Metallosis Following Non-Metal-on-Metal Hip Arthroplasty: A Case Report and Review.

Introduction: Metallosis which is traditionally associated with Metal-on-Metal (MoM) hip arthroplasty can occur with other bearing surfaces too, posing diagnostic challenges. They can be asymptomatic or present with local and systemic symptoms. This article reports a case of metallosis in a total hip replacement (THR) with metal on polyethylene (PE) articulation who presented with dislocation. It also reviews the pathology and various presentations of metallosis following hip arthroplasty. Case Report: A 35-year-old female patient presented 4 years after a left THR with recurrent dislocation. It was an uncemented prosthesis with metal on PE articulation. Serology and radiological investigations were done to evaluate for infection, implant loosening, implant malposition, etc. The femoral stem appeared to be in varus malposition. She was posted for revision surgery with a pre-operative plan to change the femoral stem and head if necessary. Intraoperative signs of local metallosis were noticed. Debridement was done along with the change of the femoral stem and bearing surface to ceramic on PE. Metallosis was also later confirmed by the histopathological report. The patient has been symptom-free during the 2-year follow-up period. Conclusion: Metallosis can occur even in non-MoM articulations and a high degree of clinical suspicion is required to detect the same preoperatively. Classical signs of metallosis can often be absent in the early disease and subtle signs of instability must be looked out for even in the absence of obvious misalignment in radiographic assessment. Metallosis when combined with malposition or malalignment can be more detrimental. If detected early before osteolysis and periarticular soft tissue damage sets in, a complete revision of all the implant components and abductor damage can be avoided. In suspected cases, a lower threshold should be adopted for sending blood and joint aspirates for cobalt-chromium levels.

Comparison of Twin Screw Derotation Type Versus Single Helical Blade Type Cephalomedullary Nail in the Management of Unstable Intertrochanteric Fractures.

BACKGROUND: The intertrochanteric fracture is a frequently occurring fracture, often attributed to osteoporosis in older populations. Recently, there has been a proposal to perform early surgical fixation on elderly patients to facilitate early rehabilitation. This approach has been shown to have a beneficial effect in lowering comorbidities. The study aims to compare the efficacy of the twin screw derotation type cephalomedullary nail with that of the single helical blade type cephalomedullary nail in the management of unstable intertrochanteric fractures. METHODOLOGY:  The research sample included patients from the orthopedic outpatient and emergency departments of Adesh Medical College and Hospital, Ambala Cantt, India, who were scheduled for surgery for unstable intertrochanteric femur fractures. The patients were categorized into two groups according to the kind of implant they were given: either a twin screw derotation cephalomedullary nail or a single helical blade cephalomedullary nail. The functional result was evaluated by comparing the modified Harris hip score (HHS). Patients with unstable intertrochanteric fractures, including reverse oblique fractures and fractures with posteromedial comminution, as well as patients who provided consent, were included in this study. RESULTS:  Thirteen individuals received treatment with proximal femoral nail antirotation (PFNA2), whereas 19 individuals received treatment with proximal femoral nail (PFN). The mean age in the PFNA2 group was 69.51, whereas the mean age in the PFN group was 70.804. There were three patients in the PFNA2 group and five patients in the PFN group who had a tip apex distance of more than 25 mm. According to the Cleveland index, nine patients in the PFNA2 group and eight patients in the PFN group had an implant location that was not optimum. Four patients in the PFNA2 group and seven patients in the PFN group had a neck shaft angle difference of more than 10° between their undamaged and operated sides. The mean HHS was 74.55 for the PFNA2 group and 69.88 for the PFN group. The PFNA2 group exhibited four problems, whereas the PFN group had five issues. CONCLUSION:  The study found that both implants offer similar functional outcomes, with adherence to specific radiological parameters optimizing results. While both face similar challenges with osteoporosis, there was no notable distinction between them. Notably, the PFNA2 group showed superior outcomes in perioperative morbidity.

A Pilot Study of Functional Outcomes in Adult Patients Treated With Valgus Intertrochanteric Osteotomy as a Primary Modality for Intracapsular Femoral Neck Fracture.

Background Intracapsular femoral neck fractures account for a majority of hip fractures. This study aimed to investigate the efficacy of valgus osteotomy as a primary treatment for intracapsular femoral neck fractures in adult patients aged 15-60 years, assessing its impact on functional outcomes and fracture union. Methodology A retrospective clinical analysis was conducted at the Department of Orthopedics and Traumatology, Osmania Government General Hospital, Hyderabad, India, focusing on patients treated with primary intertrochanteric valgus osteotomy for intracapsular femoral neck fractures. The study reviewed medical charts and radiographs of six patients aged between 15 and 60 years, diagnosed with recent isolated intracapsular femoral neck fractures, presenting between May 2019 and October 2021. The intervention involved Pauwels' intertrochanteric valgus osteotomy with various fixation methods. Main outcome measures included radiographic union, functional ability assessed by the Harris Hip Score, and evaluation for complications. Results All six patients achieved radiographic union at fracture and osteotomy sites, totaling a 100% success rate. The average follow-up duration was 14.8 months (12-20 months), with an average time of 5.1 months (2.5-6 months) from surgery to radiographic union. One patient experienced union with retroversion, while another developed avascular necrosis (AVN) by the study's conclusion. No instances of hardware failure or non-union were observed. The average Harris Hip Score obtained during the most recent clinical follow-up was 84, ranging from 69 to 94. All six patients regained independent walking ability without any support by the end of the follow-up period. Conclusion The combination of primary Pauwels' intertrochanteric valgus osteotomy with fixed-angle plating proves to be a highly effective method for addressing recent intracapsular femoral neck fractures, resulting in a 100% success rate in achieving union among the patient cohort.

A Comparative Study of Dynamic Hip Screws and Proximal Femoral Nails in Intertrochanteric Fractures.

Background Intertrochanteric fractures, which occur in the hip of older individuals due to the weak and brittle structure of the bone caused by osteoporosis, make up over 50% of all hip fractures. There are several treatment options available for these fractures. The major objective of this study was to carry out a comparative analysis to evaluate the efficacy of dynamic hip screws (DHS) and proximal femoral nails (PFN) in treating intertrochanteric fractures. Methodology Two hundred instances of intertrochanteric hip fractures were surgically treated between July 2022 and January 2024 at a tertiary care facility. The evaluation of fractures was conducted in two groups, namely, group 1, which consisted of 140 patients, each having a fracture in one hip, treated using the DHS method. Group 2 consisted of 60 patients, each having a fracture in one hip, treated using the PFN technique. The evaluation of functional results was performed with the Harris hip score. Results In the investigation within these groups, group 1 produced excellent outcomes in 53 patients, which accounts for 37.86% of the total. In group 2, the expected results were achieved in 34 patients (56.67%). Achieved outcomes were favorable in 75 (53.57%) individuals in group 1 and 21 (35%) in group 2. Out of the individuals in group 1, eight (5.71%) saw benefits, whereas four (1.6%) did not gain significantly. In group 2, five (8.33%) individuals benefitted. None of the patients in group 2 had unfavorable outcomes. Conclusion While both PFN and DHS provide comparable outcomes in stable bone, PFN demonstrated superior results in cases of unstable bone. The use of PFN results in reduced surgical duration and a smaller surgical opening. Additionally, PFN exhibited superior specificity compared to DHS, especially in cases with stable intertrochanteric bone.

Appraisal of Clinical Improvement With Total Knee Arthroplasty in Valgus Knee Deformities: A Case Series.

Introduction This case series explores the efficacy of unassisted total knee arthroplasty (TKA) in addressing valgus knee deformity secondary to osteoarthritis. The study aims to evaluate functional outcomes pre- and post-surgery using the Knee Society Score (KSS) and radiological assessments in short-term follow-up. Six patients underwent TKA and were evaluated retrospectively. Statistical analysis revealed significant improvements in the angle of deformity, KSS, and range of motion postoperatively. The study underscores the success of TKA in correcting valgus deformity, improving knee function, and enhancing patient satisfaction. TKA is a highly successful treatment for osteoarthritis, providing functional recovery and improved quality of life. However, valgus knee deformity presents a challenge in TKA, affecting approximately 10% of patients. This study aims to assess the functional outcomes of TKA for valgus deformity using KSS and radiological evaluation in short-term follow-up. Materials and methods A retrospective observational study was conducted from November 2022 to December 2023, involving six patients with valgus knee deformity secondary to osteoarthritis. TKA was performed with no technological assistance, and patients were assessed pre- and post-surgery using KSS and radiological measurements. Statistical analysis was performed using paired t-tests. Case description Six patients with grade two valgus deformity underwent technology-unassisted TKA. The postoperative assessment revealed significant improvements in the tibiofemoral angle, KSS, and range of motion. The medial parapatellar approach for TKA was utilized with a standard unconstrained primary TKA prosthesis, resulting in successful correction of deformity and improved knee alignment. Discussion TKA is a widely performed and reliable surgical intervention, with valgus knee deformity posing specific challenges. This study demonstrates the effectiveness of conventional TKA in correcting valgus deformity, improving knee function, and enhancing patient satisfaction in a very small case series. Comparison with previous studies supports the findings of the pre-existing literature, highlighting the importance of appropriate surgical approach and patient selection. Conclusion TKA utilizing a medial parapatellar approach proved effective in our small case series in correcting valgus deformity, improving knee function, and enhancing patient satisfaction. Short-term follow-up reveals significant improvements in stability, posture, and KSS scores. Further assessments and longer-term follow-up are warranted to confirm the long-term effectiveness of this approach.

Optimising safe margins in shoulder surgeries: a cadaveric study on brachial plexus nerves with anthropometric and movement correlation.

PURPOSE: Shoulder surgeries, vital for diverse pathologies, pose a risk of iatrogenic nerve damage. Existing literature lacks diverse bone landmark-specific nerve position data. The purpose of this study is to address this gap by investigating such relationships. METHOD: This cadaveric study examines axillary, radial and suprascapular nerves' relation with acromion, coracoid and greater tuberosity of the humerus (GT). It also correlates this data with humeral lengths and explores nerve dynamics in relation to arm positions. RESULTS: The mean distance from the axillary nerve to (i) GT was 4.38 cm (range 3.32-5.44, SD 0.53), (ii) acromion was 6.42 cm (range 5.03-7.8, SD 0.694) and (iii) coracoid process was 4.3 cm (range 2.76-5.84, SD 0.769). Abduction brought the nerve closer by 0.36 cm, 0.35 cm and 0.53 cm, respectively. The mean distance from radial nerve to (i) GT was 5.46 cm (range 3.78-7.14, SD 0.839), (ii) acromion was 7.82 cm (range 5.4-10.24, SD 1.21) and (iii) tip of the coracoid process was 6.09 cm (range 4.07-8.11 cm, SD 1.01). The mean distance from the suprascapular nerve to the acromion was 4.2 cm (range 3.1-5.4, SD 0.575). The mean humeral length was noted to be 27.83 cm (range 25.3-30.7, SD 1.13). There was no significant correlation between these distances and humeral lengths. CONCLUSION: It is essential to exercise caution to avoid axillary nerve damage during the abduction manoeuvre, as its distance from the greater tuberosity and tip of the coracoid process has shown a significant reduction. The safe margins, in relation to the length of the humerus and consequently the patient's stature, exhibit no significant variation. In situations where the greater tuberosity (GT) and the border of the acromion are inaccessible due to reasons such as trauma, the tip of the coracoid process can serve as a dependable bone landmark for establishing a secure surgical margin.