Revision Hip Arthroplasty Using a Porous-coated or Taper ZMR Implant: Minimum 10-year Follow-up of Implant Survivorship.

INTRODUCTION: The Zimmer Modular Revision hip (ZMR) system is available in two stem options, a porous-coated cylindrical (PCM) and a taper (TM) stem. Several concerns have been reported regarding modular implants. Specifically, because of early junctional fractures, the ZMR system was redesigned with a wider modular interface. As such, we designed a study assessing long-term ZMR survivorship and functional and radiographic outcomes. METHODS AND MATERIALS: A search of our institutional research database was performed. A minimum 10-year follow-up was selected. The following two cohorts were created: PCM and TM stems. The Kaplan-Meier survival analysis was performed, and causes of stem failure requiring revision surgery were collected. Functional outcomes as per the Harris Hip Score and radiographic stem stability were assessed as per the Engh classification. RESULTS: A total of 146 patients meeting the inclusion criteria were available for follow-up (PCM = 68, TM = 78). The mean follow-up was 13.4 years clinically and 11.1 years radiographically for the PCM cohort. Similarly, the TM cohort had a follow-up of 11.1 years clinically and 10.5 years radiographically. The Kaplan-Meier survivorships were 87.1% and 87.8% at 15 years for the PCM and TM cohorts, respectively. The most common cause of failure requiring revision surgery overall was aseptic loosening (PCM = 1.4%, TM = 5.6%). The mean postoperative Harris Hip Score was as follows: PCM = 71.2 and TM = 64.7. Engh type I or II stem ingrowth was as follows: PCM = 85% and TM = 68%. DISCUSSION: Good survivorship using the ZMR stem system can be expected at up to 15 years. Aseptic loosening remains the most commonly encountered problem for both PCM and TM stems. Previously identified modular junctional weakness seem to have been addressed.

Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review.

BACKGROUND: The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome. METHODS: A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories. RESULTS: Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures. CONCLUSIONS: The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes and complications of ulnar shortening osteotomy: an institutional review.

BACKGROUND: Ulnar impaction syndrome (UIS) is a common cause of ulnar wrist pain. Patients may be candidates for surgical intervention if nonoperative options are ineffective. At our institution, ulnar shortening osteotomy is the preferred procedure to manage this disorder. The purpose of this study was to present patient reported outcomes and complication rates of ulnar shortening osteotomy (USO) at mid-term follow-up. METHODS: A retrospective chart review of 72 patients (75 wrists) obtained from our institutional database was performed. At a mean 32 months postoperatively, telephone interviews (n = 53) were performed for all patients who were available for follow-up. The patient-rated wrist evaluation (PRWE), a validated outcome tool, was completed and complications were reviewed. RESULTS: Patient-rated outcomes were favorable; however, complications were frequent and included: delayed union (10/75, 13.3 %), nonunion (6/75, 8 %), and complex regional pain syndrome (5/75, 6.7 %). Ten patients (13.3 %) required revision surgery. Thirty-four patients (45.3 %) required hardware removal with 4/30 (11.4 %) of these patients experiencing refracture. Smokers (mean PRWE 67.1) and patients with workers' compensation claims (mean PRWE 64.9) reported higher residual pain and disability than their counterparts (mean PRWE 28.0; 25.2). CONCLUSIONS: General outcome measures were favorable. Smokers and patients with workers' compensation claims experienced significantly poorer outcomes. However, the incidence of nonunion and delayed union was higher than most reports in the literature. Furthermore, we demonstrated a high refracture rate (11.4 %) following removal of hardware.

Vertebral osteomyelitis following transrectal ultrasound-guided biopsy of the prostate.

Transrectal ultrasound-guided needle biopsy of the prostate (TRUS) is a well-tolerated and standardized procedure for the diagnosis of prostate cancer. Complications associated with TRUS requiring emergency room visits or hospital admissions are relatively low and include complications, such as a 1% risk of urinary retention and less than 1% chance of bacterial sepsis. Vertebral osteomyelitis is a rare complication of TRUS; there are 3 reported cases. Vertebral osteomyelitis has an insidious onset and usually resolves following medical intervention. We present an extremely rare case of vertebral osteomyelitis following TRUS, its clinical outcome and management.

The effects of heparin and low molecular weight heparins on bone.

Recent clinical trials have shown that the risk of developing osteoporosis is substantially lower when low molecular weight heparins (LMWHs) are used in place of unfractionated heparin. While the reason(s) for this difference has not been fully elucidated, studies with animals have suggested that heparin causes bone loss by both decreasing bone formation and increasing bone resorption. In contrast, LMWHs appear to cause less bone loss because they only decrease bone formation. Whether all LMWHs decrease bone formation and therefore cause bone loss is unknown. For example, preliminary in vitro studies with the synthetic pentasaccaride, Fondaparinux, have suggested that it may not decrease bone formation and thus, may have no deleterious effects on bone. Further studies are required in order to determine if all LMWHs cause bone loss equally.

Heparin synergistically enhances interleukin-11 signaling through up-regulation of the MAPK pathway.

Using an animal model of heparin-induced osteoporosis we previously demonstrated that heparin causes bone loss, in part, by increasing osteoclast number and activity. Furthermore, we found that, although heparin alone has no effect, it is able to synergistically enhance Interleukin-11 (IL-11)-induced signal transducer and activator of transcription 3 (STAT3) activation and thus increase osteoclast formation in vitro. In the present study, we examine the effect of various serine kinase inhibitors on the ability of heparin to act synergistically with IL-11. Inhibition of the c-Jun N-terminal kinase (JNK), p38 mitogen-activated protein kinase (MAPK), or the phosphatidylinositol 3-kinase pathways had no effect on the ability of heparin to promote either IL-11-induced STAT3.DNA complex formation or osteoclast formation in vitro. In contrast, PD098059, a MAPK kinase inhibitor, completely abolished the synergy between heparin and IL-11. In an attempt to resolve the mechanism by which this was occurring, we examined the effect of heparin on STAT3 Ser-727 phosphorylation and extracellular signal-regulated kinases 1 and 2 (Erk1/2) activation, either in the presence or absence of IL-11. Heparin alone was found to have no effect on Ser-727 phosphorylation, nor did heparin alter the phosphorylation status of Ser-727 in the presence of IL-11. Heparin was, however, found to increase Erk1/2 activation in both a time- and dose-dependent manner. When taken together, these findings suggest that heparin enhances IL-11-induced STAT3 activation and thus osteoclast formation, by a mechanism that is independent of STAT3 Ser-727 phosphorylation but that involves up-regulation of the MAPK pathway.