Outcomes of Hybrid Total Hip Arthroplasty for Subchondral Insufficiency Fracture of the Femoral Head.

Background: The purpose of this study was to evaluate functional outcomes, radiologic results, and complications after hybrid total hip arthroplasty (THA) in patients with subchondral insufficiency fractures (SIFs) of the femoral head. Methods: From June 2009 to December 2020, among 985 patients who underwent hybrid THA at our hospital, 19 patients diagnosed with SIF through a retrospective chart review were included. Those under 50 years of age, with radiographic findings of osteonecrosis on the contralateral side of surgery, a history of organ transplantation, and alcohol abuse, were excluded. Functional evaluation was performed using a modified Harris Hip Score (HHS). After surgery, inclination and anteversion of the acetabular cup and version of the femoral system were measured using postoperative x-ray. The outpatient follow-up was performed at 6 weeks, 3 months, 9 months, and 12 months after surgery and every year thereafter. Complications including dislocation, implant loosening, stem subsidence, and periprosthetic infection were observed on follow-up radiographs. Results: The average follow-up time was 29.3 ± 9.1 months (range, 24-64 months) with no loss to follow-up. The mean modified HHS was 83.4 ± 9.6 (range, 65-100) at the last outpatient clinic follow-up. The average inclination of the acetabular cup was 41.9° ± 3.4° (range, 37°-48°), and the anteversion was 27.5° ± 6.7° (range, 18°-39°). The version of the femoral stem was 19° ± 5.7° (range, 12°-29°). There was no case of intraoperative fracture. There were no cases of dislocation, loosening of the cup, subsidence of the femoral stem, intraoperative or periprosthetic fracture, or periprosthetic infection on the follow-up radiographs. Conclusions: In our study, hybrid THA showed favorable outcomes in patients diagnosed with SIF, and there were no further special considerations as for THA performed due to other diseases or fractures.

Sarcopenia and Its Association With Change of Bone Mineral Density and Functional Outcome in Old-Aged Hip Arthroplasty Patients.

This study aimed to investigate the relationship between sarcopenia and change in bone mineral density (BMD) and functional outcome in hip arthroplasty patients. Methods: Among the 221 patients who had undergone hip arthroplasty, 147 patients were enrolled. All patients were divided into 2 groups according to presence of sarcopenia. Bone mineral density (BMD) at hospitalization and 1-year after surgery and Barthel index was measured at the time of before injury, hospitalization, 3 months and 1-year after surgery. Results: BMD at hospitalization showed .627 ± .082 (g/cm2) in Sarcopenia and .726 ± .059 (g/cm2) in Non-sarcopenia at femur (total) site (P < .001), .531 ± .085 (g/cm2) vs .629 ± .057 (g/cm2) at femur neck site (P=.002), .715 ± .084 (g/cm2) vs .807 ± .058 (g/cm2) at lumbar (L1-L4) site (P < .001). BMD at 1-year follow-up period, Sarcopenia showed .626 ± .082 (g/cm2) and Non-sarcopenia showed .725 ± .060 (g/cm2) at femur (total) site (P < .001), .530 ± .085 (g/cm2) vs .629 ± .058 (g/cm2) at femur neck site (P < .001), .715 ± .084 (g/cm2) vs .806 ± .058 (g/cm2) at lumbar (L1-L4) site (P < .001). Change of BMD showed -.01 ± .25% for Sarcopenia and -.15 ± .47% for Non-sarcopenia in femur (total) site (P=.089), -.08 ± .63% vs -.01 ± 1.01% in femur neck site (P = .058), .00 ± .09% vs -.12 ± .33% for each group in lumbar (L1-L4) site (P = .052). Barthel index score showed 79.94 ± 5.66 for Sarcopenia and 84.74 ± 5.36 for Non-sarcopenia at pre-injury status (P < .001), 33.89 ± 4.94 vs 33.87 ± 5.36 at the time of hospitalization (P = .977), 57.42 ± 7.19 vs 60.06 ± 5.39 at 3 months follow up (P = .015), 73.86 ± 5.94 vs 80.71 ± 4.81 for each group at 1-year follow up (P < .001). Conclusions: Our study found that the sarcopenia showed lower BMD than the non-sarcopenia, but there was no significant difference of BMD change in the follow-up period. In addition, the sarcopenia showed poor functional results at all points except at the time of hospitalization.

Fractures of the distal femur in elderly patients: retrospective analysis of a case series treated with single or double plate.

INTRODUCTION: We evaluated the radiologic and clinical outcomes of a lateral incision single plate with and a single-incision double plating in elderly patients with osteoporotic distal femoral fractures. MATERIALS AND METHODS: We performed a retrospective study of 82 cases of distal femoral fractures from May 2004 to June 2018. Group A consisted of 42 patients who underwent single-plate fixation. Group B consisted of 40 patients who underwent double-plate fixation. The mean patient age was 77 years (67-87 years) and 76 years (64-86 years) in groups A and B, respectively. All patients were evaluated for procedure duration, time to union, range of knee motion, Lysholm knee score, and presence of complications. RESULTS: The average procedure time was 81 min (66-92 min) and 110 min (95-120 min) in groups A and B, respectively (p = 0.33). One case in group B required bone grafting after 5 months. The average time to union was 14 weeks (9-19 weeks) and 12.2 weeks (8-19 weeks) (p = 0.63), and the mean range of knee motion was 105° (90-125°) and 110.7° (90°-130°) (p = 0.37) in groups A and B, respectively. There was no significant statistical difference between the two groups in the Lysholm knee score (p = 0.44) and knee society score (p = 0.53). CONCLUSION: The clinical and radiological outcomes were similar in the 2 groups. In elderly patients, double plate fixation for distal femoral fractures is an useful method for several advantages such as adequate exposure, easy manipulation, anatomical reduction and stable fixation.

Outcomes of Wedge Wing in the Lag Screw for Unstable Intertrochanteric Fractures in Elderly Patients.

PURPOSE: To evaluate clinical-functional and radiologic outcomes of elderly patients with an unstable intertrochanteric femur fracture treated with a wedge wing in the lag screw. MATERIALS AND METHODS: Forty-eight patients treated with the Dyna Locking Trochanteric nail (DLT nail) to resolve an unstable intertrochanteric femur fracture were reviewed retrospectively. Based on AO/OTA classification, Fracture 31-A2 (34 cases) and 31-A3 (14 cases) were included in the analysis. We measured the femoral neck-shaft angle, tip-apex distance (TAD), Cleveland index, sliding distance of the lag screw, and time to the fracture union. The Harris Hip Score and Paker and Palmer's mobility score for clinical evaluation were used. RESULTS: The mean follow-up period was 21.4 months (range, 12-34 months). The postoperative state of reduction was good in 28 cases and acceptable in 20 cases. The mean TAD was 20.5 mm. The position of the lag screw was center-center in 30 cases and center-inferior in 18 cases. The mean sliding distance of the lag screw was 3.4 mm at the last follow-up. The mean union time was 4.5 months. Two cases had complications which included a cut-out (1 case) and non-union (1 case). The mean Harris Hip Score was 86.5±8.3 (range, 76-90). Walking ability in 34 of the cases (70.8%) at last follow-up was similar to that prior to fracture. CONCLUSION: Functional and radiological outcomes are satisfactory using the DLT nail in the treatment of elderly patients with unstable intertrochanteric fractures; however, wedge wing in the lag screw does not prevent implant-related complications.

The reasons for ceramic-on-ceramic revisions between the third- and fourth-generation bearings in total hip arthroplasty from multicentric registry data.

This study aimed to evaluate (1) the overall reasons for first revision in CoC THAs; (2) whether the reasons for revision differ between third-generation and fourth-generation CoC THAs; and (3) the specific factors associated with bearing-related problems as the reason for revision. We retrospectively reviewed 2045 patients (2194 hips) who underwent first revision THA between 2004 and 2013, among which 146 hips with CoC bearings underwent revision. There were 92 hips with third-generation ceramic bearings and 54 hips with fourth-generation ceramic bearings. The major reasons for CoC THA revisions were ceramic fracture and loosening of the cup or stem. When ceramic fracture, squeaking, incorrect ceramic insertion, and unexplained pain were defined as directly related or potentially related to ceramic use, 28.8% (42/146) of CoC revisions were associated with bearing-related problems. Among the third-generation ceramic bearings, revision was performed in 41.3% (38/92) of cases owing to bearing-related problems whereas revisions were performed for only 7.4% (4/54) of cases with fourth-generation ceramic bearings owing to bearing-related problems (p < 0.001). Younger age, lower American Society of Anesthesiologists (ASA) grade, and preoperative diagnosis of osteonecrosis were factors related to CoC THA revisions due to bearing-related problems.

Oral Carbohydrate Administration in Patients Undergoing Cephalomedullary Nailing for Proximal Femur Fractures: An Analysis of Clinical Outcomes and Patient Satisfaction.

PURPOSE: The purpose of this study was to investigate the clinical effects of oral carbohydrate intake for cephalomedullary nailing on proximal femoral fractures and patient satisfaction. SUBJECTS AND METHODS: 88 patients were admitted to our hospital with proximal femoral fracture from July 2019 to December 2019. All patients were treated with closed reduction and internal fixation (CR&IF, Cephalomedullary nailing) under spinal anesthesia. The exclusion criteria included the presence of endocrine disorders including diabetes mellitus (DM), patients treated with steroids, and cognitive impairment. Additionally, those with fasting blood glucose levels above 126 mg / dl or HbA1C> 6.5% were considered as having undiagnosed DM. After obtaining informed consent, the subjects were randomized into either the preoperative oral carbohydrate (POC) group or control group. Patients who were assembled into the control group fasted including water from midnight of the day of the surgical procedure according to the conventional method. Patients assembled into the POC group received 400 ml of oral carbohydrate solution (Nucare NONPO, DAESANG, 12.8%, 1 kcal/ml)) between 21-24 hours on the day before operation and 400 ml oral carbohydrate solution 2 hours before the administration of anesthesia. Serum glucose on the day before operation at 7 am (before breakfast, baseline), immediately before anesthesia, at skin incision, 1 hour, 4 hours, 6 hours, 24 hours after anesthesia, and 3 days after surgery (before breakfast) was measured, and insulin, cortisol, and IL-6 were measured at baseline 7 am at day before operation, immediately before anesthesia, 4 hours and 24 hours after anesthesia, and 3 days after surgery (before breakfast). The patients completed questionnaires about their satisfaction (thirst, hunger, nausea and vomiting, and anxiety) in the morning (before the surgery) on the day of the surgery. Additionally, the length of hospital stay (LOS) and preoperative opioid usage was also investigated. RESULTS: The operative characteristics of the patients did not differ between the groups except for the actual fasting time. The glucose levels were higher in the control group at skin incision; however, there were no significant differences in both groups at other time points. Additionally, insulin, insulin resistance, cortisol, and IL-6 also did not differ significantly between the 2 groups at all time-points. Among the factors related to patient satisfaction, the POC group showed significantly higher scores for thirst and hunger factors and shorter LOS than the control group. CONCLUSION: The intake of oral carbohydrates in patients treated with closed reduction and internal fixation for proximal femoral fractures does not affect the improvement of post-operative insulin resistance. However, there was significant improvement in patients' thirst and hunger before surgery and LOS.

Osteochondroma formation after avulsion fracture of anterior inferior iliac spine: A case report.

BACKGROUND: Hip avulsion fractures occur mostly during adolescence when actions such as kicking or running cause forceful contraction of attached muscle. Osteochondroma is benign tumor that mostly occurs at the metaphysis of a long bone, being usually asymptomatic. CASE SUMMARY: A 15-year-old patient experienced feeling and sound of a break while kicking a ball in soccer game three years prior to his visit to our hospital. A simple X-ray revealed an avulsion fracture of the apophysis of the anterior inferior iliac spine (AIIS). Later in the follow-up X-ray, a palpable mass was found and demonstrated by magnetic resonance imaging to be a pedunculated osteochondroma in the superolateral aspect of the AIIS. For surgical treatment, we performed osteotomy for surgical excision and excisional biopsy. A mass with smooth surface and an unclear superolateral AIIS border was found intraoperatively. Pathologic exam showed definite diagnosis of osteochondroma. Postoperatively, discomfort during hip flexion was improved, and the hip joint range of motion during walking was recovered at the last follow-up, which was three weeks after the surgery. CONCLUSION: This is a rare case to demonstrate relevant previous trauma history prior to the formation of osteochondroma.

Monofilament Cerclage Wiring Fixation with Locking Plates for Distal Femoral Fracture: Is it Appropriate?

PURPOSE: We aimed to determine the efficacy of cerclage wiring by comparing the clinical and radiological results between internal fixation with locking plates after distal femoral fracture reduction with or without cerclage wiring. MATERIALS AND METHODS: One hundred and one patients who received open reduction internal fixation for distal femoral fractures of oblique, spiral, and spiral wedge type between 2007 and 2014 were reviewed retrospectively. Only locking plate fixation was performed in 46 patients, and locking plate fixation with additional cerclage wiring was performed in 55 patients (Group CW). Demographic, clinical, and radiologic factors were evaluated in both the groups. Age, gender, bone mineral density, bone graft, and the presence of concomitant fractures were measured as demographic factors. The range of motion of knee joint, Lysholm knee score, visual analog scale score, procedure time, and C-arm time were measured as clinical factors preoperatively and at the final followup. We also evaluated the duration of bone union and knee joint alignment radiologically. RESULTS: There were no demographic differences between the two groups. Furthermore, there were no statistically significant differences between the two groups in terms of clinical and radiological parameters. However, the procedure time used was significantly longer in Group LP than in Group CW (108.4 vs. 95.2 min; P = 0.027). The C-arm time was longer in Group LP (2.8 vs. 1.2 s; P = 0.017). CONCLUSIONS: Open reduction and locking plate fixation with additional cerclage wiring is a useful method for the reduction of complicated distal femoral fractures, without increased complications such as nonunion. LEVEL OF EVIDENCE: Level III, retrospective cohort design, treatment study.

Long-term Outcome of Polished Stems in Total Hip Arthroplasty.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes and radiologic findings of primary total hip arthroplasty (THA) using cemented polished femoral stems. MATERIALS AND METHODS: We retrospectively reviewed 91 hips (91 patients) that had undergone primary THA with cemented polished femoral stems who were followed for at least 10 years. The mean age at surgery was 57 years (47-75 years). Mean follow up period was 12.8 years (10.1-14.0 years). Harris Hip Score (HHS) was used for clinical evaluation. Radiologic evaluation was focused on cementing technique including subsidence within the cement mantle, radiolucent lines at the cement-bone or cement-stem interface, cortical hypertrophy, and calcar resorption. RESULTS: The average HHS was 55.2 points before the surgery that improved to an average of 93.2 points at the final follow-up. According to Barrack classification, there were 50, 32, and 9 cases in A, B, and C grades, respectively. Subsidence of femoral stem was less than 2 mm except in one patient. There were no progressing radiolucent line or loosening of the femoral stem. CONCLUSION: In this study, THA using cemented polished femoral stems was found to have favorable outcomes in long term follow-up.

Inhibition of IL-1beta-mediated inflammatory responses by the IkappaB alpha super-repressor in human fibroblast-like synoviocytes.

The IL-1beta-NF-kappaB axis is a key pathway in the pathogenesis of rheumatoid arthritis (RA) and is central in the production of proinflammatory mediators in the inflamed synovium. Therefore, we examined whether fibroblast-like synoviocytes (FLS) could be spared from IL-1beta-induced toxicity by an overexpressing IkappaB super-repressor. Infection of FLS with Ad-IkappaB alpha (S32A, S36A), an adenovirus-containing mutant IkappaB alpha, inhibited IL-1beta-induced nuclear translocation and DNA binding of NF-kappaB. In addition, Ad-IkappaB alpha (S32A, S36A) prevented IL-1beta-induced inflammatory responses; namely, the production of chemokines, such as ENA-78 and RANTES, and activation of MMP-1 and MMP-3. Finally, increased cellular proliferation of FLS after IL-1beta treatment was significantly reduced by Ad-IkappaB alpha (S32A, S36A). However, Ad-IkappaB beta (S19A, S23A), the IkappaB beta mutant, was not effective in preventing IL-1beta toxicity. These results suggest that inhibition of IkappaB alpha degradation is a potential target for the prevention of joint destruction in patients with RA.