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.

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.

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.

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.

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.

Calcific tendinitis of the biceps-labral complex: a rare cause of acute shoulder pain.

Calcific tendinitis most commonly affects the rotator cuff and has not been previously reported affecting the biceps-labral complex. We report a case of calcific tendinitis of the biceps-labral complex attachment, a rare cause of acute, severe shoulder pain. Clinically, it can be misdiagnosed as supraspinatus tendinitis or septic arthritis of the shoulder joint. Non-operative treatment failed to resolve the symptoms. Arthroscopic debridement of the calcific deposit resulted in resolution of symptoms. Knowledge of this clinical condition and its imaging features is crucial for a correct diagnosis of this uncommon cause of shoulder pain.

Arthroscopic double-row suture anchor fixation of minimally displaced greater tuberosity fractures.

In cases of displaced greater tuberosity fractures, treatments by arthroscopic-assisted reduction and percutaneous screw fixation have been reported. However, in cases in which there is a comminuted fracture or a minimally displaced fracture combined with concomitant lesions such as rotator cuff tear or labral pathology, it is difficult to reduce the fracture and to treat other pathologies by use of a percutaneous screw. Recently, many surgeons have used the double-row repair method in rotator cuff repair, which provides a tendon-bone interface better suited for biologic healing and restoring normal anatomy. In accordance with this method, we used the arthroscopic technique of double-row suture anchor fixation for a minimally displaced greater tuberosity fracture without additional incision. Initially, debridement was performed on the fracture surface by use of a shaver, and the medial-row anchor was inserted through the anterior portal or the intact cuff. Two lateral-row anchors were inserted just anterior and posterior to the lower margin of the fractured fragment under C-arm guidance. The medial-row sutures and lateral-row sutures were then placed. Arthroscopic double-row suture anchor fixation of a displaced greater tuberosity fracture restores the original footprint of the rotator cuff and normal tendon-bone interface of the displaced greater tuberosity fracture.

Compressive neuropathy of the tibial nerve and peroneal nerve by a Baker's cyst: case report.

We report a case of Baker's cyst that induced compression of both the tibial and common peroneal nerves. The patient presented with calf atrophy and foot drop over a 6-month period. These signs and symptoms could have been mistaken for those of spinal origin. Based on an electrodiagnostic study and magnetic resonance imaging, compression of nerves by an asymptomatic Baker's cyst measuring 6x4 cm was confirmed. This cyst communicated with the articular joint which was also associated with a medial meniscal lesion. We treated the patient arthroscopically by performing partial medial meniscectomy, and through the posterolateral and the posteromedial portal, decompression of the Baker's cyst was performed. Approximately 6 weeks after the arthroscopic decompression, the cyst recurred. Therefore open resection was performed. At 1-year follow-up, the patient had considerable improvement in motor as well as sensory function and showed no evidence of recurrence. Although the electrodiagnostic studies showed an improvement in symptoms, the patient continued to complain of lower leg weakness owing to delayed diagnosis and cyst decompression. We believe that Baker's cysts should also be considered in the differential diagnoses of patients who present with neuromuscular dysfunction in the calf and leg.

Intrapelvic migration of a well-fixed femoral stem after removal of an acetabular cup.

Failure of total hip arthroplasty with central migration of prosthetic components is uncommon. Various pelvis and visceral complications have been reported from intrapelvic migration of the acetabular cup or the cement or from the heat generated by methylmethacrylate polymerization. To our knowledge, we are the first to report intrapelvic migration of a femoral stem causing ipsilateral lower-extremity swelling, pressure sores, and severe bowel symptoms after the removal of the acetabular component.

Spontaneous and simultaneous rupture of both quadriceps tendons in a patient with chronic renal failure. A case studied by MRI both preoperatively and postoperatively.

Spontaneous bilateral rupture of the quadriceps tendons without a significant history of trauma is an uncommon disease. It is generally associated with chronic metabolic disorders such as chronic renal failure and secondary hyperparathyroidism. Here, we report a case of spontaneous bilateral tendon rupture in a patient on chronic hemodialysis for the past 5 years. We performed a preoperative MRI to confirm the diagnosis; then we repaired the ruptured quadriceps tendons and reviewed the patient both clinically and by performing MRI postoperatively 4 yrs later. The patient attained the full function of the quadriceps tendon.

Posteromedial compartment cement extrusion after unicompartmental knee arthroplasty treated by arthroscopy: a case report.

Unicompartmental knee arthroplasty (UKA) with extrusion of cement into the posterior compartment of the knee is uncommon. Various problems after a UKA procedure, such as aseptic loosening, polyethylene wear and progressive arthritis have been reported. This study will report on a patient with extrusion of cement fragments into the posteromedial compartment of the knee after a UKA procedure. This complication was treated successfully with the direct posterior-posterior triangulation arthroscopic visualization method. In cementing the prosthesis, it is of paramount importance to take caution to completely remove extruded cement remnants in order to prevent this complication during UKA.

Joystick reduction and percutaneous pinning for an acutely anteriorly dislocated coccyx: a case report.

A sacrococcygeal dislocation is a rare occurrence, and the treatment options vary. Initial treatment is nonoperative, consisting of a manual reduction with a gloved finger and local rest. Acute operative treatment of a failed closed reduction is unusual. We report a case of an acute irreducible anteriorly dislocated coccyx successfully treated with a minimally invasive technique: joystick reduction and Steinman pin fixation.