A Comparison of Patients with Hip Fracture, Ten Years Apart: Morbidity, Malnutrition and Sarcopenia.

OBJECTIVES: To investigate possible differences in morbidity, malnutrition, sarcopenia and specific drug use in patients with hip fracture, ten years apart. To analyse 1-year mortality and possible associations with variables. DESIGN: A prospective, observational study. SETTING: Örebro University Hospital, Sweden. PARTICIPANTS: Two cohorts of patients with hip fracture, included in 2008 (n=78) and 2018 (n=76). MEASUREMENTS: Presence of comorbidity according to the Elixhauser comorbidity measure, multimorbidity defined as ≥3 comorbidities, preoperative American Society of Anaesthesiologists Classification (ASA-class), malnutrition according to the definition by the Global Leadership Initiative on Malnutrition (GLIM), sarcopenia according to the most recently revised definition by the European Working Group on Sarcopenia in Older People (EWGSOP), polypharmacy defined as ≥5 prescribed medications, use of Potentially Inappropriate Medications (PIM) and Fall-Risk-Increasing-Drugs (FRID) and postoperative 1-year mortality. RESULTS: When comparing the cohorts, significant increases over time was seen for mean comorbidity-count (Difference -1; p=0.002), multimorbidity (Difference -15%; 95%CI -27;-2), ASA-class 3-4 (Difference -25%; 95%CI -39;-9) and polypharmacy (Difference -17%; 95%CI -32;-2). Prevalence of malnutrition and sarcopenia coherently decreased with 22% (95%CI 5;37) and 14% (95%CI 1;29) respectively. One-year mortality remained unchanged and a significant association was found for a higher ASA-class in 2008 (OR 3.5, 95%CI 1.1;11.6) when adjusted for age. Results on PIM exposure suggest a decrease while exposure to FRID remained high. CONCLUSION: Our findings support an increasing morbidity within the population over time. However, also presented is a coherent decrease in malnutrition and sarcopenia, suggesting a decrease in frailty as a possible explanation for the observed unaltered mortality, in turn suggesting advances in treatment of comorbidities.

Combined volar and dorsal plating vs. volar plating of distal radius fractures. A single-center study of 105 cases.

Despite recent advances in the surgical management of distal radius fractures (DRFs), the optimal treatment remains controversial as different fixation methods often have similar clinical functional and radiographic outcomes. The objective of this study was to assess the differences in outcomes 1 year postoperatively between volar plating and combined plating for DRFs. In a retrospective cohort study, we evaluated 105 consecutive patients operated with either a volar locking plate or combined dorsal and volar plating. The primary outcome was wrist range of motion (ROM). Secondary outcome measures included hand grip strength, visual analog scale (VAS) pain scores, radiographic examination and patient-related outcome measures. Patients treated with combined plating had significantly inferior wrist flexion, extension and ulnar deviation. The radiographic Batra score 1 year postoperatively was similar for both groups. The PRWE (patient-rated wrist evaluation) score was 16 for the volar plating group and 14 for the combined plating group. The QuickDASH (Quick disabilities of the arm, shoulder and hand) score was 9 for the volar plating group and 16 for the combined plating group. VAS pain scores were 0 at rest and 2 during activity for both groups. Grip strength was similar between the two groups. Hardware removal was done in 18/78 patients for the combined plating group and 1/27 for the volar plate group. Two patients operated with combined plating had tendon ruptures. Our findings indicate that both methods can yield satisfactory clinical and radiographic outcomes. However, combined plating resulted in inferior wrist ROM and substantially higher frequency of hardware removal. The potential advantages of combined plating in stabilizing a comminuted DRF must be balanced by the potential drawbacks such as inferior wrist ROM and higher frequency of hardware removal.

Plasma concentration of ketorolac after local infiltration analgesia in hip arthroplasty.

BACKGROUND: Local infiltration analgesia (LIA) with local anaesthetic (ropivacaine), a nonsteroidal anti-inflammatory drug (ketorolac) and epinephrine after lower extremity arthroplasty has gained increasing popularity during the last decade. This method has certain advantages, which include minimal systemic side effects, faster post-operative mobilization, earlier post-operative discharge from hospital and less opioid consumption. However, information regarding plasma concentrations of ketorolac after LIA mixture is insufficient to predict the risk of renal impairment in patients subjected to arthroplasty. AIM: To determine the maximal plasma concentration and the exposure of ketorolac during the first 30 h following LIA in hip arthroplasty. METHODS: Thirteen patients scheduled for primary total hip arthroplasty with LIA (ropivacaine 200 mg, ketorolac 30 mg and epinephrine 0.5 mg in a volume of 106 ml) were included. Plasma concentration of ketorolac was quantified by liquid chromatography-mass spectrometry. In addition, we assessed the effect of increasing age and decreasing glomerular filtration rate on the maximal plasma concentration and the total exposure to ketorolac during 30 h. RESULTS: The range of the maximal plasma concentration, 0.3-2.2 mg/l, was detected 30 min-4 h after completing the infiltration. Similar plasma levels have been reported after intramuscular injection of the same dose of ketorolac to healthy elderly volunteers. CONCLUSION: Exposure to ketorolac after LIA may be comparable to an intramuscular injection of the same dose. Decision of dose reduction should be based on clinical assessment of risk factors.

Patient-reported outcome is influenced by surgical approach in total hip replacement: a study of the Swedish Hip Arthroplasty Register including 42,233 patients.

The effects of surgical approach in total hip replacement on health-related quality of life and long-term pain and satisfaction are unknown. From the Swedish Hip Arthroplasty Register, we extracted data on all patients that had received a total hip replacement for osteoarthritis through either the posterior or the direct lateral approach, with complete pre- and one-year post-operative Patient Reported Outcome Measures (PROMs). A total of 42 233 patients met the inclusion criteria and of these 4962 also had complete six-year PROM data. The posterior approach resulted in an increased mean satisfaction score of 15 (sd 19) vs. 18 (sd 22) (p < 0.001) compared with the direct lateral approach. The mean pain score was 13 (sd 17) vs. 15 (sd 19) (p < 0.001) and the proportion of patients with no or minimal pain was 78% vs. 74% (p < 0.001) favouring the posterior approach. The patients in the posterior approach group reported a superior mean EQ-5D index of 0.79 (sd 0.23) vs. 0.77 (sd 0.24) (p < 0.001) and mean EQ score of 76 (sd 20) vs. 75 (sd 20) (p < 0.001). All observed differences between the groups persisted after six years follow-up. Although PROMs after THR in general are very good regardless of surgical approach, the results indicate that some patients operated by the direct lateral approach report an inferior outcome compared with the posterior approach. The large number of procedures and the seemingly sustained differences make it likely these findings are clinically relevant.

Quantifying gait deviations in individuals with rheumatoid arthritis using the Gait Deviation Index.

OBJECTIVES: In this study we evaluated the usability of the Gait Deviation Index (GDI), an index that summarizes the amount of deviation in movement from a standard norm, in adults with rheumatoid arthritis (RA). The aims of the study were to evaluate the ability of the GDI to identify gait deviations, assess inter-trial repeatability, and examine the relationship between the GDI and walking speed, physical disability, and pain. METHOD: Sixty-three adults with RA and 59 adults with typical gait patterns were included in this retrospective case-control study. Following a three-dimensional gait analysis (3DGA), representative gait cycles were selected and GDI scores calculated. To evaluate the effect of walking speed, GDI scores were calculated using both a free-speed and a speed-matched reference set. Physical disability was assessed using the Health Assessment Questionnaire (HAQ) and subjects rated their pain during walking. RESULTS: Adults with RA had significantly increased gait deviations compared to healthy individuals, as shown by lower GDI scores [87.9 (SD = 8.7) vs. 99.4 (SD = 8.3), p < 0.001]. This difference was also seen when adjusting for walking speed [91.7 (SD = 9.0) vs. 99.9 (SD = 8.6), p < 0.001]. It was estimated that a change of ≥ 5 GDI units was required to account for natural variation in gait. There was no evident relationship between GDI and low/high RA-related physical disability and pain. CONCLUSIONS: The GDI seems to useful for identifying and summarizing gait deviations in individuals with RA. Thus, we consider that the GDI provides an overall measure of gait deviation that may reflect lower extremity pathology and may help clinicians to understand the impact of RA on gait dynamics.

Change in Gait Deviation Index after anti-tumour necrosis factor-α treatment in individuals with rheumatoid arthritis: a pilot study.

OBJECTIVES: Anti-tumour necrosis factor-alpha (TNF-α) inhibitors provide fast, effective resolution of rheumatoid arthritis (RA) inflammation. In this study we aimed to quantify the impact of TNF-α treatment on gait dynamics. METHOD: The sample comprised 16 subjects [11 female, median age 56 (range 48-66) years, median disease duration 9.5 (range 4.6-20.6) years] with RA who met the American College of Rheumatology (ACR) criteria, had lower extremity involvement, did not use walking aids, and had started TNF-α treatment within 1 week of baseline gait analysis. Gait analysis focused on three-dimensional (3D) lower extremity joint kinematics, kinetics, time and distance parameters. The Gait Deviation Index (GDI) and GDI-Kinetic were calculated. Data on gait, disease activity, and physical disability were collected at baseline and at 3.5 months. RESULTS: Following treatment with TNF-α, statistically significant improvements were found in disease activity [using the 28-joint Disease Activity Score based on C-reactive protein (DAS28-CRP); median difference (m(d)) = 2.3, p < 0.01], physical disability [Health Assessment Questionnaire (HAQ) m(d) = 0.4, p < 0.01], and pain during walking [visual analogue scale (VAS) m(d) = 11.0, p < 0.05]. Reductions in gait deviations were noted (GDI m(d) = 3.7, p = 0.04; GDI-Kinetic m(d) = 4.1, p = 0.05) along with reductions in dimensionless time and distance parameters. A moderate to good negative correlation existed between baseline GDI and GDI change scores (r(s) = -0.7, p < 0.01). CONCLUSIONS: Treatment with TNF-α improved gait dynamics in adults with RA. Significant gait deviations were, however, still present after treatment. In this study, GDI and GDI-Kinetic scores appeared to be useful outcome measures to quantify changes in gait deviations after this intervention.

Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients.

OBJECTIVES: To describe the overall use and temporal trends in orthopaedic upper limb surgery associated with RA on a nation wide basis in Sweden between 1998 and 2004. METHODS: Data for all inpatient visits during 1998-2004 for patients older than 18 yrs with RA-related diagnoses were extracted from the Swedish National Hospital Discharge Registry (SNHDR). The SNHDR prospectively collects data on all hospital admissions in Sweden according to the International Classification of Diseases (ICD). Data were analysed with respect to orthopaedic surgery of the hand, elbow and shoulder. RESULTS: During the study period, 54,579 individual RA patients were admitted to a Swedish hospital and 9% of these underwent RA-related surgery of the upper limbs. The RA patient cohort underwent a total of 8251 RA-related upper limb surgical procedures. The hand (77%) was most frequently operated on, followed by the shoulder (13%) and the elbow (10%). There was a statistically significant decrease of 31% for all admissions associated with RA-related upper limb surgery during 1998-2004 (P = 0.001). Some 10% of all RA-related upper limb surgery was due to total joint arthroplasties (TJAs), mostly for the elbow (59%). During 1998-2004, all TJAs, elbow-TJAs and shoulder-TJAs had a stable occurrence. In contrast, the overall numbers of hand-TJAs significantly increased (P = 0.009). CONCLUSIONS: Rates of RA-related upper limb surgery decreased and TJAs had a stable occurrence in Sweden during 1998-2004. The findings of this study may reflect trends in disease management and health outcomes of RA patients in Sweden.

Ankle/hindfoot arthrodesis in rheumatoid arthritis improves kinematics and kinetics of the knee and hip: a prospective gait analysis study.

OBJECTIVES: To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip. METHODS: In this prospective follow-up study, 14 RA patients scheduled for ankle/hindfoot arthrodesis (talo-calcaneal, talo-navicular, calcaneo-cuboid and/or talo-crural joints) and 14 age- and sex-matched healthy controls were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- vs post-operative conditions, Wilcoxon's matched pairs test and Friedman ANOVA by rank test were used. RESULTS: At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up. CONCLUSIONS: Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.

Arthrodesis versus Mayo resection: the management of the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group. These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.

Orthopaedic surgery of the lower limbs in 49,802 rheumatoid arthritis patients: results from the Swedish National Inpatient Registry during 1987 to 2001.

OBJECTIVES: To analyse changes in the rates of hospital admission and use of orthopaedic surgery to the lower limbs in Swedish patients with rheumatoid arthritis between 1987 and 2001. METHODS: Data for all rheumatoid patients admitted to hospital between 1987 and 2001 were abstracted from the Swedish National Hospital Discharge Register (SNHDR). The data in the register are collected prospectively, recording all inpatient admissions throughout Sweden. The SNHDR uses the codes for diagnoses at discharge and surgical procedures according to the Swedish version of the International Classification of Diseases (ICD). RESULTS: In all, 49,802 individual patients with rheumatoid arthritis were identified, accounting for 159,888 inpatient visits. Hospital admissions for rheumatoid arthritis decreased by 42% (p<0.001) during the period 1987 to 2001. Twelve per cent of all admissions were for a rheumatoid arthritis related surgical procedure to the lower limbs; those admissions decreased markedly (by 16%) between 1987 and 1996, and by 12% between 1997 and 2001, as did the overall number of rheumatoid arthritis related surgical procedures to the lower limbs during both time periods. Between 1997 and 2001, 47% of all rheumatoid arthritis related surgical procedures were total joint arthroplasties. There was an overall trend towards reduced length of hospital stay after orthopaedic surgery to the lower limbs during the study period. CONCLUSIONS: Rates of hospital admission and rheumatoid arthritis related surgical procedures to the lower limbs in Swedish patients with rheumatoid arthritis decreased between 1987 and 2001. This may reflect trends in disease severity, management, and health outcomes of this disease in Sweden.

Morphological characterization of receptor activator of NFkappaB ligand (RANKL) and IL-1beta expression in rodent collagen-induced arthritis.

Bone loss represents a major unsolved problem in rheumatoid arthritis (RA). The receptor activator of nuclear factor-kappaB ligand (RANKL) is essential for the development and activation of osteoclasts, which are key mediators of bone erosions. This study was performed to determine temporal and spatial expression of RANKL compared with the potentially destructive cytokine interleukin-1beta (IL-1beta), related to progression of synovitis and joint destruction in collagen-induced arthritis (CIA), a model of RA. CIA was induced in dark agouti (DA) rats, and tissue specimens were obtained for immunohistochemical analyses at various time points before and after disease onset. Arthritis was monitored visually, and joint pathology was examined histologically. No disease-preceding expression of RANKL was detected. However, a marked increase of both RANKL- and IL-1beta-expressing cells correlated with the progression of synovial inflammation and clinical disease severity. Abundant and concomitant expression of these cytokines was detected at sites of bone erosion, where a colocalization by osteoclast-like multinuclear tartrate-resistant acid phosphatase (TRAP)+ cells was noted. In contrast to the paucity of RANKL expression in cartilage, an abundant expression of IL-1beta was demonstrated, particularly in superficial cartilage layers. These data support the hypothesis that RANKL and IL-1beta are central contributors to joint destruction in CIA.

Human skeletal muscle cell differentiation is associated with changes in myogenic markers and enhanced insulin-mediated MAPK and PKB phosphorylation.

AIM: We hypothesized that myogenic differentiation of HSMC would yield a more insulin responsive phenotype. METHODS: We assessed expression of several proteins involved in insulin action or myogenesis during differentiation of primary human skeletal muscle cultures (HSMC). RESULTS: Differentiation increased creatine kinase activity and expression of desmin and myocyte enhancer factor (MEF)2C. No change in expression was observed for big mitogen-activated protein kinase (BMK1/ERK5), MEF2A, insulin receptor (IR), hexokinase II, and IR substrates 1 and 2, while expression of glycogen synthase, extracellular signal-regulated kinase 1 and 2 (ERK1/2 MAP kinase) and the insulin responsive aminopeptidase increased after differentiation. In contrast to protein kinase B (PKB)a, expression of (PKB)b increased, with differentiation. Both basal and insulin-stimulated PI 3-kinase activity increased with differentiation. Insulin-mediated phosphorylation of PKB and ERK1/2 MAP kinase increased after differentiation. CONCLUSION: Components of the insulin-signalling machinery are expressed in myoblast and myotube HSMC; however, insulin responsiveness to PKB and ERK MAP kinase phosphorylation increases with differentiation.

Methodological concerns using intra-cortical pins to measure tibiofemoral kinematics.

The complexity of human tibiofemoral joint motion is now better understood with the advancement of new methodologies to measure tibiofemoral kinematics in vivo. Marker clusters anchored to stainless steel bone pins inserted directly into the femur and tibia provide the most sensitive and accurate means for directly measuring skeletal tibiofemoral joint motion. Despite its invasiveness, this technique has been successful, although complications have been reported with the femoral pin and its insertion site. The purpose of this technical report is twofold: to review the difficulties with the femoral pin and its insertion site from a historical perspective, and to identify the load force required from biological tissue to permanently deform the pin. In addition, proposals in the advancement of this method are discussed in the context of reducing impingement with the femoral pin and the Iliotibial band. Because stainless steel exhibits plastic behaviour with no sharp yield point, Apex self-drilling/self-tapping bone pins underwent incremental loading on an Instron materials testing machine. Loads were transmitted perpendicular to the pin with the threads partially exposed and fully secured in vice. Since the accuracy of our combined stereophotogrammetry and Optoelectric motion analysis was less than 0.4 mm, it was decided that plastic deformation occurred after deflections of 0.4 mm. With exposed threads, deflections larger than 0.4 mm were observed at 150 N and 100 N when loads were applied at 15 mm and 20 mm from the vice (representative of where the tissue came in contact with the pin). Loads greater than 200 N produced deflections less than 0.2 mm when threads were fully inserted. The 90 Hz resonant frequency for the marker cluster-bone pin complex is beyond the spectrum of human movement and can be lowpass filtered. To reduce impingement and pin bending, one solution may be to implant pins with a shorter threaded section. By completely penetrating the bone, only the smooth surface of the pin is exposed which is more resistant to bending. Otherwise pins with larger diameters and longer longitudinal incisions about the femoral insertion site are an alternative. Lengthening the longitudinal incisions about the insertion site, and correctly aligning and inserting the femoral pin between the Iliotibial band and quadriceps tendon may diminish impingement. Performing dynamic open chain flexion and extension movements while on the operating table may aid in aligning the pin at the incision site. This may stretch the IT band and quadriceps tendon and may guide the femoral pin into a more optimal position prior to it being inserted into the cortex of the bone.

Variation in the position and orientation of the elbow flexion axis.

We analysed the axis of movement in the normal elbow during flexion in vivo using radiostereometric analysis (RSA). The results show an intraindividual variation in the inclination of the axis ranging from 2.1 degrees to 14.3 degrees in the frontal and from 1.6 degrees to 9.8 degrees in the horizontal plane analysed at 30 degrees increments. The inclination of the mean axis of rotation varied within a range of 12.7 degrees in the frontal and 4.6 degrees in the horizontal plane. In both planes, the mean axes were located close to a line joining the centres of the trochlea and capitellum. The intra- and interindividual variations of the axes of flexion of the elbow were greater than previously reported. These factors should be considered in the development of elbow prostheses.

Assessment of functional knee bracing: an in vivo three-dimensional kinematic analysis of the anterior cruciate deficient knee.

OBJECTIVE: To describe three-dimensional tibial and femoral movements in vivo and examine the effect of a brace on knee kinematics during moderate to intense activity. DESIGN: Skeletal kinematics of anterior cruciate ligament deficient knees was measured with and without braces during moderate to intense activity. BACKGROUND: Invasive markers implanted into the tibia and femur are the most accurate means to directly measure skeletal motion and may provide a more sensitive measure of the differences between brace conditions. METHODS: Steinmann traction pins were implanted into the femur and tibia of four subjects having a partial or complete anterior cruciate ligament rupture. Non-braced and braced conditions were randomly assigned and subjects jumped for maximal horizontal distance to sufficiently stress the anterior cruciate ligament. RESULTS: Intra-subject peak vertical force and posterior shear force were generally consistent between conditions. Intra-subject kinematics was repeatable but linear displacements between brace conditions were small. Differences in angular and linear skeletal motion were observed across subjects. Bracing the anterior cruciate ligament deficient knee resulted in only minor kinematic changes in tibiofemoral joint motion. CONCLUSION: In this study, no consistent reductions in anterior tibial translations were observed as a function of the knee brace tested. Relevance. Investigations have reported that knee braces fail when high loads are encountered or when load is applied in an unpredictable manner. Questions remain regarding tibiofemoral joint motion, in particular linear displacements. The pin technique is a means for direct skeletal measurement and may provide a more sensitive measure of the differences between brace conditions.

Biomechanics of the knee: methodological considerations in the in vivo kinematic analysis of the tibiofemoral and patellofemoral joint.

The purpose of this review article is twofold: to report on the use of intracortical pins to measure three-dimensional tibiofemoral and patellofemoral joint kinematics and highlight methodological concerns associated with this procedure. Tibiofemoral and patellofemoral kinematics has been extensively investigated using reflective markers attached to the surrounding soft tissue of the calf and thigh. However, surface markers may not adequately represent true anatomical locations and skin movement artefacts present the most critical source of measurement error. Consequently, knowledge about skeletal tibiofemoral kinematics is limited, in particular abduction-adduction and internal-external rotations. Considerable questions remain regarding what constitutes normal motion of the knee. A way to avoid the problem of surface markers is use invasive markers to directly measure skeletal motion. To date, many co-ordinate systems have been used to describe three-dimensional skeletal kinematics of the lower limb in vivo. They include helical axes, finite helical axes, instantaneous helical axes, and the joint co-ordinate system based on local anatomic landmarks. Although each method accurately describes the relative motion in 6 d. of f., the differences in how the motion is partitioned may account for the differences across investigations. Additionally, the problem of defining the anatomical co-ordinate system makes comparisons across subjects and studies difficult since subtle differences may be caused by small deviations in the anatomical reference alignment. Cross talk is also a primarily a concern. For joints that articulate principally about one axis, the primary flexion/extension that is registered will be cross-talked into ab/adduction and internal/external rotations.

Femoral bone regeneration subsequent to impaction grafting during hip revision: histologic analysis of a human biopsy specimen.

Cemented revision with impaction grafting shows encouraging early clinical results; postoperative biopsy specimens taken from the proximal femur in humans have demonstrated viable trabecular and cortical bone. Human radiographic studies also illustrate density changes within the proximal femur, consistent with remodeling of bone-graft. In an animal experiment, bone incorporation was shown in the proximal femur, but graft lysis was reported around the distal portion of the implant. We report on a patient who sustained a traumatic femoral fracture at the level of the tip of the femoral component 27 months after revision with impaction grafting and a collarless polished taper stem. At the time of open reduction and internal fixation of the fracture, we obtained circumferential biopsy specimens from the fracture site. Three distinct zones could be identified histologically: i) an inner zone consisting of bone-cement, fibrous tissue, and partially necrotic trabeculae with evidence of bone remodeling; ii) a middle zone consisting of viable trabecular bone and probable neocortex formation with fewer particles of bone-cement; and iii) an outer zone with viable cortex. Fibrous tissue was present around some of the incorporating bone-graft fragments, but no continuous fibrous membrane was present. Cement particles were identified, but no polyethylene debris was found by light microscopy. Biopsy specimens from the distal aspect of the prosthesis may not reflect changes seen proximally, but based on the available tissue, this case illustrated histological evidence of bone-graft remodeling after impaction grafting. These results are consistent with our expectations based on radiographic findings and clinical results.

Complex cemented revision using polished stem and morselized allograft. Minimum 5-years' follow-up.

The aim of this study was to evaluate the results of complex hip revision using a cemented, collarless and polished femoral stem design (CPT, Zimmer, Warsaw, In.) within a tightly impacted morselized allograft. We have now been using the impaction grafting technique in combination with the CPT stem (Zimmer) for 10 years in complex cases of severe bone loss. In this study we have elected to report only those patients who have been revised at least once before revision using the impaction grafting technique. All the patients in the study group have a minimum follow-up of 5 years after the impaction grafting revision. In total, 43 consecutive hips in 40 patients, 22 men and 18 women, with a follow-up time of between 5 and 7 years are included in the study. The complications related to the revised hip consist of three early dislocations managed by closed reduction. Two patients suffered from periprosthetic fracture, both managed with plate osteosynthesis. Two cementless sockets were revised due to aseptic socket loosening. The Endoklinik rating of preoperative bone loss for the revised hips was 2 in 13 hips, 3 in 23 hips, and 4 in 7 hips. During the first year 29 stems subsided 2-4 mm within the cement mantle. In 8 cases, a subsidence of 5-9 mm was measured. The subsidence was nonprogressive, and no subsidence occurred after the 1st year. The Charnley, D'Aubigne, Postel scoring (maximum 6 points) for pain improved from 2.2 points preoperatively to 4.4 postoperatively, function from 2.3 to 4.3, and movement from 2.3 to 4.1. In conclusion, the concept of impaction grafting in THR revision in our study has so far proven to be successful with good clinical results at 5 years despite the relatively high early subsidence of the femoral component.