Neurovascular Structural Deviations in Patients Who Have Fused Hips: Implications for Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to compare the fused and normal sides of patients who have fused hips to determine the differences in neurovascular structures and factors that increase the risk of neurovascular injury. METHODS: We evaluated 38 patients who underwent total hip arthroplasty, with a fused hip between 2003 and 2021. Excluding patients who had bilateral lesions, differences in the location of neurovascular structures were measured by comparing the fused side with the normal side. The position of neurovascular structures was measured by the distance from the acetabular rim and the shortest distance to the particular bony structure. In addition, the patient's sex, weight, body mass index cause of fused hips, estimated age of fusion onset, and preoperative range of motion were investigated to examine the correlations with neurovascular deviation and these factors. RESULTS: The neurovascular distances for all the measured neurovascular structures were significantly reduced on the fused side compared with the normal side. Sex-based analysis revealed that women had significantly shorter distances to the femoral neurovascular bundle than men. Although height and body weight were associated with differences in neurovascular distances, body mass index was not associated with significant differences, except for the femoral nerve distance from the nearest bone. When classified by the estimated age of fusion onset, significant differences in neurovascular distances were found between the adolescent- and adult-onset groups. CONCLUSIONS: In patients who have fused hips, neurovascular structures are located closer to the bone than on the normal side. Moreover, patients in whom the fusion occurred before the completion of growth may exhibit a shorter neurovascular distance, thereby increasing the potential risk of direct injury during total hip arthroplasty .

Stricter correction of leg length discrepancy is required during total hip arthroplasty in patients with ankylosing spondylitis.

BACKGROUND: Patients with ankylosing spondylitis often have fusions in the spine and sacroiliac joints, such that it is difficult to compensate for leg length discrepancy (LLD). METHODS: We retrospectively measured the LLD after total hip arthroplasty (THA) in 89 patients with ankylosing spondylitis from June 2004 to February 2021 at our institute. Patients were divided into two groups based on an LLD of 5 mm. Clinical outcomes were investigated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Harris Hip Score (HHS). In addition, these points are investigated: patient satisfaction with the operation; whether there was a current difference in leg length; and whether there was a limping gait. RESULTS: The group with an LLD of 5-10 mm rather than < 5 mm had significantly worse WOMAC pain and stiffness. The survey revealed statistically significant differences in patient satisfaction with the operation, limping gait, and whether back pain had improved. CONCLUSION: For patients with ankylosing spondylitis, reducing the LLD to < 5 mm, which is more accurate than the current standard of < 10 mm, may produce greater improvement in clinical outcomes after hip arthroplasty.

Subscapularis-sparing deltopectoral approach in reverse total shoulder arthroplasty.

PURPOSE: This study compared the clinical and radiologic results of reverse shoulder arthroplasty (RSA) using either the subscapularis-sparing deltopectoral approach (SSDA) or traditional deltopectoral approach (TDA) in cuff tear arthropathy patients. MATERIALS AND METHOD: We retrospectively evaluated 71 patients who underwent RSA for cuff tear arthropathy between July 2014 and December 2018. Patients were divided into two groups according to the surgical approach: TDA (34 cases) and SSDA (37 cases). The mean patient age was 78.6 years, and the mean (range) follow-up period was 23.5 (12-48) months. Clinical results were assessed using the Visual Analogue pain Scale (VAS), American Shoulder and Elbow Surgeon score (ASES), Korean Shoulder Scoring System (KSS), and Constant score. Radiographic indicators prosthesis-scapular neck angle (PSNA), peg-glenoid rim distance (PGRD), inferior overhang, acromion-greater tuberosity (AT) distance, and glenoid-greater tuberosity (GT) distance) were assessed, and notching severity was assessed according to the Nerot-Sirveaux classification. RESULTS: The radiographic indicator results of the TDA and SSDA groups were as follows: PSNA (131.4° ± 17.2°, 136.1° ± 7.7°), PGRD (18.7 mm ± 2.9 mm, 21.4 mm ± 2.0 mm), AT distance (38.3 mm ±6.9 mm, 37.5 mm ± 6.8 mm), GT distance (51.6 mm ± 6.3 mm, 51.4 mm ± 5.3 mm), and inferior overhang (4.4 mm ± 2.2 mm, 2.9 mm ± 1.3 mm). PGRD and inferior overhang showed statistically significant differences between groups, but the clinical results showed no significant differences. There were no complications such as neurovascular injury, implant loosening, surgical site infection, or acromion fracture in either group. CONCLUSION: SSDA for RSA showed no significant differences in clinical and radiological results compared with TDA. Therefore, SSDA is a viable alternative for RSA in cuff tear arthropathy.

Cementless total hip arthroplasty for failed treatment of subtrochanteric fracture.

BACKGROUND: Failed treatment of subtrochanteric fractures commonly leads to pain, limping, and poor limb function. Cementless total hip arthroplasty (THA) could serve as an efficient salvage procedure in such cases. This study aimed to evaluate the outcomes and complications of salvage THA in failed subtrochanteric fracture fixation cases. METHODS: From January 2001 to December 2017, cementless THA for failed treatment of subtrochanteric fractures was performed in 18 hips of 11 men and 7 women (average age, 74 years; age range, 57.0-89.0 years). Patients were followed up for clinical and radiological assessments in terms of implant survival and complications after a minimum follow-up of 2 years. The Wagner femoral stems (Zimmer, Warsaw, USA) were used in all 18 patients (100%), with the long-length stem (Wagner SL stem) and standard-length stem (Wagner cone stem) used in 11 and 7 patients, respectively. RESULTS: The mean follow-up period was 5.2 years (range: 2.2-10.8 years). The mean Harris hip score (HHS) was 38.2 (range: 24-56) preoperatively and 85.4 (range: 79-92) at the last follow-up. The mean postoperative limb length discrepancy was 6.4 mm (range: 4-9 mm). Only one patient underwent revision due to bone in-growth failure of the femoral stem. One patient had an episode of postoperative dislocation and was treated with closed reduction without reoccurrence. Delayed union of the fracture site occurred in one patient. Patients who were previously treated with an intramedullary nail had a significantly shorter surgical duration, lesser intraoperative blood loss, and fewer blood transfusions than those who were previously treated with plate and screws. Kaplan-Meier survival rate with an endpoint of revision was 94.4% (95% confidence interval 72.7-99.9) at 5 years. CONCLUSION: Our results indicate that cementless THA is a beneficial and effective procedure for salvaging the failed treatment of subtrochanteric fractures. The Wagner conical prosthesis has shown satisfactory function outcomes, stable fixation, and survival rate for these complex situations. However, attention should be paid to increased operation time, blood loss, and complications when performing THA for subtrochanteric fractures with failed fixation devices especially, plates and screws.

Mid-term results of total hip arthroplasty with modified trochanteric osteotomy in Crowe type IV developmental dysplasia of the hip.

BACKGROUND: This study aimed to explore mid-term clinical results of cementless total hip arthroplasty (THA) with modified trochanteric osteotomy in Crowe type IV developmental dysplasia of the hip (DDH). METHODS: Thirteen patients (13 hips) with Crowe type IV DDH who underwent THA with modified trochanteric osteotomy between May 2013 and October 2015 were retrospectively analyzed. The mean follow-up duration was 5.2 years (range, 4.9-6.1 years). RESULTS: The mean Harris Hip Score (HHS) significantly (p < 0.05) improved from 30.7 (range, 22-38) to 87.5 (range, 83-93). The mean leg length discrepancy (LLD) was 53.4 mm (range, 42.1-68.5 mm) preoperatively. The final LLD was 5.6 mm (range, 2.4-9.1 mm; p < 0.05). The mean leg length after surgery was 47.4 mm (range, 33.6-67.2 mm) and the femur shortening distance was 43.8 mm (range, 31.2-53.4 mm). The average duration of bone union for the greater trochanter (GT) was 2.5 months (range, 1.5-3.6 months). There was no infection, GT non-union, or loosening (septic or aseptic) of the stem or cup in any case. CONCLUSIONS: THA with modified trochanteric osteotomy with a cementless cup is an effective treatment for Crowe type IV DDH. It can rebuild complex biomechanics and biology of hip dysplasia without increasing complications.

Survival Analysis of Total Hip Arthroplasty for High Hip Dislocation Secondary to Developmental Dysplasia or Septic Arthritis of the Hip.

BACKGROUND: This retrospective study was conducted to know clinical and radiographic outcomes, complication rate, and survival of THA in patients with high hip dislocation secondary to developmental dysplasia(DDH) or septic arthritis of the hip(SSH). METHODS: Between March 2005 and September 2014, there were consecutive series of 53 THAs in patients with a highly dislocated hip secondary to DDH or SSH. Of these, 48 hips (DDH 24 and SSH 24) were reviewed at a mean follow-up of 7.9 years(range, 5.0-14.3 years). The mean age at the time of THA was 39.1 years(range, 18.0-59.0 years). RESULTS: Intraoperative blood loss, total drainage and blood transfusion amounts, and mean time to greater trochanter union were significantly lower in the DDH group than in the SSH group (P = .001, P = .039 and P = .014, and P = .015, respectively). No significant difference in Kaplan-Meier survivorship was observed between groups (log-rank, P = .343). The survival rates with an endpoint of cup aseptic loosening in cases with a cemented cup at 7.9 and 10 years (68.1% and 60.5%, respectively) were significantly lower than those in cementless cup cases (100%) at the same checkpoints (P = .019).. CONCLUSION: We found similar clinical outcomes between the DDH and SSH groups. However, due to poor bone quality and a lack of containment, cementless acetabular cups could not be performed in more than 50% of patients. Our experience shows that revision cementless fixation cup was possible due to reconstitution of the acetabulum in cases with failed cemented fixation.

Revision total hip arthroplasty with metal on metal bearing for ceramic bearing fractures.

BACKGROUND: Due to concern of potential metallosis caused by residual microscopic ceramic particles, metal-on-metal (MoM) bearing is deemed undesirable in revision total hip arthroplasty (THA) for ceramic bearing fracture. We determined whether MoM bearing is suitable to be used in revision THA for ceramic fractures and also evaluated whether this treatment increases serum iron levels compared with MoM bearing revision THA for polyethylene failure. METHODS: Between 2006 and 2012, 22 patients underwent revision surgery using MoM bearing (28 mm femoral head in 18 hips and 32 mm in 4 hips) for ceramic bearing fracture and followed average 52.1 months. We assessed radiological parameter and functional outcome using Harris hip score (HHS) and WOMAC score. Also, serum cobalt (Co) and chromium (Cr) blood tests were performed and compared with the result obtained from age, sex- and follow-up duration-matched patients with MoM revision THA for failed polyethylene bearing. RESULTS: The mean HHS improved from 60.6 preoperatively to 90.3 at final follow-up. There were no changes in cup position, progression of osteolytic lesions, and measurable wear of MoM bearing articulation at final follow-up radiographs. There was one case of recurrent dislocation after surgery, which was treated with greater trochanter distal advancement and one case of deep infection, which underwent two-stage revision. Mean serum Co level (1.7 vs. 1.4 µg/dl; p = 0.211) and Cr level (0.70 vs. 1.01 µg/dl; p = 0.327) showed no significant difference. CONCLUSIONS: MoM articulation with liner cementation into the acetabular cup along with total synovectomy can be chosen in revision surgery for ceramic fracture with good midterm follow-up. However, the use of MoM bearing is indicated when the stem and metal shell can be retained and ceramic on ceramic or ceramic on polyethylene bearing cannot be selected. Also long-term outcome needs to be further evaluated.

Muscle pedicle bone grafting using the anterior one-third of the gluteus medius attached to the greater trochanter for treatment of Association Research Circulation Osseous stage II osteonecrosis of the femoral head.

PURPOSE: The aim of this study was to evaluate the effectiveness of our technique on further collapse of the femoral head in Association Research Circulation Osseous (ARCO) stage II, patient's functional improvements, and analyze the survival rate of the affected hip. METHODS: Between June 2007 and March 2015, 24 hips diagnosed with osteonecrosis of the femoral head (ONFH) were treated with our muscle pedicle bone grafting (MPBG) technique using anterior one-third of gluteus medius attached to the greater trochanter. The group was consisted of 15 men and eight women, mean age of 36 years at the time of surgery. Mean follow-up was 6.2 years. RESULTS: Four hips showed regeneration, 11 hips showed no progression, and nine hips showed slight extent of the lesion. But during the follow-up, three hips underwent total hip arthroplasty at the mean follow-up of 5.8 years after the surgery. The survival rate at the last follow-up was approximately 87.5%. Excluding the three failed cases, the mean total Harris hip score was improved from 57.2 to 82.3 points (p < 0.05). We had no case of complications such as limping, numbness, wound infection, heterotopic ossification, nor intra- and post-operative fracture. CONCLUSION: We showed 87.5% of survival rate by average of 6.2-year follow-up, maximum of 10.1 years. And compared to other reports, our technique showed relatively good results. In the short term, our modified MPBG technique seems to be effective in ARCO stage II ONFH. We, therefore, suggest this technique as one of the promising treatments of choices for patients with ARCO stage II ONFH.

Revision Total Hip Arthroplasty Using an Acetabular Reinforcement Ring With a Hook: A Precise Follow-Up, at Average 11.4 Years, of a Previous Report.

BACKGROUND: This study aims at determining the average long-term result of revision total hip arthroplasty (THA) using the acetabular reinforcement ring with a hook (ARRH) and bone grafting in severe acetabular bony defect. Expected 15-year survival of ARRH in revision THA is included in the study. METHODS: Retrospective review of 48 patients (48 hips) with follow-up duration of average 11.4 years (range, 6.1-21.4 years) was conducted. At each follow-up, Harris hip score was used to assess functional outcome, and radiographic acetabular component osteolysis was measured by DeLee and Charnley classification. Bone defects were assessed preoperatively and intraoperatively using American academy of orthopedic surgeons and Paprosky classification. The common modes of ARRH failures were evaluated. Bone consolidation, presence of heterotopic ossification, and complications such as infection and dislocation were recorded. RESULTS: The bone defects were varied and included cavitary, segmental, and combined defects without any pelvic discontinuity. Mean Harris hip score improved from 52.6 points preoperatively to 82.0 points postoperatively. Nine acetabular revisions and 3 stem revisions (2 concurrent with acetabular revisions and 1 isolated stem revision) were performed. There were 5 infected cases and 1 patient with recurrent dislocation. The 11.4-year survival of revision THA with ARRH was 71% as the end point for acetabular revision surgery for any reason. The expected 15-year survival of revision THA with ARRH was 60%. The most common failure mode of ARRH was superomedial migration followed by lateral migration. CONCLUSION: ARRH combined with bone grafting produces relatively good average long-term clinical results.

The Survival Analysis in Third-Generation Ceramic-On-Ceramic Total Hip Arthroplasty.

A total of 527 patients (577 hips) who underwent primary THA using third-generation ceramic-on-ceramic (CoC) articulation were retrospectively reviewed. They were followed up for an average of 5.9 years. Seven hips experienced liner fracture and 14 hips experienced head fracture. Squeaking occurred in eight hips. The revision rate in this study was 5.2%, but excluding the cases of ceramic head and liner fracture, there were nine cases (1.6%) of revision surgery. Considering revision for any reason as the end point, mean survivorship was 93% at 10 years. According to the femoral head size and neck length, 28 mm head with short neck has the worst survivorship of 89% at 10 years. Overall, our study showed a higher rate of ceramic fracture compared with other studies.

Clinical and radiographic outcomes of femoral head fractures: excision vs. fixation of fragment in Pipkin type I: what is the optimal choice for femoral head fracture?

BACKGROUND: In this work, we present relatively long-term results of femoral head fractures with a specific focus on Pipkin type I fractures. METHODS: Fifty-nine femoral head fractures were treated according to modified Pipkin's classification as follows: type I, small fragment distal to the fovea centralis (FC); type II, large fragment distal to the FC; type III, large fragment proximal to the FC; type IV, comminuted fracture. There were 15 cases of type I, 28 of type II, 9 of type III, and 7 of type IV fractures. Conservative treatment with skeletal traction was performed in 4 type II cases, excision of the fragment in 15 type I and 10 type II cases, fixation of the fragment in 14 type II and all 9 type III cases, and total hip replacement in all 7 type IV cases. The overall clinical and radiographic outcomes were evaluated using previously published criteria, focusing on the results in Pipkin type I fractures with relatively large fragments. RESULTS: Based on Epstein criteria, in type II fractures, excellent or good clinical results were seen in 6 of 10 patients (60.0 %) treated by excision of the fragment and 12 of 14 patients (85.7 %) treated by internal fixation (p = 0.05). Also, excellent or good radiologic results were seen in 4 of 10 (40.0 %) patients treated by excision of the fragment and 12 of 14 (85.7 %) patients treated by internal fixation (p = 0.03). CONCLUSIONS: Even in Pipkin type I fractures, if the fragment is large (modified Pipkin type II), early reduction and internal fixation can produce good results.

Conversion total hip arthroplasty after previous transtrochanteric rotational osteotomy for osteonecrosis of the femoral head.

The results of conversion total hip arthroplasty (THA) after failed transtrochanteric rotational osteotomy (TRO) are still controversial. We retrospectively reviewed 18 patients with ONFHs who had been treated previously by TRO and were later converted to THAs (conversion group). We made a matched control group of 18 primary THAs for ONFH done by same hip surgeon (PTHA group). There was an improvement in the Harris hip score and WOMAC score at the final follow-up but the improvement was not statistically significant between the two groups. Only internal rotation was significantly better in the PTHA group than in the conversion group. THA after TRO provides satisfactory clinical and radiological outcomes with no significant increase in perioperative morbidity in comparison with that in the primary THA.

Total hip arthroplasty using large-diameter metal-on-metal articulation in patients with neuromuscular weakness.

The purpose of this prospective study was to evaluate the clinical and functional outcomes of THA using large-diameter metal-on-metal articulation in patients with neuromuscular weakness. Nineteen consecutive patients (19 hips) with neuromuscular weakness and displaced femoral neck fractures were enrolled. Functional improvement and recovery, radiological evaluation of THA and surgical morbidity were assessed. Mean Harris hip and WOMAC scores at final follow-up were 81.0 and 42.9, respectively. At final follow-up, no dislocation, metal hypersensitivity, or osteolysis was observed and no patient required revision of THA. The findings of this study indicate that the functional results of THA using large-diameter metal-on-metal articulation in patients with neuromuscular weakness can produce satisfactory outcomes with early functional recovery and a low dislocation rate.

Periprosthetic Acetabular Fracture after Total Hip Arthroplasty: A Report on Two Cases.

We report two cases of postoperative total hip arthroplasty periprostehtic fracture of the acetabulum which treated by open reduction with internal fixation without acetabular cup revision. From these cases, we should consider open reduction with internal fixation as the first treatment option in cases where spot welding of the cup to the host bone is observed.

Comparison of Short Curved Stems and Standard-length Single Wedged Stems for Cementless Total Hip Arthroplasty.

Purpose: The purpose of this study was to compare the clinical and radiographic outcomes with use of short-curved stems versus standard-length single wedged stems over a minimum follow-up period of five years. Materials and Methods: A retrospective study of primary total hip arthroplasties performed using the Fitmore® stem (127 hips, 122 patients) and the M/L taper® stem (195 hips, 187 patients) between October 2012 and June 2014 was conducted. The clinical and radiographic outcomes were obtained for evaluation over a minimum follow-up period of five years. Results: In both the Fitmore® and M/L taper® groups, the mean Harris hip score improved from 52.4 and 48.9 preoperatively to 93.3 and 94.5 at the final follow-up, respectively (P=0.980). The mean Western Ontario and McMaster Universities Osteoarthritis Index scores also improved from 73.3 and 76.8 preoperatively to 22.9 and 25.6 at the final follow-up, respectively (P=0.465). Fifteen hips (Fitmore®: 14 hips; M/L taper®: one hip, P<0.001) developed intraoperative cracks and were treated simultaneously with cerclage wiring. Radiography showed a radiolucent line in 24 hips in the Fitmore® group and 12 hips in the M/L taper® group (P=0.125). Cortical hypertrophy was detected in 29 hips (Fitmore® group: 28 hips; M/L taper® group: one hip, P<0.001). Conclusion: Similarly favorable clinical and radiographic outcomes were achieved with use of both short-curved stems and standard-length single wedged stems. However, higher cortical hypertrophy and a higher rate of femoral crack were observed with use of Fitmore® stems.

Surgical Excision for Refractory Ischiogluteal Bursitis: A Consecutive Case Series of 21 Patients.

Purpose: A response to conservative treatment is usually obtained in cases of ischiogluteal bursitis. However, the time required to achieve relief of symptoms can vary from days to weeks, and there is a high recurrence rate, thus invasive treatment in addition to conservative treatment can occasionally be effective. Therefore, the aim of this study was to examine surgical excision in cases of refractory ischiogluteal bursitis and to evaluate patients' progression and outcome. Materials and Methods: A review of 21 patients who underwent surgical excision for treatment of ischiogluteal bursitis between February 2009 and July 2020 was conducted. Of these patients, seven patients were male, and 14 patients were female. Injection of steroid and local anesthetic into the ischial bursa was administered at outpatient clinics in all patients, who and they were refractory to conservative treatment, including aspiration and prescription drugs. Therefore, surgery was considered necessary. Excisions were performed by two orthopedic specialists using a direct vertical incision on the ischial area. A review of each patient was performed after excision, and quantification of the outcomes recorded using clinical scoring systems was performed. Results: The results of radiologic evaluation showed that the mean lesion size was 6.2 cm×4.5 cm×3.6 cm. The average disease course after excision was 21.6 days (range, 15-48 days). Measurement of clinical scores, including the visual analog scale and Harris hip scores, was performed during periodic visits, with scores of 0.7 (range, 0-2) and 98.1 (range, 96-100) at one postoperative month, respectively. Conclusion: Surgical excision, with an expectation of favorable results, could be considered for treatment of ischiogluteal bursitis that is refractory to therapeutic injections, aspirations, and medical prescriptions, particularly in moderate-to-severe cases.

An analysis of the usefulness for using skin adhesive without closed-suction drainage in primary total hip arthroplasty: A retrospective propensity score matched study.

The closed suction surgical drainage system (CSSD) is routinely used after total hip arthroplasty (THA) by orthopedic surgeons in many institutions. However, it has not been shown to decrease the rate of wound infection significantly and may even increase blood loss. This study aimed to evaluate the usefulness of using skin adhesive without CSSD in uncomplicated THA. From July 2015 to September 2017, 200 patients undergoing unilateral THA were enrolled and divided into 2 groups, either receive CSSD (134 patients) or not receive CSSD (66 patients). Then, the propensity matched was performed. Calculated total blood loss, changes in hemoglobin (Hgb) level, transfusions were evaluated. In addition, data on the length of hospital stay, operation time, closure time, time to using crutches following THA were collected. Finally, Harris hip score (HHS), total estimated cost, and complications were assessed. The non-CSSD group had comparatively less blood loss (508.5 ± 280.3 mL compared with 742.1 ± 330.3 mL, P < .001), fewer transfusions (0.03 units compared with 0.3 units, P = .02), less transfusion rate (1.9% compared with 17.3 %, P = .02), lower change of Hgb from immediate postoperative period to 3 days later(1.6 ± 1.0 g/dL compared with 2.0 ± 0.8 g/dL, P = .03), than the CSSD group. There was a longer duration of hospital stay in the CSSD groups (7.2 days compared with 7.8 days, P = .03) The mean total cost in the non-CSSD group was $162.1, which was less than that of the CSSD group, which spent $288.5 on average (P < .001). there was 1 allergic reaction in the non-CSSD group (P = .32). The use of skin adhesive without CSSD could help decrease blood loss, the need for transfusion, and the length of hospital stay, and seems to more cost-effectiveness than using CSSD. It may also provide superior results and allow the patient to recover faster. Using this type of skin adhesive without CSSD is an efficient wound closure method for patients undergoing uncomplicated THA. However, care must be taken for allergic reactions, especially for patients with known or suspected allergies to cyanoacrylate or formaldehyde.