Stress Fracture after Arthroscopic Lesser Trochanter Resection: Diagnosis and Therapy.

We report on the case of a 52-year-old female who presented with a stress fracture after undergoing an endoscopic resection of the lesser trochanter in ischiofemoral impingement, which was resistant to maximal conservative treatment. To the best of our knowledge, this complication has not been previously described. Non-weight-bearing and intravenous alendronic acid were prescribed for management. No additional surgery was required. The patient was pain free with the ability to perform sports on the same level as before and had no complaints.

Surfing After Hip Resurfacing Surgery.

OBJECTIVE: There is no information about surfing after hip resurfacing arthroplasty (HRA). We did a retrospective study aiming to evaluate the safety and feasibility to resume surfing-an extreme sport with high-impact physical activity-after HRA. DESIGN: Retrospective case series. SETTING: Specialist Orthopaedic Group, Mater Hospital Sydney, NSW, Australia. PATIENTS: We evaluated 45 patients who practiced surfing before the onset of pain and hip surgery. Complete clinical and radiographical follow-up and a completed questionnaire were available for 37 (82%) patients. INTERVENTIONS: Hip resurfacing arthroplasty. MAIN OUTCOME MEASURES: Postel-Merle d'Aubigne score, the Oxford hip score, the Harris hip score, and the University of California at Los Angeles activity score. Radiographical evaluation at 6 weeks, 3, and 12 months after surgery and yearly thereafter. Return to surf rates using a specific questionnaire. Complications and failures during follow-up. RESULTS: All clinical scores improved significantly after HRA. Eight of 37 (22%) patients stopped surfing after their HRA. More than 80% of patients commenced surfing within the first 6 months after surgery. During surfing, 21 patients (72%) were completely pain free. CONCLUSION: No literature exists regarding the return to a high-impact sport as surfing after HRA. Most of our patients (71%) were able to return at least to their preoperative level of surfing after surgery. No complications related to this sport activity were observed during short-term follow-up. We believe that surfing is compatible with HRA, but long-term studies are necessary to assess the influence of this extreme sport on loosening and revision rates.

Lower pelvic tilt, lower pelvic incidence, and increased external rotation of the iliac wing in patients with femoroacetabular impingement due to acetabular retroversion compared to hip dysplasia.

AIMS: The effect of pelvic tilt (PT) and sagittal balance in hips with pincer-type femoroacetabular impingement (FAI) with acetabular retroversion (AR) is controversial. It is unclear if patients with AR have a rotational abnormality of the iliac wing. Therefore, we asked: are parameters for sagittal balance, and is rotation of the iliac wing, different in patients with AR compared to a control group?; and is there a correlation between iliac rotation and acetabular version? METHODS: A retrospective, review board-approved, controlled study was performed including 120 hips in 86 consecutive patients with symptomatic FAI or hip dysplasia. Pelvic CT scans were reviewed to calculate parameters for sagittal balance (pelvic incidence (PI), PT, and sacral slope), anterior pelvic plane angle, pelvic inclination, and external rotation of the iliac wing and were compared to a control group (48 hips). The 120 hips were allocated to the following groups: AR (41 hips), hip dysplasia (47 hips) and cam FAI with normal acetabular morphology (32 hips). Subgroups of total AR (15 hips) and high acetabular anteversion (20 hips) were analyzed. Statistical analysis was performed using analysis of variance with Bonferroni correction. RESULTS: PI and PT were significantly decreased comparing AR (PI 42° (SD 10°), PT 4° (SD 5°)) with dysplastic hips (PI 55° (SD 12°), PT 10° (SD 6°)) and with the control group (PI 51° (SD 9°) and PT 13° (SD 7°)) (p < 0.001). External rotation of the iliac wing was significantly increased comparing AR (29° (SD 4°)) with dysplastic hips (20°(SD 5°)) and with the control group (25° (SD 5°)) (p < 0.001). Correlation between external rotation of the iliac wing and acetabular version was significant and strong (r = 0.81; p < 0.001). Correlation between PT and acetabular version was significant and moderate (r = 0.58; p < 0.001). CONCLUSION: These findings could contribute to a better understanding of hip pain in a sitting position and extra-articular subspine FAI of patients with AR. These patients have increased iliac external rotation, a rotational abnormality of the iliac wing. This has implications for surgical therapy with hip arthroscopy and acetabular rim trimming or anteverting periacetabular osteotomy (PAO). Cite this article: Bone Jt Open 2021;2(10):813-824.

Total hip arthroplasty using the direct anterior approach and intraoperative neurophysiological monitoring for Crowe III hip dysplasia : surgical technique and case series.

Developmental dysplasia of the hip with a high dislocation may lead to severe hip pain and a marked shortening. Nerve palsy rates following THA in dysplastic hips have been reported as being higher by ten times or more compared to the general population. We report a new technique to perform THA in high congenital dislocations. Between 2013 and 2015, 3 consecutive patients (4 hips) with severe hip pain and Crowe III hip dysplasia were treated. Surgeries were performed on a standard table using the DAA and intraoperative neurophysiological monitoring. At final follow-up (mean 24 months, range 15-43), all 3 patients reported excellent pain relief and significant improvement in activities of daily living. Radiographs showed the components to be solidly fixed in satisfactory position. Average postoperative leg lengthening was 24 mm (range 20-36). None of the patients experienced an acute or delayed neurologic deficit. Total hip arthroplasty for high congenital dislocations can be safely performed using the direct anterior approach and neuromonitoring. Significant lengthening could be obtained without neurological complications.

Acetabular reconstruction with a custom-made triflange acetabular component through direct anterior approach - A case report.

Complex acetabular reconstruction sometimes requires the use of a custom-made triflange acetabular component (CTAC). In this article we describe the surgical technique to achieve its implantation through the direct anterior approach (DAA). Meanwhile we report on our first aMace® CTAC placement in revision total hip arthroplasty through the DAA. Most procedures concerning the implantation of a CTAC are performed through the posterolateral approach to obtain adequate exposure. However, literature reports a high overall dislocation rate of 14% using this approach for revision hip arthroplasty. Because of the documented lower dislocation rate and a faster early rehabilitation of procedures performed through DAA, we considered to implant this vast acetabular reconstruction component through the same approach we use for our primary and standard revision cases. In collaboration with the engineers, the design and the screw direction were adapted to the DAA. We used a standard DAA with longitudinal incision and had no difficulty to successfully implant the CTAC in the desired implant position.

Articulation of Native Cartilage Against Different Femoral Component Materials. Oxidized Zirconium Damages Cartilage Less Than Cobalt-Chrome.

BACKGROUND: Oxidized zirconium (OxZr) is produced by thermally driven oxidization creating an oxidized surface with the properties of a ceramic at the top of the Zr metal substrate. OxZr is much harder and has a lower coefficient of friction than cobalt-chrome (CoCr), both leading to better wear characteristics. We evaluated and compared damage to the cartilage of porcine patella plugs, articulating against OxZr vs CoCr. Our hypothesis was that, owing to its better wear properties, OxZr would damage cartilage less than CoCr. If this is true, OxZr might be a better material for the femoral component during total knee arthroplasty if the patella is not resurfaced. METHODS: Twenty-one plugs from porcine patellae were prepared and tested in a reciprocating pin-on-disk machine while lubricated with bovine serum and under a constant load. Three different configurations were tested: cartilage-cartilage as the control group, cartilage-OxZr, and cartilage-CoCr. Macroscopic appearance, cartilage thickness, and the modified Mankin score were evaluated after 400,000 wear cycles. RESULTS: The control group showed statistically significant less damage than plugs articulating against both other materials. Cartilage plugs articulating against OxZr were statistically significantly less damaged than those articulating against CoCr. CONCLUSION: Although replacing cartilage by an implant always leads to deterioration of the cartilage counterface, OxZr results in less damage than CoCr. The use of OxZr might thus be preferable to CoCr in case of total knee arthroplasty without patella resurfacing.

Percutaneous hardware free corrective osteotomy for bunionnette deformity.

When bunionette deformities are not responding to conservative treatment, several surgical procedures are available. Recently, minimal invasive techniques have been proposed with good results. We present our results of a strictly percutaneous 5th metatarsal osteotomy to correct the deformity with bandage after care. We present a retrospective review on 20 percutaneous distal oblique 5th metatarsal osteotomies for correction of bunionette deformity. Aftercare consisted of 5-6 weeks of corrective taping with full weight bearing using a post-op shoe. Patients were evaluated radiographically and clinically by the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Inter-phalangeal scale, Visual Analogue scale (VAS) and Coughlin classification. At a mean follow-up of 27.05 months, the AOFAS improved from a mean of 51 points to 91.6 points (max 100). 90% of patients had good or excellent clinical result and a mean pain score on the visual analog scale was 0.7 out of 10. Radiographic evaluation showed a good correction of the intermetatarsal and metatarsophalangeal angle. We did not encounter any complications such as infections, wound breakdown, neurovascular problems, non-union or recurrence. The percutaneous hardware free corrective osteotomy is an effective, reliable and safe procedure concerning the treatment of bunionette deformity. The results are comparable with previously published outcomes of open and minimal invasive procedures with considerable less soft tissue damage, shorter operating time and the lack of internal fixation.

Acetabular Fracture after Hip Hemiarthroplasty: One Stage Procedure to a Total Hip Arthroplasty after Stabilization of the Fracture by Means of Cerclage Wires.

Introduction: Hip fractures in the elderly pose an increasing problem in society. In the elderly, a bipolar hemiarthroplasty (HA) remains the treatment of choice in case of hip fractures related to osteoporosis. However, due to an ongoing osteoporosis in this age group, a periprosthetic femoral fracture and a fracture of the unresurfaced acetabulum are increasingly noticed.In the literature, no information can be found regarding the treatment options for this kind of periprosthetic acetabular fracture. Case Report: We present a case report of a patient suffering an acetabular fracture 6 years after a HA. A one stage surgical procedure was the treatment of choice, consisting of a stabilization the acetabulum fracture by means of cerclage wires and a conversion of the HA to a total hip arthroplasty (THA). 4 months after surgery, she regained her pre-operative functional status, and a radiographic evaluation of the right hemipelvis showed good signs ofthe fracture healing without migration ofthe acetabular component. Conclusion: This case shows a "one stage" surgery solution for an acetabular fracture after HA. Stabilization of the acetabulum fracture by means of cerclage wires and a conversion ofthe HA to a THAis a viable solution for this rare and challenging problem.

Incidence and risk factors of lower leg fractures in Belgian soccer players.

INTRODUCTION: Soccer is the world's most popular sport and one that is physically demanding and highly competitive. Consequently, the rate of injuries resulting from this sport is only increasing. It is estimated that 2-20% of all such injuries are fractures, one-third of which are located in the lower extremities. The aim of this epidemiological study was to investigate the incidence of lower-leg fractures (LLFs) in Belgian soccer players and determine the possible risk factors that lead to them. METHODS: All injuries of players associated with the Royal Belgium Football Association (RBFA) were reported and collected in a nationwide registry. We retrospectively compared the incidence rate of and risk factors for LLFs in Belgian soccer players during two seasons, 1999-2000 and 2009-2010. RESULTS: In total, 1600 fractures (3%) were located in the lower leg. After a decade, the number of LLFs remained unchanged. Ankle fractures were the most common (37%), followed by foot and tibia fractures (33% and 22%, respectively). The least common were fibula fractures, which accounted for just 9%. A higher incidence of every type of LLF was observed in older and amateur-level soccer players, when compared with their younger and professional counterparts. Male players experienced more tibia and foot fractures, whereas the incidences of ankle and fibula fractures were comparable with those in female soccer players. The vast majority of fractures occurred during soccer games. CONCLUSION: Ankle fractures and foot fractures represented two-thirds of all fractures noted in this analysis. Male gender, recreational level and adult age were important risk factors for LLFs. After 10 years, the incidence of LLFs did not decrease. Given the socioeconomic impact of these injuries, improved prevention techniques are required to reduce their incidence, particularly with regard to the frequently occurring ankle and foot fractures in this population.

Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees.

PURPOSE: Restoration of correct alignment is one of the main objectives of total knee arthroplasty (TKA). However, the influence of residual malalignment on clinical and functional outcomes is currently uncertain. This study was therefore undertaken to ascertain its influence in patients undergoing TKA for varus osteoarthritis of the knee. METHODS: A cohort of 132 consecutive patients (143 knees) with pre-operative varus alignment was evaluated with a mean follow-up period of 7.2 years. Based upon the post-operative alignment, patients were stratified into three groups: neutral, mild varus, and severe varus. These groups were compared with respect to clinical and functional outcomes. RESULTS: All patients had post-operative improvements in Knee Society Score (KSS). Knees that were left in mild varus scored significantly better for the KSS and the Western Ontario and McMaster Universities Arthritis Index, compared with knees that were corrected to neutral and knees that were left in severe varus exceeding 6°. No revisions occurred in any of the groups at midterm follow-up. CONCLUSION: The results of this study contradict the conventional assumption that correction to neutral mechanical alignment leads to the best outcome following TKA. Patients with pre-operative varus had better clinical and functional outcome scores if the alignment was left in mild varus, as compared with patients with an alignment correction to neutral. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Cementing the tibial component in total knee arthroplasty: which technique is the best?

Aseptic loosening of the tibial component remains a major cause of failure in total knee arthroplasty and may be related, directly or indirectly, to micromotion. Therefore, good fixation of the tibial component is a prerequisite to achieve long-term success of the implant. Cementing technique is one of the factors that play a role in this respect. We investigated the effect of different cementing techniques on the cement penetration in the proximal tibia. We compared 5 different cementing techniques in an anatomical open pore sawbone model (n = 25), using a contemporary total knee arthroplasty design and standard polymethylmetacrylate cement. We demonstrated that applying cement to both the undersurface of the tibial baseplate and as well as onto the tibial bone, either by a spatula or fingerpacking technique, leads to an optimal cement penetration of 3 to 5 mm. When cement is applied only onto the tibial component, penetration is insufficient. When a cement gun is used, cement penetration is too excessive.

Variations of the intra-articular portion of the long head of the biceps tendon: a classification of embryologically explained variations.

BACKGROUND: Although the intra-articular portion of the long head of the biceps (LHB) usually runs free, different types of fusions with the inferior surface of the capsule are known to be possible. Anatomic variations of this part of the LHB have been previously described and were nearly always considered to be innocent. MATERIALS AND METHODS: Out of 2 populations of 1500 arthroscopies each, we collected prospectively and retrospectively all possible variations of the proximal portion of the LHB. RESULTS: We included 57 cases (1.91%) of this total population in an attempt to describe the complete range of these form variants: the simple vinculum or pulley-like sling, the partial or complete mesotenon between biceps and capsule, the complete adherent LHB, the double-tendon origin, the reversed-type split-tendon, and the complete absence of the LHB. We suggest a classification of 12 variations of the intra-articular portion of the LHB. DISCUSSION: By taking into account an extensive literature review, we suggest that these conditions are congenital and consider them as a result of partial detachment from the mesothelial or synovial fusion with the inferior surface of the capsule. The incidence of these variants and their associated pathologies are investigated. CONCLUSION: By offering this new classification and a physiopathologic hypothesis, we try to explain why some of these anatomic variants may also acquire a pathologic significance.