Is dual cup mobility better than hemiarthroplasty in patients with dementia and femoral neck fracture? A randomized controlled trial.

PURPOSE: Treatment of patients with dementia and hip fracture is challenging. Total hip arthroplasty (THA) with dual mobility cup (DMC) has been designed to reduce the rate of dislocation by increasing the stability of the implant. This study aimed to compare the dislocation rates of DMC THA with hemiarthroplasty (HA) in elderly patients with displaced femoral neck fracture (FNF) and a diagnosis of dementia. METHODS: All patients with a displaced FNF and dementia diagnosis were prospectively randomized to hemiarthroplasty or THA with DMC treatment during a 2-year period. Finally, the outcomes of 30 patients in the HA group were compared with those of 30 patients in the DMC THA group. Dislocation rate at a minimum follow-up of 1 year was evaluated as the primary outcome. Reoperation rate, time to surgery, surgical time, length of hospital stay, and 30-day and 1-year mortality were also evaluated. RESULTS: There was a significant difference regarding rates of dislocation in favor of THA with DMC and with regard to length of surgery (p = 0.04) in favor of bipolar HA. Dislocation occurred in five patients (16.6%) treated with bipolar HA and no one (0%) in patients treated with THA with DMC (p = 0.019). There was no difference with regard to the 30-day mortality, 1-year mortality, reoperations, and length of hospital stay between the two groups of patients. DISCUSSION: THA with DMC seems to be a safe and reliable choice to reduce the rate of dislocation at 1 year in patients with dementia and FNF without a higher risk of mortality.

Intertrochanteric fractures: comparison between two different locking nails.

PURPOSE: The aim of this study was to compare two intramedullary devices used in the treatment of intertrochanteric fractures. METHOD: During the period 2006-2007 46 TGN and 51 PFNA were used for the treatment of intertrochanteric fractures in our hospital. Clinical and radiological follow-up were available. Surgical time, blood loss and complications have been considered. RESULTS: The mean operative time for the TGN group was significantly higher than in the PFNA group (62 min and 45 min, respectively) with a p = 0.04. The mean blood loss was significantly higher in the TGN group (285 ml; SD 145) in relation to the PFNA group (226 ml; SD 136) with p = 0.03. Also, rate of complications was higher in the TGN group (p = 0.01). Clinical outcomes were good for both groups. Intra-operative and post-operative complications in the TGN group were associated with a longer operative time and a higher blood loss, probably due to the reaming needed in TGN that can increase blood loss and risk of comminution or fracture propagation. Moreover, all but one of the procedure-related complications were observed in very elderly patients. CONCLUSIONS: Based on our results in the intertrochanteric fracture, use of PFNA should be recommended in cases of elderly and osteoporotic patients, while TGN should be used in more severely displaced fractures in patients with a slightly better bone mineral density.

Reliability of cup position in navigated THA in the lateral decubitus position using the 'flip technique'.

Malpositioning of the acetabular component in total hip arthroplasty (THA) increases the risk of dislocation, reduces the range of motion and may contribute to bearing surface wear. During computer assisted navigation, the anterior pelvic plane is registered intraoperatively by percutaneous palpation, but this may be unreliable. The aim of our study was to evaluate the reliability of imageless navigation in acetabular positioning employing data acquisition in the supine position and surgery in the lateral position ('flip technique'). We report 24 patients affected by primary osteoarthritis undergoing THA in which implants were placed with a conventional free-hand technique using the acetabular transverse ligament for cup orientation. For imageless navigation we used Orthopilot-Aesculap software. All patients had a postoperative computed tomography (CT) scan at three months, using previously validated dedicated software for cup orientation. Data collected using navigation software were compared with CT measurements. The mean acetabular inclination and anteversion recorded intra-operatively using navigation software were respectively 41°5' (SD: 9.61) and 9°5' (SD: 4.01) respectively. The mean inclination and anteversion calculated post-operatively by the CT based image software were 44°2' (SD 5.83) and 14°4' (SD 6.42) respectively. There was a statistically significant difference between the anteversion values (p=0.04). Therefore, the acquisition of parameters in the supine position with surgery performed in the lateral decubitus position creates unreliable data concerning cup anteversion using an imageless navigation system, and therefore the 'flip technique' cannot be recommended.

Navigated knee kinematics after tear of the ACL and its secondary restraints: preliminary results.

In this study we evaluated the role of the anterior cruciate ligament (ACL) and its secondary restraint in controlling knee stability using a navigation system. The purpose of this study was to evaluate the kinematics of the knee in different conditions of instability: ACL intact, after transection of the posterolateral (PL) bundle, after transection of the anteromedial (AM) bundle, and after lesion of the anterolateral femorotibial ligament (ALFTL). Anterior tibial translation and rotation were measured with a computer navigation system in 6 knees in whole fresh-frozen human cadavers by use of a manual maximum load. Anterior translation was evaluated at 30°, 60°, and 90° of flexion; rotation at 0°, 15°, 30°, 45°, 60°, and 90° of flexion. Cutting the PL bundle does not increase anterior translation and rotation of the knee. Cutting the AM bundle significantly increased the anteroposterior (AP) translation at 30° and 60° of flexion (P=.01), but does not increase rotation of the knee. Cutting the ALFTL increased anterior translation at 60° of flexion (P=.04) and rotation at 30°, 45°, and 60° of flexion (P=.03). The PL bundle does not affect anterior translation and rotation of the knee. The AM bundle is the primary restraint of the anterior translation but does not affect rotation of the knee. The lateral compartment becomes the primary restraint of rotation after ACL cut. The primary kinematic effect of an ACL injury is an increase in anterior tibial translation, but there is no significant change in maximum internal or external rotation. The lesion of the ALFTL increases tibial rotation and could be correlated to the pivot shift phenomenon.

Hip arthroplasty for failed treatment of proximal femoral fractures.

Failed treatment of an intertrochanteric fracture typically leads to profound functional disability and pain. Salvage treatment with hip arthroplasty may be considered. The aim of this study was to evaluate the results and complications of hip arthroplasty performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Twenty-one patients were treated in our hospital with hip arthroplasty for failed treatment of intertrochanteric hip fracture. There were sixteen women and five men with a mean age of 75.8 years (range 61-85 years). Fourteen patients had failure of a previous nail fixation procedure, five had failure of a plate fixation, one of hip screws fixation and one of Ender nail fixation. In 19 out of 21 patients we performed a total hip arthroplasty-14 cases used modular implants with long-stems and five cases used a standard straight stem. In 2 of 21 cases we used a bipolar hemiarthroplasty. A statistically significant improvement was found comparing pre and postoperative conditions (p < 0.05). Our experience confirms that total hip arthroplasty is a satisfactory salvage procedure after failed treatment of an intertrochanteric fracture in elderly patients with few serious orthopaedic complications and acceptable clinical outcomes.

Assessment of the initial stability of the Symax femoral stem with EBRA-FCA: a multicentric study of 85 cases.

We report a study of 85 Symax femoral stems that were followed at regular intervals with radiographs at 6, 12, 24 and 36 months. The radiological migration of each stem was measured using the computer-assisted EBRA -FCA method. In 30 cases in which the EBRA method did not provide a complete measurement another computer-assisted method (Roman version 1.7) was employed. In all cases the distal migration of the stems was minimal, The threshold migration value used to define the stability of a stem was 1.5 mm at 24 months. The mean migration within the first two years was -0.17 mm (+/- 0.3) at 6 months, -0.31 mm (+/- 0.4) at 12 months and -0.45 mm (+/- 0.5) at 24 months. Only two cases exceeded the threshold limit of 1.5 mm at the two-year follow-up, but both values were lower than 2 mm. In the 25 cases which reached three-year follow-up the mean distal migration was -0.84 (+/-0.7). In four of them the subsidence exceeded 1.5 mm, but only one exceeded 2 mm. These data represent a positive predictive factor for the minimal risk of future aseptic loosening.

Learning curve in tissue sparing total hip replacement: comparison between different approaches.

BACKGROUND: The tissue sparing surgery (TSS) concept means not only smaller incisions but also less tissue disruption, allowing decreased blood loss and improved function. However, TSS techniques can result in more complications related to the learning curve. The aim of this study was to compare the learning curve of an experienced surgeon with different TSS approaches for total hip replacement (THR) from a clinical and surgical point of view, focussing especially on complications related to the use of different geometric stems. MATERIALS AND METHODS: Sixty patients scheduled to be operated for a primary THR were enrolled in the study and were randomly assigned to surgery by one of three different TSS approaches: lateral with mini incision (group A), minimally invasive anterior (group B) and minimally invasive antero-lateral (group C). Results from the three TSS groups were compared with a control group of 149 patients (group D). RESULTS: Our results reveal significantly reduced blood loss in the TSS groups compared with the control group, with no differences between the TSS groups. We found better early functional scores in the two minimally invasive groups (anterior and anterolateral), and a lower rate of complications with the antero-lateral TSS approach. CONCLUSION: The antero-lateral TSS approach seems to be safer and less demanding than standard THR surgery, and is suitable for use with different stems.

Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. Surgical technique.

BACKGROUND: The outcome of revision anterior cruciate ligament reconstruction has only rarely been reported. The purpose of this study was to evaluate the results of revision anterior cruciate ligament surgery with use of an autogenous doubled semitendinosus and gracilis graft in association with an extra-articular procedure. METHODS: Between 1997 and 2003, thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament with use of a doubled semitendinosus and gracilis graft combined with an extra-articular reconstruction. Primary reconstruction had been done with an autogenous patellar tendon graft in twenty-six patients and with a prosthetic ligament in four patients; the average time from the primary reconstruction to the revision was five years. Functional outcomes, graft survival, and radiographic outcomes were evaluated at a mean of five years. A graft was considered to have failed when a revision was done or when the side-to-side difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift test grade was greater than a trace. RESULTS: One patient underwent another revision reconstruction because of graft failure at three years postoperatively. The mean International Knee Documentation Committee (IKDC) subjective knee score for the remaining twenty-nine patients was 84 +/- 12 points, and the mean Lysholm knee score was 90 +/- 10 points. The side-to-side difference as measured with the KT-1000 arthrometer with maximum manual force was <3 mm in twenty patients (of the twenty-eight who returned for follow-up), between 3 and 5 mm in six patients, and >5 mm in two patients. The result of the pivot shift examination was normal in fifteen patients, slightly positive in eleven patients, and positive in two patients. Twenty-five percent of the patients showed no radiographic signs of degenerative joint disease. CONCLUSIONS: Revision anterior cruciate ligament reconstruction with use of an autogenous doubled semitendinosus and gracilis graft combined with an extra-articular procedure provided satisfactory functional outcomes, with a failure rate of 10%.

Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction.

BACKGROUND: The outcome of revision anterior cruciate ligament reconstruction has only rarely been reported. The purpose of this study was to evaluate the results of revision anterior cruciate ligament surgery with use of an autogenous doubled semitendinosus and gracilis graft in association with an extra-articular procedure. METHODS: Between 1997 and 2003, thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament with use of a doubled semitendinosus and gracilis graft combined with an extra-articular reconstruction. Primary reconstruction had been done with an autogenous patellar tendon graft in twenty-six patients and with a prosthetic ligament in four patients; the average time from the primary reconstruction to the revision was five years. Functional outcomes, graft survival, and radiographic outcomes were evaluated at a mean of five years. A graft was considered to have failed when a revision was done or when the side-to-side difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift test grade was greater than a trace. RESULTS: One patient underwent another revision reconstruction because of graft failure at three years postoperatively. The mean International Knee Documentation Committee (IKDC) subjective knee score for the remaining twenty-nine patients was 84 +/- 12 points, and the mean Lysholm knee score was 90 +/- 10 points. The side-to-side difference as measured with the KT-1000 arthrometer with maximum manual force was <3 mm in twenty patients (of the twenty-eight who returned for follow-up), between 3 and 5 mm in six patients, and >5 mm in two patients. The result of the pivot shift examination was normal in fifteen patients, slightly positive in eleven patients, and positive in two patients. Twenty-five percent of the patients showed no radiographic signs of degenerative joint disease. CONCLUSIONS: Revision anterior cruciate ligament reconstruction with use of an autogenous doubled semitendinosus and gracilis graft combined with an extra-articular procedure provided satisfactory functional outcomes, with a failure rate of 10%.

Fractures of the olecranon in children. Long-term follow-up of 39 cases.

Thirty-nine patients, who had received a fracture of the olecranon at an average age of 7.4 years, were reviewed at an average age of 32 years, in order to evaluate the results of treatment. All patients had reached skeletal maturity at follow-up. Thirty-four fractures were treated conservatively and five, surgically. Of the 34 fractures treated conservatively, six also had surgical treatment of associated fractures. We identified five patterns of fracture on the basis of the anatomic site of the fracture line, the interfragmentary displacement and the presence of an associated lesion. According to our grading scale, 34 patients had a good result, two a fair result and three a poor result. We observed poor results in only 7.6% of cases, even though 85% of the patients had received an intraarticular fracture. We believe that the long-term prognosis of olecranon fractures in children is related to the anatomic site of the fracture line, to the interfragmentary displacement and to the presence of an associated lesion. Conservative treatment may be indicated when the interfragmentary displacement is less than 2 mm. The presence of an associated lesion is a negative prognostic factor.