Salvage of failed osteosynthesis for an atypical subtrochanteric femoral fracture associated with long-term bisphosphonate treatment using a 95° angled blade plate.

AIMS: The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. PATIENTS AND METHODS: Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale. RESULTS: In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group. CONCLUSION: The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511-17.

Incidence, risk factors, and fracture healing of atypical femoral fractures: a multicenter case-control study.

The incidence of atypical femoral fractures (AFFs) was 2.95% among 6644 hip and femoral fractures. Independent risk factors included the use of bisphosphonates (BPs), osteopenia or osteoporosis, rheumatoid arthritis, increased femoral curvatures, and thicker femoral cortices. Patients with AFFs and BP treatment were more likely to have problematic healing than those with typical femoral fractures (TFFs) and no BP treatment. INTRODUCTION: To determine the incidence and risk factors of atypical femoral fractures (AFFs), we performed a multicenter case-control study. We also investigated the effects of bisphosphonates (BPs) on AFF healing. METHODS: We retrospectively reviewed the medical records and radiographs of 6644 hip and femoral fractures of patients from eight tertiary referral hospitals. All the radiographs were reviewed to distinguish AFFs from TFFs. Univariate and multivariate logistic regression analyses were performed to identify risk factors, and interaction analyses were used to investigate the effects of BPs on fracture healing. RESULTS: The incidence of AFFs among 6644 hip and femoral fractures was 2.95% (90 subtrochanter and 106 femoral shaft fractures). All patients were females with a mean age of 72 years, and 75.5% were exposed to BPs for an average duration of 5.2 years (range, 1-17 years). The use of BPs was significantly associated with AFFs (p < 0.001, odds ratio = 25.65; 95% confidence interval = 10.74-61.28). Other independent risk factors for AFFs included osteopenia or osteoporosis, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex at the shaft level. Interaction analyses showed that patients with AFFs using BPs had a significantly higher risk of problematic fracture healing than those with TFFs and no BP treatment. CONCLUSIONS: The incidence of AFFs among 6644 hip and femoral fractures was 2.95%. Osteopenia or osteoporosis, use of BPs, rheumatoid arthritis, increased anterior and lateral femoral curvatures, and thicker lateral femoral cortex were independent risk factors for the development of AFFs. Patients with AFFs and BP treatment were more likely to have problematic fracture healing than those with TFFs and no BP treatment.

Clinical and radiologic results after open-wedge high tibial osteotomy in haemophilic knee arthropathy with varus deformity.

INTRODUCTION: The previous studies have described only closed-wedge high tibial osteotomy (HTO) in haemophilic arthropathy (HA). AIM: The purpose of this study was to evaluate clinical and radiographic results after open-wedge HTO in HA with varus knee deformity. METHODS: We included 13 open-wedge HTOs in HA performed between 2005 and 2016. The mean age of patients was 28.9 years. Visual analogue scale (VAS), Western Ontario and McMaster Universities (WOMAC), and range of motion (ROM) indices were assessed. Any complications or requirements for total knee arthroplasty (TKA) were investigated. Mechanical axis (MA), minimal joint space width (mJSW) and Pettersson score were measured. Bone union rates at 3 and 6 months postoperative were evaluated. RESULTS: VAS improved from 5.1 to 2.4 (P < .001). WOMAC was 66.5 preoperatively, and 26.6 postoperatively (P < .001). Pre- and postoperative ROM did not differ significantly. There were no cases of HTO converted to TKA, but one case of HTO required TKA 152 months postoperative. No complications were observed. The MA was corrected from varus 5.1° to valgus 1.2° (P < .001). Pre- and postoperative mJSW did not significantly differ. Pettersson score improved from 3.84 to 2.47 (P < .001). The bone union rates at the osteotomy gap were 45.2% and 67.8% at 3 and 6 months postoperative. CONCLUSIONS: Open-wedge HTO should be considered in cases of HA with varus deformity in young haemophilic patients, even though inflammatory arthritis is not an optimal indication for this procedure. It can be an appropriate treatment with respect to the choice to postpone TKA.

Robot-assisted total knee arthroplasty in haemophilic arthropathy.

INTRODUCTION: Execution of total knee arthroplasty (TKA) in end-stage haemophilic arthropathy is challenging because of soft tissue fibrosis, flexion contractures, poor quality of the bone, and the altered bony anatomy. Restoring the lower limb alignment and achieving range of motion (ROM) is difficult. Robots have been used in TKA to reduce the chances of malalignment and improve accuracy and precision. However, there has been no report in literature on use of robots for TKA in haemophilic arthropathy. The aim of this study was to evaluate whether robot-assisted TKA can be successfully carried out in haemophilic arthropathy and what precision could be obtained. METHODS: Thirty-two robot-assisted TKA were evaluated in 29 haemophilia patients. The mean follow up period was 5 years (range, 3-7 years). Hip-knee-ankle (HKA) axis, component angles, and radiographic loosening were evaluated. Clinically ROM, Knee Society scores (KSS) and SF-36 were assessed. RESULTS: The HKA axis was within a range of 0 ± 3° in 30 knees (93.8%). The alignment of the components also presented satisfying results. KSS were improved from 27.1 to 82.8 postoperatively (P < 0.001). The ROM was improved from 70.7 to 84.7 postoperatively (P = 0.006). Complications included early haematoma in three knees, heterotopic ossification in three knees, periprosthetic infection in two knees. CONCLUSIONS: Though robotic TKA gives excellent accuracy of lower limb and component alignment, expensive cost, additional preparation time, longer operation time with similar clinical results in haemophilic arthropathy should be concerned.

Cementless total hip arthroplasty for haemophilic arthropathy: follow-up result of more than 10 years.

The improvement of prophylaxis and adequate replacement of clotting factors, the quality of life and natural history of haemophilia have been significantly improved. However, significant functional impairment is inevitable. This study was performed to evaluate over 10 years clinical and radiographic outcomes of cementless total hip arthroplasty (THA) for treatment of haemophilic hip arthropathy. Between 1995 and 2003, 27 cases of cementless total hip arthroplasties were performed in 23 haemophilic patients. A total of 21 cases from 17 patients were available for follow-up analysis over 10 years. Modified Harris hip score, the range of motion of the hip joint, perioperative coagulation factor requirements and complications associated with bleeding were evaluated as part of the clinical assessment. For the radiographic assessment, fixation of component, osteolysis, loosening and other complications were evaluated. Clinically, the mean Harris hip score improved from 57 points before the operation to 94 points at the last follow-up. The mean flexion contracture was 10° preoperatively and 0.9° at the final follow-up. The further flexion improved from 68.4° to 90.5° after surgery. The mean monthly requirement of factor VIII reduced from 3150 units before surgery to 1800 units at the time of the last follow-up. There were three cases of rebleeding. In one case, a progressive haemophilic pseudotumour was found. Reoperation for any reason including revision was performed in three cases. We believe that cementless THA in patient with haemophilic hip arthropathy can bring reliable pain relief and functional improvement for longer than 10 years.

Application of finite element analysis in pre-operative planning for deformity correction of abnormal hip joints--a case series.

In experimental and clinical research, it is difficult to directly measure responses in the human body, such as contact pressure and stress in a joint, but finite element analysis (FEA) enables the examination of in vivo responses by contact analysis. Hence, FEA is useful for pre-operative planning prior to orthopaedic surgeries, in order to gain insight into which surgical options will result in the best outcome. The present study develops a numerical simulation technique based on FEA to predict the surgical outcomes of osteotomy methods for the treatment of slipped capital femoral epiphyses. The correlation of biomechanical parameters including contact pressure and stress, for moderate and severe cases, is investigated. For severe slips, a base-of-neck osteotomy is thought to be the most reliable and effective surgical treatment, while any osteotomy may produce dramatic improvement for moderate slips. This technology of pre-operative planning using FEA can provide information regarding biomechanical parameters that might facilitate the selection of optimal osteotomy methods and corresponding surgical options.

Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy.

Radiosynoviorthesis is a safe and easy method for synovectomy in haemophilic arthropathy. Various agents have been used in radiosynoviorthesis, especially newly developed agent Holmium-166-chitosan complex has good clinical outcome. This study analysed clinical results and radiologic evaluation of radioisotope synoviorthesis using Holmium-166-chitosan complex in haemophilic arthropathy. From March 2001 to December 2003, 58 radiosynoviorthesis were performed in 53 haemophiliacs. The average age at procedure was 13.8 years. The Arnold and Hilgartner stage of the patients was from I to IV. Holmium-166-chitosan complex was injected in 31 ankle joints, 19 elbow joints and 8 knee joints. Average follow-up was 33 months since primary procedure. The range of motion of each joint, frequency of intra-articular bleeding and factor dose used were analysed for clinical assessment. There was no significant improvement of range of motion in affected joints. After procedure, the average frequency of bleeding of the elbow joint has decreased from 3.76 to 0.47 times per month, the knee joint from 5.87 to 1.12 times per month, and the ankle joint from 3.62 to 0.73 times per month respectively (P < 0.05). After treatment, the average coagulation factor dose injected was significantly decreased to 779.3 units per month from 2814.8 units per month before treatment (P < 0.001). Radioisotope synoviorthesis with Holmium-166-chitosan complex in haemophilic arthropathy is a very safe and simple procedure with the expectation of a satisfactory outcome without serious complication. It has excellent bleeding control effect on target joint and the need for substitution of coagulation factor concentrate can be reduced.

In vitro release of vancomycin from vancomycin-loaded blood coated demineralised bone.

In vitro and in vivo studies have demonstrated the possibility that cancellous bone could be used as a carrier of antibiotics for local delivery. However, the release of antibiotics from the loaded cancellous bone is too rapid and uncertain. We hypothesised that demineralisation of cancellous bone would increase the amount of antibiotic adsorbed, and coating of the freeze-dried antibiotic-impregnated cancellous bone with bio-compatible material would prolong antibiotic release. Bovine cancellous bone blocks of equal size were demineralised using a 0.5 N HCl solution and loaded with vancomycin solution under vacuum. The loaded bone blocks were then freeze-dried. To obtain a bio-compatible coating, the vancomycin-impregnated bone blocks were soaked in fresh human venous blood for 3 h. The release of impregnated antibiotic from the bone blocks was evaluated in phosphate-buffered saline and foetal bovine serum. It was found that significantly larger amounts of vancomycin were adsorbed into the demineralised bone blocks than into the un-demineralised blocks. The blood coating was found to increase the duration of vancomycin release from the blocks. With demineralisation and blood coating, the blocks eluted vancomycin higher than therapeutic concentration for a 5-week period.