Analysis on association between sagittal stem alignment and early functional and radiological outcome following primary cementless total hip replacement.

INTRODUCTION: Accurate reconstruction of hip anatomy and biomechanics is mandatory for achieving good clinical outcomes following total hip replacement (THR). Optimal stem alignment is essential to avoid impingement or loosening. This study aimed to evaluate sagittal stem position following cementless THR and its relationship with patient's functional outcome and post-operative radiological parameters. METHOD: We performed analytical observational study with cross-sectional design on 71 hips (67 patients, ranged 18-85 years old) that underwent primary cementless THR in two orthopedic centers in Jakarta, Indonesia. All hips were operated through either anterolateral or posterior approach using either extended/full-coating wedge-tapered stem or proximal-coated wedge-tapered stem. Clinical outcomes were evaluated at follow-up time using mHHS questionnaire, VAS level of thigh pain, and hip ROM. Stem sagittal alignment and other radiological parameters, including combined anteversion and offset, were measured from conventional radiograph. RESULTS: There were no significant differences on mHHS score, VAS level on thigh pain, and ROM between stem alignment groups. Post-operative anteversion and offset of the implant were not affected by the stem sagittal position. All influencing factors have significant effect on sagittal stem alignment. Linear regression test on femur morphology showed 0.69° increase in stem posterior tilt for every 1° increase in the anterior bowing (coeff. = 0.502). CONCLUSION: Stem tilting in sagittal plane did not affect patient's functional outcome or post-operative radiological parameters. In addition, for every degree of increased anterior femoral bowing, 0.69° increase in posterior stem tilting can be expected.

The management of pelvic ring fractures in low-resource environments: review.

Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.

Management of pelvic ring fractures in limited resources country: a retrospective study.

PURPOSE: Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country. METHODS: We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score. RESULTS: From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score. CONCLUSION: The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment.

Cross-cultural adaptation and psychometric validation of the Indonesian version of the Oxford Hip Score.

AIMS: The aim of this study was to perform a cross-cultural adaptation of Oxford Hip Score (OHS) to Indonesian, and to evaluate its psychometric properties. METHODS: We performed a cross-cultural adaptation of Oxford Hip Score into Indonesian language (OHS-ID) and determined its internal consistency, test-retest reliability, measurement error, floor-ceiling effect, responsiveness, and construct validity by hypotheses testing of its correlation with Harris Hip Score (HHS), vsual analogue scale (VAS), and Short Form-36 (SF-36). Adults (> 17 years old) with chronic hip pain (osteoarthritis or osteonecrosis) were included. RESULTS: A total of 125 patients were included, including 50 total hip arthroplasty (THA) patients with six months follow-up. The OHS questionnaire was translated into Indonesian and showed good internal consistency (Cronbach's alpha = 0.89) and good reliability (intraclass correlation = 0.98). The standard error of measurement value of 2.11 resulted in minimal detectable change score of 5.8. Ten out of ten (100%) a priori hypotheses were met, confirming the construct validity. A strong correlation was found with two subscales of SF-36 (pain and physical function), HHS (0.94), and VAS (-0.83). OHS-ID also showed good responsiveness for post-THA series. Floor and ceiling effect was not found. CONCLUSION: The Indonesian version of OHS showed similar reliability and validity with the original OHS. This questionnaire will be suitable to assess chronic hip pain in Indonesian-speaking patients. Cite this article: Bone Jt Open 2021;2(9):765-772.

Submuscular gluteal abcess: An unusual presentation of rare sacral tuberculosis.

INTRODUCTION: Both gluteal abscess and sacral tuberculosis are rare entities in spinal tuberculosis cases. Even in endemic country, this atypical presentation may be the cause of delayed diagnosis and treatment. PRESENTATION OF CASE: A 51-year-old woman was admitted with painless massive lump on both of her thighs that have been enlarging for the past 6 months. She had a history of previous tuberculosis treatment. From the MRI examination submuscular gluteal abscess, which was an extension of the sacral tuberculosis, were found. Open debridement and biopsy were performed, which confirmed the suspicion of tuberculosis. Oral anti tuberculosis drugs were administered after. There was no recurrence and complication at the final follow up. DISCUSSION: Cold abscess formation is common in spine tuberculosis however the formation of gluteal abscess as the extension of sacral tuberculosis is rare. Although MRI's specificity in determining the underlying cause is poor, it has a great role not only determining the location and size of the lesion, but also to describe anatomical pathophysiology of the abscess dissemination from sacral tuberculosis. CONCLUSION: Despite the limitation of the study and the rarity of this case, tuberculosis should be made as the main differential diagnosis for atypical sacral lesion that occurs with submuscular gluteal abscess.

Hypersensitivity to orthopaedic implant manifested as erythroderma: Timing of implant removal.

INTRODUCTION: Incidence of hypersensitivity to orthopaedic implant, once estimated in less than 1% of population, recently has increased to 10%. Controversies about the timing of implant removal remain, especially due to the fact that implant hypersensitivity may be a contributing factor to implant failure. We present a case report and literature reviews to establish the decision making for the timing of implant removal in the presence of implant hypersensitivity. PRESENTATION OF CASE: Female, 42 years old with nonunion of mid-shaft tibia and fibula which was treated with ORIF with conventional SAE16 stainless steel plate and bone graft. A week after, she developed a generalized rash, which is later diagnosed as erythroderma, that relapsed despite adequate systemic corticosteroid. Poor healing of surgical site wound were marked. After the implant removal, the cutaneous condition improved and no relapse were found. DISCUSSION: Management of hypersensitivity to implants involved corticosteroid administration, removal or replacement of implants, or implants coating with polytetrafluoroethylene. Currently there are no specific guidelines regulating the management of implant allergy based on the timing of the onset, especially in fracture cases. The decision-making would be straightforward if union was already achieved. Otherwise, controversies would still occur. In this paper, we proposed an algorithm regarding the steps in managing metal allergy due to implant in fracture cases. CONCLUSION: Despite the concerns regarding implant survival in hypersensitivity cases, the decision whether the implant should be removed or replaced should be based on the time and condition of the fracture healing process.