Factors Affecting Periprosthetic Bone Loss after Hip Arthroplasty.

Periprosthetic bone loss may lead to major complications in hip arthroplasty, including aseptic loosening, implant migration, and even periprosthetic fracture. Such a complication leads to revision surgeries, which are expensive, technically demanding, and result in a low satisfaction rate. Therefore, a study was conducted of the factors affecting the periprosthetic bone loss around the stem that caused these complications. Factors influencing periprosthetic bone loss include demographic factors such as age, sex, obesity, smoking, and comorbidity including diabetes and osteoporosis. The implant design and fixation method are also factors that are determined before surgery. In addition, there are surgical factors, such as surgical approach and surgical technique, and we wish to investigate the factors affecting periprosthetic bone loss around the stem by comparing the effects of postoperative rehabilitation protocols and osteoporosis drugs.

Is there a correlation between fragility fractures of the pelvis (FFP) and the morphology of the true pelvis in geriatric patients?

PURPOSE: There has been no prior study to demonstrate the relationship between the occurrence of fragility fractures of the pelvis and its morphology. The aim of this study was to investigate the effect of pelvic morphology on fragility fractures of the pelvis caused by low-energy trauma in elderly female patients. MATERIALS AND METHODS: As a normal pelvis group, 643 female patients over 65 years of age who underwent pelvic CT were collected. Using three-dimensional multiplanar reconstruction (3D-MPR) function of RadiAnt software, the DT (diameter of transverse true pelvis)/DS (diameter of sagittal true pelvis) values of normal pelvis were measured. Sorted in ascending order, the mean DT/DS value of normal pelvis was 1.13 ± 0.09. The values corresponding to the 25th percentile and the 75th percentile were 1.06 and 1.18, respectively. We arbitrarily named DT/DS values of 1.06 or less corresponding to lower than 25th percentile as 'Circle types', and DT/DS values of 1.18 or higher corresponding to higher than 75th percentile as 'Ellipse types'. Total of 76 female patients over 65 years of age who underwent 3D reconstructions of pelvic CT scans with fragility fractures of the pelvis, who fell into the criteria corresponding to FFP classification type II, were studied separately. Of the 76 female FFPs, two were FFP type IIa, 32 were FFP type IIb, and 42 were FFP type IIc. Their DT/DS was measured. RESULTS: Based on the above mentioned criteria, we classified the pelvis shape of 76 patients with fragility fracture of the pelvis type II. 33 patients (43.4%) were classified as circle types and eight patients (10.5%) were classified as ellipse types. The odds ratio of "circle type" for fragility fractures of pelvis type II was 4.1. CONCLUSION: With digital reconstruction and 3D measurement of normal adult pelvic CT scans, this study obtained a series of DT/DS values describing the shape of true pelvises. Circle-type true pelvis was found to be more common in patients with fragility fracture of the pelvis type II.

Characteristics of medial condyle sagittal fracture of distal femur involving intercondylar notch in geriatric patients.

INTRODUCTION: Unicondylar femoral fractures are uncommon injuries, known to occur primarily in young people, with high energy trauma. However, according to our experiences, unicondylar femoral fractures in geriatric patients generally involved the medial femoral condyle, unlike previously reported. In addition, the fractures of medial femoral condyle (FMFC) showed a characteristic fracture pattern. To date, there has been no published article focusing on the FMFC in geriatric patients. Thus, the aim of this study was to determine the characteristics of FMFC in geriatric patients and to present their outcomes. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 13 patients over age of 65 who underwent surgery for FMFC (AO-OTA 33B2). Of the 13, 10 patients were treated with Tomofix medial distal femoral plate (MDF) (Synthes GmbH, Switzerland) and additional screws fixation; the other three were treated with screw fixation and cast application. RESULTS: The mean age of patients was 76.8 years, and 10 patients were females. The fracture was due to low-energy trauma in all of the cases. Eight patients had medial knee osteoarthritis, and 2 patients were on osteoporosis treatment. A characteristic fracture pattern was observed. The fracture line extended from the lateral aspect of the intercondylar notch to the posteromedial column of the distal femur, with a characteristic medial beak. All fractures belonged to AO classification 33B2.1; there were no cases of AO classification 33B2.2 or 33B2.3. The postoperative joint function was graded according to the Kolmert functional criteria: ten cases were excellent, one case was good, one case was fair, and one case was poor. CONCLUSION: FMFC caused by low-energy trauma in geriatric patients tend to have a characteristic pattern. We believe that anatomic reduction and firm fixation with Tomofix MDF plate and cannulated screw for low-energy trauma FMFC in geriatric patients would yield good outcomes.

Intrapelvic Migration of the Lag Screw with Wedge Wing from Dyna Locking Trochanteric Nail: A Case Report and Literature Review.

The intrapelvic migration of cervicocephalic lag screws is a rare complication after intertrochanteric fracture synthesis with an intramedullary nail. Only 15 cases of intrapelvic penetration by three different instrument systems have been described in the literature. However, to our knowledge, there is no report of intrapelvic migration of the lag screw with wedge wing designed to increase fixation power using the Dyna locking trochanteric (DLT) nail. We present a case of intrapelvic migration of the lag screw with wedge wing from DLT nail. The patient described herein underwent a two-staged operation of implant removal without intrapelvic approach followed by bipolar hemiarthroplasty. With intrapelvic migration conditions, although it is not uncommon to require an additional intrapelvic approach, this modification can lead to lethal consequences. For this reason, it is recommended to coordinate with the vascular surgery department due to the close proximity of the major vessels.

Minimally invasive surgical treatment using 'iliac pillar' screw for isolated iliac wing fractures in geriatric patients: a new challenge.

PURPOSE: There have been no prior case series of isolated iliac wing fracture (IIWF) due to low-energy trauma in geriatric patients in the literature. The aim of this study was to describe the characteristics of IIWF in geriatric patients, and to present a case series of IIWF in geriatric patients who underwent our minimally invasive screw fixation technique named 'iliac pillar screw fixation'. MATERIALS AND METHODS: We retrospectively reviewed six geriatric patients over 65  years old who had isolated iliac wing fracture treated with minimally invasive screw fixation technique between January 2006 and April 2016. RESULTS: Six geriatric patients received iliac pillar screw fixation for acute IIWFs. The incidence of IIWFs was approximately 3.5% of geriatric patients with any pelvic bone fractures. The main fracture line exists in common; it extends from a point between the anterosuperior iliac spine and the anteroinferior iliac spine to a point located at the dorsal 1/3 of the iliac crest whether fracture was comminuted or not. Regarding the Koval walking ability, patients who underwent iliac pillar screw fixation technique tended to regain their pre-injury walking including one patient in a previously bedridden state. The visual analog scale score for pain at the last follow-up was quite satisfactory. Union was achieved in all patients at the last follow-up. CONCLUSIONS: Geriatric patients can have a form of IIWF caused by low-energy trauma that is a type of fragility fracture of the pelvis. Because subsequent deterioration of their walking status followed by a long period of non-weight bearing in geriatric patients could be as threatening as the fracture itself, the treatment paradigm for IIWF due to low-energy trauma in geriatric patients should differ from that due to high-energy trauma in most patients. In these types of fractures, minimally invasive surgical management that includes iliac pillar screw fixation can lead to good outcomes.

Short-term Outcomes of Ceramic Coated Metal-on-Metal Large Head in Total Hip Replacement Arthroplasty.

PURPOSE: This study characterizes the short-term outcomes of ceramic coated metal-on-metal (MoM) large head total hip arthroplasty (THA) in prospectively selected patients aged 70 to 75 years. MATERIALS AND METHODS: Eighteen patients (18 hips) between the ages of 70 and 75-years old with THA using ceramic-coated MoM large heads between June 2014 and December 2014 were evaluated. We prospectively selected patients younger than 70 years for bipolar hemiarthroplasty and older than 75 years for conventional THA. There were one case of osteoarthritis, 8 cases of femur neck fracture, and 9 cases of intertrochanteric fracture. All patients underwent clinical and radiological follow-up at 6 weeks, 6 and 12 months, and every year postoperatively. The mean duration of follow-up was 24.2 months (range, 18-34 months). RESULTS: The average Harris hip score at the final follow-up was 81.0, except one case which was ultimately converted to conventional THA due to acetabular cup loosening. Radiographically, mean acetabular cup inclination was 45.8°(range, 38-56°) and anteversion was 20.1° (range, 11-25°). The average femoral head size was 48.7 mm. All stems were neutral-positioned except 1 varus-positioned stem. There was 1 case of a soft tissue infection, 3 patients complained of persistent groin pain, and no dislocations occurred. CONCLUSION: Ceramic coated large MOM articulation (ACCIS) have many complications: cup loosening, groin pain, which can lead to fatal outcomes in the elderly patients. Especially in patients with communicated intertrochanter fracture (AO 31-A22, 23), careful attention should be paid to the choice of surgical option.

Posterior locked lateral compression injury of the pelvis in geriatric patients: an infrequent and specific variant of the fragility fracture of pelvis.

INTRODUCTION: Posterior locked lateral compression injury (PLLCI) of the pelvic ring is an infrequent variant of lateral compression injury, a condition described in only eight reported cases since 2000. Lateral compression injury usually results from high-energy trauma and is characterized by locking between the medially translated fractured ilium and the anterior border of the sacrum, regardless of whether the fractured ilium involves the sacroiliac joint. However, in our experience, lateral compression injury can also result from low-energy trauma as a manifestation of pelvic fragility fracture. The aim of the present study was to describe this rare form of PLLCI in a case series of geriatric patients. METHODOLOGY: A retrospective analysis of consecutive patients with pelvic ring injuries who were admitted to our hospital from January 2008 to April 2015 identified seven geriatric patients (1 male and 6 females; median age 81 years) with a form of PLLCI. RESULTS: All injuries were due to falls from a standing position onto the ground. All seven cases demonstrated characteristics of a locking fractured ilium over the anterior border of the sacrum on axial computed tomography images, but were not detected on plain radiographs. All underwent follow-up at 1 year or later with improved mean visual analogue scale scores (range 0-3). Regarding Koval walking ability scores, patients who underwent pelvic brim plating with anterior external fixation were more likely to regain their pre-injury walking ability than patients who only underwent anterior external fixation or conservative treatment. CONCLUSION: Geriatric patients can experience PLCCIs of the pelvis due to low-energy trauma. These fractures have different characteristics from those associated with severe injuries due to high-energy trauma, and they comprise an infrequent form of Rommens fragility fracture of the pelvis (type IIIa). In these cases, appropriate surgical management that includes sacroiliac plating combined with anterior external fixation can yield good outcomes.

Superior Gluteal Artery Pseudoaneurysm Caused by Pelvic C-Clamp Blind Application: A Case Report.

To control such a hemorrhage, a displaced pelvic ring must be rapidly reduced and stabilized with a pelvic binder, an external fixator, or a pelvic clamp. Among them, pelvic clamps can be life-saving but pin malposition may cause vascular complications. We present a case of superior gluteal artery pseudoaneurysm caused by AO pelvic C-clamp pin malposition.

Primary total hip arthroplasty using modified posterior approach through quadratus femoris flap osteotomy; comparison with conventional posterior approach.

INTRODUCTION: The quadratus femoris muscle has not attracted attention as a structure for surgical exposure during posterior hip approaches. We sought to introduce a modified posterior approach through the quadratus femoris muscle area only, by flap osteotomy, which we have named the quadratus femoris osteotomy (QFO) approach. We compare this with the conventional posterior approach to determine the effectiveness of the new technique. METHODS: We retrospectively reviewed the medical records of 329 patients (383 hips) who had undergone primary total hip arthroplasty (THA) between March 2006 and January 2013 by a single hip surgeon. The conventional group consisted of consecutive 118 patients (138 hips) who had undergone THA using the conventional posterior approach. The QFO group consisted of consecutive 101 patients (120 hips) who were treated with THA using the QFO approach. RESULTS: The 2-year postoperative average Harris hip score were 88.8 ± 6.6 in the conventional group and 93.1 ± 6.9 in the QFO group. The 2-year postoperative average WOMAC scores were 20.8 ± 6.7 in the conventional group and 14.1 ± 6.6 in the QFO group. Complications in the conventional group were 2 deep vein thrombosis (DVT)s, 1 intraoperative fracture, and 6 posterior dislocations; the QFO group experienced 1 DVT and 3 intraoperative fracture. No dislocation was noted within 2 years after surgery. CONCLUSIONS: Although further studies are needed to confirm the validity of our findings, a modified posterior approach using a quadratus femoris flap osteotomy could be an option worth considering among the variants of posterior approaches in THA.

Underestimated Sacroiliac Joint Lesion on Computed Tomography in Pelvic Open-book Injury: A Case Report.

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis <2.5 cm) injuries. Here authors present a case demonstrating a necessity of intraoperative stress test for excluding concealed posterior ring disruption.

Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft.

PURPOSE: To evaluate the clinical and radiological outcomes of unstable proximal humeral fractures (PHFs) treated with a locking plate and fibular strut allograft. METHODS: This study included 36 patients [7 men, 29 women; mean age, 68 years (range, 22-94 years)] with unstable PHFs with medial column disruption. All patients were treated with open reduction and internal fixation using a locking plate and fibular strut allograft. Post-operative assessment included clinical outcomes, shoulder range of motion, radiographic examination, and any complications. Post-operative radiological assessment including the humerus neck-shaft angle (NSA) and the humeral head height was performed. RESULTS: At the mean two year follow-up visit, the mean American Shoulder and Elbow Society (ASES) and University of California, Los Angeles (UCLA) scores were 77 and 28, respectively. According to the UCLA rating scale, the result was excellent in six, good in 20, fair in six, and poor in four cases. According to the Paavolainen method, 31 patients had good results with an NSA of 130 ± 10°; three patients showed fair results with an NSA of 100-120°, and two patients experienced a poor result with an NSA of <100°. When calculating the humeral head height, the mean loss of reduction was measured as 1.6 mm (from 10.8 or 9.2 mm). Varus collapse and avascular necrosis of the humeral head was noted in two patients for each condition. CONCLUSIONS: For unstable proximal humerus fractures, particularly in elderly patients with severe osteoporosis or in younger patients with a four-part fracture, locking plate fixation with a fibular strut allograft provided rigid medial support and showed satisfactory clinical and radiological outcomes.

Surgical resolution of obstructive dyspareunia after traumatic pelvic injury.

As more of the patients with traumatic pelvic injuries survive, they desire an optimal quality of life, including normal sexual function, even after the most severe injuries. We present the case of a 31-year-old woman who had dyspareunia due to impaired vaginal penetration after severe pelvic injury. After excision of a disunited fragment of pelvic bone and an adhesion band at the vaginal wall, dyspareunia was considerably resolved and the patient resumed sexual function. In cases of severe pelvic injury, physicians used to be satisfied with the patient's survival alone, and tended to regard sexual dysfunction as a trivial outcome. However, restoration of sexual function is an important part of management of these patients. In selected cases, obstructive dyspareunia resulting from traumatic pelvic injury can be managed by planned surgical intervention.

Treatment of Unstable Pelvic Ring Injuries.

Pelvic fractures are classified according to the stability of the pelvic ring. Unlike stable pelvic fractures, which heal without complications, unstable fractures may lead to pelvic ring deformities, which cause severe complications. An orthopedic surgeon must determine the stability of the pelvic ring by radiography and physical examination of the patient in order to ensure early, prompt treatment. This article includes anatomy of the pelvic ring, classification of pelvic ring injuries, its treatment algorithm, and corresponding cases involving unstable pelvic ring injury.

Atypical Pelvic Crescent Fracture Caused by Vertical Shear Force.

The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the sacroiliac joint. This fracture represents a subset of lateral compression injury. The strong posterior ligaments of sacroiliac joint remain intact and a fracture fragment (crescent shape) involving the posterior superior iliac spines remains firmly attached to the sacrum. We report a patient with atypical pelvic crescent fracture that is mainly influenced by vertical shear injury and is characterized by posterior fracture-dislocations of the sacroiliac joint. In this case report, we review the literature on classification and treatment of atypical type of crescent fracture.

Surgical management of pilon fractures with large segmental bone defects using fibular strut allografts: a report of two cases.

We present two patients with open pilon fractures with large bone defects treated successfully with fibular strut allografts. The patients were initially treated by massive irrigation, wound debridement, and temporary external fixation. After complete wound healing, the bone defects were managed. Because autologous iliac crest or fibular bone grafts were impossible to be harvested due to multiple fractures, the bone defects were reconstructed with fibular strut allografts. Fixation was performed with a periarticular distal tibia locking plate. At 2 months postoperatively, the patients ambulated with partial weight-bearing; at 6 months, they had full range of motion of the ankle joint and full weight-bearing.

Clinical outcomes of arthroscopic single and double row repair in full thickness rotator cuff tears.

BACKGROUND: There has been a recent interest in the double row repair method for arthroscopic rotator cuff repair following favourable biomechanical results reported by some studies. The purpose of this study was to compare the clinical results of arthroscopic single row and double row repair methods in the full-thickness rotator cuff tears. MATERIALS AND METHODS: 22 patients of arthroscopic single row repair (group I) and 25 patients who underwent double row repair (group II) from March 2003 to March 2005 were retrospectively evaluated and compared for the clinical outcomes. The mean age was 58 years and 56 years respectively for group I and II. The average follow-up in the two groups was 24 months. The evaluation was done by using the University of California Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow Surgeons (ASES). RESULTS: In Group I, the mean ASES score increased from 30.48 to 87.40 and the mean ASES score increased from 32.00 to 91.45 in the Group II. The mean UCLA score increased from the preoperative 12.23 to 30.82 in Group I and from 12.20 to 32.40 in Group II. Each method has shown no statistical clinical differences between two methods, but based on the sub scores of UCLA score, the double row repair method yields better results for the strength, and it gives more satisfaction to the patients than the single row repair method. CONCLUSIONS: Comparing the two methods, double row repair group showed better clinical results in recovering strength and gave more satisfaction to the patients but no statistical clinical difference was found between 2 methods.

Development of new SLAP lesion after the arthroscopic, isolated decompression of ganglion cyst of the shoulder.

Ganglion cysts of the shoulder are rare, and the pathogenesis is similar to that of meniscal cysts. We present details of two cases of isolated ganglion cyst of shoulder which were treated arthroscopically. Both patients following 1 year after the surgery, complained of nonspecific shoulder pain and magnetic resonance imaging revealed new SLAP lesion which was treated arthroscopically.

Subacromial bony erosion: a rare presentation of pigmented villonodular synovitis of the shoulder.

Pigmented villonodular synovitis (PVNS) rarely affects the shoulder. We describe two cases of PVNS arising from the shoulder joint, which caused rotator cuff tears and sub-acromial bony erosion, and which were treated arthroscopically. Sub-acromial erosion is frequently associated with various glenohumeral joint disorders, but it has not been reported in association with PVNS. We believe PVNS should also be considered in the differential diagnosis of patients who present with sub-acromial erosion.