± 6.2 SD. One patient (2.1%) developed recurrent dislocation following lumbar spinal fusion. None of the other patients experienced instability. The survival rate for the adapter was 98%. Conclusion: The BUA gives good clinical outcomes with very low post revision instability. It is a valuable option for the elderly because it avoids the morbidity and risks associated with the removal of a well-fixed femoral stem. Level of Evidence: Level IV.

Comparison of two tapered fluted modular titanium (TFMT) stems used in revision hip arthroplasty from a single center.

Background: TFMT stems are modular porous coated stems widely used in revision hip arthroplasty. Although TFMT stems are popular due to its proven advantage in the setting of severe bone deficiency, subsidence is a concern in these stem designs. We used two TFMT stems between 2013 and 2019, ARCOS(Zimmer Biomet) and Reclaim(Depuy Synthes). We reviewed our results and compared these stems. Aim: The primary aim was a) look for early to mid-term stem survival b) radiological outcome measuring subsidence, secondary aim was to measure proximal femoral bone stock changes. Materials and methods: Data was collected retrospectively. There were 51 patients in Arcos and 57 patients in Reclaim cohort. Both cohorts were comparable with respect to gender, side, BMI, paprosky defect, indications for surgery, ETO and stem length. The mean age group was 78.03 in Arcos and 73.75 in Reclaim. Results: At a mean follow up of 5 years both cohorts showed excellent stem survival, 96.4% in Reclaim cohort as compared to 100% in Arcos. Subsidence was observed in both but none required a revision due to subsidence. There was a significant difference (p = 0.017) between the cohorts with mean of 2.3 mm(0-12 mm) in Arcos as compared to 4.5 mm(0-25 mm) in Reclaim. Both cohorts showed excellent restoration of proximal femoral bone stock. Conclusion: Our data shows promising results using TFMT stems at 5 year follow up with more than 95% stem survival, minimal subsidence and good restoration of proximal femoral bone stock. The difference in subsidence between these stems may be attributed to stem geometry and difference in taper.

Late Medial Migration of Lag Screw After Gamma3 Nailing Threatening the Internal Iliac Vessels: A Case Report.

CASE: A 77-year-old woman underwent Gamma3 Nail (Stryker) for an extracapsular fracture of the neck of femur on the left side. Eight months later, the lag screw had migrated medially into the pelvis and was in contact with the internal iliac vessels. After a multidisciplinary team meeting, embolization of the internal iliac artery was carried out prophylactically before the removal of screw and conversion to a total hip replacement. CONCLUSION: Although there are increasing number of case reports on late medial migration of lag screw, medial migration into pelvis with vascular complication is a very rare complication with 1 case report in the literature. The authors would like to make the orthopaedic community aware of this rare but potentially fatal complication and present the option for successful management.

Fractures in the elderly: when is hip replacement a necessity?

As the world's population ages, hip fractures pose a significant health care problem. Hip fractures in the elderly are associated with impaired mobility, and increased morbidity and mortality. Associated conditions, such as osteoporosis, medical comorbidity, and dementia, pose a significant concern and determine optimal treatment. One-year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. The incidence of hip fractures is bimodal in its distribution. Young adult hip fractures are the result of high energy trauma, and the larger peak seen in the elderly population is secondary to low-energy injuries. The predilection for the site of fracture at the neck of femur falls into two major subgroups. Pertrochanteric fractures occur when the injury is extracapsular and the blood supply to the head of femur is unaffected. The management of this group involves internal fixation through a sliding hip screw device or intramedullary fixation device, both of which have good results. The other group of patients who sustain an intracapsular fracture at the femoral neck are at increased risk of nonunion and osteonecrosis. Recent papers in the literature have shown better functional outcomes with a primary hip replacement over other treatment modalities. This article reviews the current literature and indications for a primary total hip replacement in these patients.

Predicting the outcome of Legg-Calve-Perthes' disease in children under 6 years old.

PURPOSE: In this study, we investigated the outcome of Legg-Calve-Perthes disease in children presenting under 6 years old. Firstly, we wished to know the outcome in terms of femoral head deformity in this age group. Secondly, we investigated the potential for improvement in femoral head deformity with growth and remodelling after the Perthes lesion had healed. Thirdly, we assessed the ability of Herring's lateral pillar classification to predict femoral head deformity in this age group. METHODS: The outcome in this group was assessed using Stulberg's classification of femoral head deformity and compared to that for older children with Perthes seen at our institution over the same period. To investigate the potential for improvement of Stulberg grade with growth we assessed the hips at the stage of final healing (Waldenstrom IV) and again at skeletal maturity. To assess whether Herring's classification of lateral column collapse is predictive of deformity at this age we recorded the Herring class A, B or C at the time of maximum fragmentation and compared this to Stulberg grade. RESULTS: Out of a total of 127 children (131 hips) seen at our institution, 67 children (69 hips) presented before the age of 6 years. The number of Stulberg III and IV hips was 14 (20%) and 10 (15%), respectively. Chi-squared test of age against outcome confirmed that the younger children overall had a better outcome (P < 0.001). Stulberg grade did not improve predictably after the stage of final healing. Twenty-three hips graded as Stulberg III and IV at Waldenstrom IV were reassessed at skeletal maturity. Three changed from Stulberg III to IV and five changed from Stulberg IV to III, but none had improved to Stulberg I/II. Herring's classification was predictive of outcome, with 96% of Herring A hips having Stulberg I or II outcome, 61% of Herring B hips having Stulberg I or II outcome, while 60% of Herring C hips (18 hips) had significant femoral head deformity, and 10 hips Stulberg III and 6 hips Stulberg IV. CONCLUSIONS: Perthes in children presenting before 6 years of age can result in significant femoral head deformity which does not predictably improve with time. The risk of a poor outcome can be predicted by Herring's classification of lateral pillar collapse.

Proximal femoral geometry: a radiological assessment.

We aimed to analyze radiographically the relationship between the tip of the greater trochanter and the center of the femoral head. One hundred fifty randomly selected radiographs of patients due to undergo total hip arthroplasty were analyzed for the relationship between the center of the femoral head and the tip of the greater trochanter. We found that the center of the femoral head was 9.5 +/- 6 mm below (9 mm above to 24 mm below) the tip of the greater trochanter. Many techniques have been described to diminish the inadvertent limb lengthening during total hip arthroplasty. One of the commonly used methods has been alignment of the tip of the greater trochanter with the center of the femoral head. The aim of the article is to discourage the use of the tip of the greater trochanter as guide because it may lead to inadvertent limb lengthening.

Perthes' disease in the very young child.

We report two cases of very young children who presented with irritable hips and in whom magnetic resonance imaging with gadolinium-enhancement revealed ischaemic changes affecting the capital ossific nucleus. Radiological changes consistent with Perthes' disease subsequently appeared. In the published literature Perthes' disease has been reported in children as young as 24 months. Gadolinium-enhanced magnetic resonance imaging has revealed Perthes' disease in younger children which can predate the appearance of radiographic changes by up to 3 months.