Resection of the femoral neck: a new technique for the treatment of mallory type I intraoperative femoral fracture during total hip arthroplasty.

Intraoperative femoral fracture is a common complication during cementless total hip arthroplasty (THA). Cerclage wiring has been used for this type of fractures to attain intraoperative stability of the femoral stem. We designed a new technique to treat Mallory type 1 intraoperative femoral fractures. We excised fractured femoral neck fragment and without additional fixation and lightly tapped down the femoral stem to obtain a tight contact to the femoral cortex at the subtrochanteric level. In this case series, we described this technique and reported its outcomes. From January 2015 to December 2017, 600 cementless THAs (557 patients) were done with use of a proximally coated tapered stem design at our department. Among the 600 THAs, Mallory type 1 intraoperative femoral fracture occurred in 8 hips (8 patients), and all of them were treated with the excision of the fractured femoral neck. Mean age of the 8 patients was 58.1 years (range, 30.4 to 81.3 years) at the time of surgery. We report the results of this new technique at postoperative 2 to 5 years (mean, 3.4 years). All stems were placed in the neutral position. There was no revision and no stem showed any evidence of subsidence or loosening during the follow-up. The mean Harris hip score was 85.9 points at the latest follow-up. We recommend to use the femoral neck excision technique for the treatment of Mallory type 1 intraoperative femoral fractures.

Osteoporosis case ascertainment strategies in European and Asian countries: a comparative review.

While many clinical guidelines recommend screening for osteoporosis for early detection and treatment, there is great diversity in the case-finding strategies globally. We sought to compare case-finding strategies, focusing on the approaches used in European and Asian countries. This article provides an overview of the current case-finding strategies in the UK, Germany (including Austria and German-speaking regions of Switzerland), China, Japan, and Korea. We conducted a review of current treatment guidelines in each country and included expert opinions from key opinion leaders. Most countries define osteoporosis among patients with a radiographically identified fracture of the hip or the vertebrae. However, for other types of fractures, or in the absence of a fracture, varying combinations of risk-factor assessment and areal bone mineral density (aBMD) assessed by dual X-ray absorptiometry are used to define osteoporosis cases. A T-score ≤ - 2.5 is accepted to identify osteoporosis in the absence of a fracture; however, not all countries accept DXA alone as the sole criteria. Additionally, the critera for requiring clinical risk factors in addition to aBMD differ across countries. In most Asian countries, aBMD scanning is only provided beyond a particular age threshold. However, all guidelines recommend fracture risk assessment in younger ages if risk factors are present. Our review identified that strategies for case-finding differ regionally, particularly among patients without a fracture. More homogenized ways of identifying osteoporosis cases are needed, in both the Eastern and the Western countries, to improve osteoporosis case-finding before a fracture occurs.Case-finding in osteoporosis is essential to initiate treatment and minimize fracture risk. We identified differences in case-finding strategies between Eastern and Western countries. In the absence of a diagnosed fracture, varying combinations of risk factors and bone density measurements are used. Standardized case-finding strategies may help improve treatment rates.

Incidence of subsequent osteoporotic fractures after distal radius fractures and mortality of the subsequent distal radius fractures: a retrospective analysis of claims data of the Korea National Health Insurance Service.

A better understanding of the features of subsequent fractures after distal radius fracture (DRF) is important for the prevention of further osteoporotic fractures. This study found that the cumulative incidence of subsequent osteoporotic fractures in South Korea increased over time and that the mortality rates of subsequent DRFs were lower than those of first-time DRFs. INTRODUCTION: We examined the incidence of osteoporotic fractures following distal radius fractures (DRFs) and the mortality rate after subsequent DRFs using claims data from the Korea National Health Insurance (KNHI) Service. METHODS: We identified records for 41,417 patients with first-time DRFs in 2012. The occurrence of osteoporotic fractures of the spine, hip, wrist, and humerus at least 6 months after the index DRF was tracked through 2016. All fractures were identified by specific diagnosis and procedure codes. One-year mortality rates and standardized mortality ratios (SMRs) for initial and subsequent DRFs were calculated for all patients. RESULTS: The 4-year cumulative incidence of all subsequent osteoporotic fractures was 14.74% (6105/41,417; 9.47% in men, 15.9% in women). The number of associated subsequent fractures was 2850 for the spine (46.68%), 2271 for the wrist (37.2%), 708 for the hip (11.6%), and 276 for the humerus (4.52%). The cumulative mortality rate 1 year after the first-time and subsequent DRF was 1.47% and 0.71%, respectively, and the overall SMR was 1.48 (95% CI: 1.37-1.61) and 0.71 (95% CI: 0.42-1.21), respectively. CONCLUSION: The cumulative incidence of osteoporotic fractures following DRFs increased over the study period and was higher among women. The cumulative mortality rates and SMRs of subsequent DRFs were lower than those of first-time DRFs at the 1-year follow-up. Given the increasing incidence rate of DRFs, the incidence of subsequent osteoporotic fractures may also increase.

The change of bone mineral density and bone metabolism after gastrectomy for gastric cancer: a meta-analysis.

Bone mineral density (BMD) is significantly decreased after gastrectomy in patients with gastric cancer. Calcium malabsorption, secondary hyperparathyroidism, and dominant bone resorption appear to contribute to bone loss in these patients. Patients should undergo early surveillance and nutritional or pharmacologic intensive interventions for bone health. PURPOSE: Survivorship care, including bone health, has become an important issue in gastric cancer. We performed a meta-analysis of the available observational studies to determine whether and how osteoporosis risk is increased after gastrectomy in patients with gastric cancer. METHODS: A total of 1204 patients (802 men) from 19 cohort studies were included. We evaluated the prevalence of osteoporosis in postgastrectomy patients, comparing the incidence according to the type of gastrectomy and sex. Additionally, we evaluated changes in bone mineral density (BMD) and bone metabolism-related markers pre- to postoperatively and between patients who underwent gastrectomy and matched controls. Proportion meta-analysis was performed and pooled odds ratios (ORs) were calculated. RESULTS: The pooled incidence estimate was 36% [95% confidence interval (CI), 32-40]. The incidence of osteoporosis was significantly higher in women than in men (OR = 1.90, p < 0.001) but was similar between partial and total gastrectomy groups (OR = 0.983, p = 0.939). BMD was significantly decreased, and calcium, phosphorous, and parathyroid hormone levels were significantly increased in patients after gastrectomy compared to those before gastrectomy. BMD and calcium and 25OH-vitamin D levels were significantly decreased, and parathyroid hormone and 1,25OH-vitamin D levels were significantly increased in the gastrectomy group compared to that in the control group. CONCLUSION: We found that BMD is significantly decreased after gastrectomy in patients with gastric cancer. Vitamin D deficiency and secondary hyperparathyroidism are suggested to be common mechanism underlying BMD impairment. After resection, patients should undergo long-term nutritional and bone health surveillance, in addition to their oncological follow-up.

High dietary sodium intake is associated with low bone mass in postmenopausal women: Korea National Health and Nutrition Examination Survey, 2008-2011.

The present cross-sectional study performed using data from the Korea National Health and Nutrition Examination Survey in 9526 women older than 18 years of age demonstrates that high sodium intake is associated with lower bone mineral density and sodium intake ≥2000 mg/day is a risk factor for osteoporosis in postmenopausal women. INTRODUCTION: Several studies have reported that large amount of dietary sodium intake is highly associated with elevated urinary calcium. However, the direct effect of excessive dietary sodium intake on bone mass, as a risk factor for osteoporosis, is still a controversial issue. The aim of the present study was to assess the relationship between high intake of sodium and lower bone mass and risk of osteoporosis in adult women. METHODS: This cross-sectional study was performed using data from the Korea National Health and Nutrition Examination Survey (KNHANES), 2008-2011. Participants (n = 9526 women older than 18 years) were divided into a premenopausal (n = 4793) and postmenopausal (n = 4733) group. Both groups were subdivided into five groups according to quintiles of energy-adjusted sodium intake. Multiple regression analysis was performed to assess relationships between sodium intake and lower bone mass. RESULTS: Multivariate linear regression analysis showed that high sodium intake was negatively associated with bone mineral content (BMC) and bone mineral density (BMD) in postmenopausal women. After adjusting confounding factors, high sodium intake was negatively associated with BMC and BMD of the lumbar spine in postmenopausal women. Postmenopausal women, whose sodium intake was ≥2000 mg/day (odds ratio 1.284, 95% CI 1.029-1.603, P = 0.027), were at risk of developing osteoporosis after adjustment of confounding variables. CONCLUSIONS: The present study suggested that high sodium intake could be a potential risk factor for low bone mass after adjusting for confounding factors in postmenopausal women.

Atypical subtrochanteric fractures in Korean hip fracture study.

In Korean, atypical subtrochanteric fractures (ASF) were rare. Higher BMI and use of bisphosphonate were significant risk factors of ASF. INTRODUCTION: Recently, ASF have been reported to increase among patients on bisphosphonate. However, the incidence of ASF and the association between ASF and bisphosphonate use have not been well defined in Asian population. Our purposes are (1) to estimate the proportion of ASF among Korean patients with proximal femur fracture and (2) to determine the associated risk factors of ASF in the Korean patients. METHODS: We conducted a multicenter (16 academic hospitals), prospective Korean hip fracture study on hip fracture in a cohort of patients aged 50 years or older from South Korea between July 2014 and May 2016. As a part of Korean hip fracture study, primary analysis examined the proportion of ASF among proximal femur fracture. To identify ASF, according to the definition by ASBMR task force, all radiographs of subtrochanteric fracture were reviewed. Associated risk factors for occurrence of ASF were also evaluated by using multivariable logistic regression analysis. RESULTS: Among 1361 patients with proximal femoral fractures due to low-energy trauma, 17 fractures (1.2%) were identified as ASF. Higher BMI and use of bisphosphonate before injury were independent risk factors of ASF. CONCLUSION: In Korean, ASF were rare. Higher BMI and use of bisphosphonate were significant risk factors of ASF.

Risk of fractures and diabetes medications: a nationwide cohort study.

UNLABELLED: The effects of diabetes medications on risk of fracture were investigated using the South Korea nationwide claims database. We demonstrated that the use of dipeptidyl peptidase-4 inhibitor could be associated with decreased risk of fracture. Thiazolidinedione use was associated with about 60 % increased risk of fracture in real clinical practice. INTRODUCTION: The effects of diabetes medication on fracture have important clinical health consequences, since most diabetes patients are at high risk of fracture. We aimed to investigate the effect of diabetes medication on fracture risk. METHODS: The nationwide medical claim database in South Korea was investigated. Among 2,886,555 subjects with antidiabetes prescriptions, 207,558 subjects aged 50 years and older, who initiated diabetes medication from 2008 to 2011, were analyzed. The subjects were classified based on diabetes medication classes: non-user (insufficient exposure), metformin (MET), sulfonylurea (SU), alpha-glucosidase inhibitor (AGI), MET + SU, MET + thiazolidinedione (TZD), MET + dipeptidyl peptidase-4 inhibitor (DPP4-I), and SU + TZD. RESULTS: A total of 5996 fractures were observed. The fracture rate varied significantly across type of diabetes medications, with MET + DPP4-I combination group having the lowest rate and SU + TZD combination group having the highest rate. Compared to non-users, MET + DPP4-I inhibitor combination group had significantly reduced composite fracture risk (hazard ratio (HR) = 0.83, P = 0.025) and significantly reduced vertebral fracture risk (HR = 0.73, P = 0.013) in the unadjusted analysis. Compared to MET + SU users, MET + DPP4-I users showed a trend of lower non-vertebral fracture risk (HR = 0.82, P = 0.086) after adjusting for all confounding variables. Patients using TZD had significantly increased risk of fracture (HR = 1.59, P < 0.001) compared with patients not using TZDs adjusting for all confounding variables. CONCLUSIONS: The results of this nationwide study showed a trend that DPP4 inhibitor might have a protective effect on bone metabolism compared with SU, when added to MET. Clinicians should take these results into consideration when prescribing diabetes medication, especially in elderly patients or those at high risk or fracture.

Current trends and future projections of hip fracture in South Korea using nationwide claims data.

UNLABELLED: Incidence of hip fracture increased in Korean populations over age 50 between 2008 and 2012, and the number of fractures was predicted to increase by 1.4 times by 2025. This is important information for public health planning. INTRODUCTION: The purposes of this study were to evaluate the trends in the incidence and mortality of hip fracture between 2008 and 2012 and predict the number of hip fractures in Korea through 2025 using nationwide claims data. METHODS: The data managed by the National Health Insurance Service were used to identify the hip fractures in patients aged >50 years between 2008 and 2012. Projections of hip fractures were conducted using the Poisson distribution from 2016 to 2025 in Korea. RESULTS: The incidence of hip fractures (per 100,000) increased by 14.1 % over the 5 years of the study, by 15.8 % in women and 10.9 % in men; the older age group showed a steep rise and shift in the incidence from 2008 to 2012. The cumulative mortality rates at 1 year after hip fractures were 17.2 % (3575/20,849) in 2008 and 16.0 % (4547/28,426) in 2012. Overall standardized mortality ratios (SMRs) for hip fracture were higher in men (11.93) than in women (11.22) and were higher than those in the general population in all age groups. In 2016, the total number of hip fractures was estimated to increase an overall of 1.4 times by 2025. CONCLUSIONS: The incidence of hip fracture continues to increase, and the related mortality is still high, although it has decreased over time. The socioeconomic burden of hip fracture is expected to increase in Korea along with the increased estimated number of fractures. Nationwide strategies should include attempts to reduce the future socioeconomic burdens of hip fractures.

Incidence of second hip fracture and compliant use of bisphosphonate.

UNLABELLED: We determined the incidence of second hip fracture and evaluated whether compliant users of bisphosphonate had a lower incidence of second hip fracture after prior hip fracture. INTRODUCTION: Bisphosphonate has been used to prevent osteoporotic fracture and is recommended for the secondary prevention after hip fracture. However, little is known regarding secondary prevention after first hip fracture. Our purpose was to determine the incidence of second hip fracture and to evaluate whether compliant use of bisphosphonate can reduce the risk of second hip fracture. METHODS: Eight hundred twenty-six patients who sustained the first hip fracture from May 2003 to October 2011 were retrospectively evaluated. The incidence of second hip fracture was compared between compliant users of bisphosphonate and nonusers. RESULTS: Seventy-one (8.6 %) patients suffered a second hip fracture at mean 30.0 months (SD 24.6, range 1 to 90 months) after the initial hip fracture. The cumulative incidence of second hip fracture was 5.1 % (42/826) at 2 years and 8.6 % (71/826) at 8 years. The incidence of second hip fracture was 4.2 % (12/283) in compliant users and 10.9 % (59/543) in nonusers (p = 0.001). CONCLUSIONS: Compliant use of bisphosphonate is effective in the prevention of second hip fractures.

Bisphosphonate use and increased incidence of subtrochanteric fracture in South Korea: results from the National Claim Registry.

SUMMARY: We evaluated trends in the incidences of typical and atypical hip fracture in relation to bisphosphonate use in Korea from 2006 to 2010, using nationwide data obtained from the Health Insurance Review and Assessment Service (HIRA). INTRODUCTION: Recently, atypical hip fractures in the subtrochanteric region have been reported among patients on bisphosphonate. However, the association between atypical hip fracture and bisphosphonate is controversial. We evaluated trends in the incidences of typical and atypical hip fracture in relation to bisphosphonate use in Korea from 2006 to 2010, using nationwide data obtained from the HIRA. METHODS: All new visits or admissions to clinics or hospitals for a typical and atypical hip fractures were recorded nationwide by HIRA using the ICD-10 code classification. Typical and atypical hip fractures were defined as femoral neck/intertrochanteric and subtrochanteric fracture, respectively. Bisphosphonate prescription data were also abstracted from the HIRA database. RESULTS: The absolute number of typical and atypical hip fracture increased during the study period. Although age-adjusted incidence rates of typical hip fractures were stable in men and women, those of atypical hip fractures increased in women. Nationally, the annual numbers of prescriptions of bisphosphonate also increased during the study period. CONCLUSIONS: The results of this study suggest a possible causal relationship between bisphosphonate use and the increased incidence of atypical hip fracture in Korea.

Bisphosphonate use and subsequent hip fracture in South Korea.

UNLABELLED: We determined the incidence of second hip fracture and evaluated whether compliant and persistent users of bisphosphonate had a lower incidence of second hip fracture after prior hip fracture, from a national claim registry. INTRODUCTION: Bisphosphonate is prescribed worldwide for the primary prevention of osteoporotic fracture. However, the association between adherent use of bisphosphonate and prevention of second hip fracture is unclear. Our purpose was to determine whether the adherent use of bisphosphonate was associated with a decreased risk of second hip fracture in South Korea, using a nationwide database. METHODS: From 2007 to 2011, first and second hip fractures were identified using the ICD-10 and procedure code form from the nationwide database of the Health Insurance Review and Assessment Service. Compliant use of bisphosphonate was defined as a patient medication possession ratio of 80 or more. Persistent users were defined patients with a refill gap of 30 days or less. We compared the incidence of second hip fracture in compliant and persistent users and non-users. RESULTS: Among 59,782 patients with first hip fracture, in this study, 1,336 second hip fracture occurred after the initial hip fracture during the study period. The mean age at the first hip fracture was 75.4 years (range, 50 to 100 years). The cumulative 1-year, 2-year, and 3-year incidence of second hip fracture was 1.0% (552/59,782), 1.9% (1,123/59,782), and 2.2% (1,336/59,782), respectively. After multivariate analysis, compliant and persistent use of bisphosphonate was significantly independent protectors for second hip fracture (HR, 0.595; 95% CI, 0.400-0.885; HR, 0.433; 95% CI, 0.327-0.573, respectively). CONCLUSIONS: Compliant and persistent use of bisphosphonate decreases the risk of second hip fracture, in terms of secondary prevention.

Teriparatide, a nonsurgical solution for femoral nonunion? A report of three cases.

We medicated teriparatide in three patients, who had a nonunion of the femur even after the initial surgical intervention. Teriparatide was administered for 3-9 months after a diagnosis of nonunion. A successful union was obtained in all three patients without further surgical intervention, and no adverse events related to the use of teriparatide were observed. Our report showed that teriparatide could be an alternative to surgical intervention in nonunion of the femur.

Persistence with intravenous zoledronate in elderly patients with osteoporosis.

UNLABELLED: The present study evaluates the proportion of patients who had re-infusion of intravenous zoledronate after first administration and identifies the factors that contribute to discontinuation. INTRODUCTION: In terms of persistence, annual administration of zoledronate seems to overcome a shortcoming of oral bisphosphonate. However, little information is available concerning persistence with intravenous zoledronate for osteoporosis in a usual care setting. The aim of this study was to assess the persistence of intravenous zoledronate after first administration and to identify the factors that contribute to its discontinuation. METHODS: A questionnaire survey concerning the second administration of zoledronate was performed on 259 patients, who had been administered with first intravenous zoledronate injection between January 2009 and December 2009, when they visit for second injection. The questionnaire asked whether patients were administered a second zoledronate injection or not, and non-persistent patients were asked why they declined the second infusion. RESULTS: One hundred and ninety-two patients revisited our outpatient clinic a year after first visit, and 94 patients (36.3%, 94/259) agreed to a second injection. Of the 136 patients that completed the questionnaire, 47 refused second administration and requested a change to oral bisphosphonate. Thirty-nine of the 47 patients (83%) stated that post-infusion syndrome was the reason why they refused the second administration. CONCLUSION: Although the effects of annual intravenous zoledronate are guaranteed to last for a year, this study shows that only a third of patients agree to second administration. The factors associated with discontinuation were male gender, adverse effects (especially post-infusion syndrome) and under-explanation of intravenous drug. These findings should be of concern to clinicians and indicate that patients should be informed before the administration.

Mortality after vertebral fracture in Korea: analysis of the National Claim Registry.

SUMMARY: The present study evaluates the incidence and mortality of vertebral fractures in Korea, using data from the Health Insurance Review Assessment Service, which includes nationwide information entrusted by Korean government. INTRODUCTION: A vertebral compression fracture is a serious complication associated with osteoporosis of the spine. We evaluated the incidence of vertebral fracture and subsequent mortality in South Korea, using nationwide data from the Health Insurance Review and Assessment Service (HIRA). METHODS: All new visits or admissions to clinics or hospitals for fractures were recorded in nationwide cohort by the Korean HIRA using International Classification of Disease, tenth Revision (ICD-10) code. The incidence of vertebral fracture and excess mortality associated with vertebral fracture were evaluated, in men and women aged 50 years or more between 2005 and 2008. Standardized mortality ratio (SMR) was calculated to determine excess mortality associated with vertebral fracture. RESULTS: The crude overall incidence of vertebral fractures was 984 per 100,000 person years from 2005 to 2008. The overall mortality rate at 3 months, 6 months, 1 year, and 2 years after vertebral fracture in men (5.56%, 9.41%, 14.6%, and 20.61%, respectively) were higher than that in women (2.41%, 4.36%, 7.16%, and 10.48%, respectively). In both genders, the age-specific mortality rates were more than those of the general population. The SMR was highest during the first 3 months and gradually declined to 2.53 in men and 1.86 in women at the 2-year period. CONCLUSIONS: The incidence of vertebral fracture in South Korea was comparable with other countries such as Switzerland, and the mortality after vertebral fracture is higher than that of normal populations. The incidence of osteoporotic vertebral fracture and following high mortality are likely to become serious socioeconomic problems.

SARC-F as a Useful Tool for Screening Sarcopenia in Elderly Patients with Hip Fractures.

BACKGROUND: SARC-F is recommended as a sarcopenia screening tool and comprised of five assessment items: strength, assistance walking, rising from a chair, climbing stairs, and falls. OBJECTIVE: The purpose of this study was to assess whether the SARC-F questionnaire in elderly patients with hip fractures was a valid screening tool for sarcopenia by comparison of the results with criteria from the Europe, Asia, and international working groups. MEASUREMENTS: 115 men and woman with hip fractures were assessed. The SARC-F self-reported questionnaire scores range from 0 to 10 and a score ≥ 4 defines sarcopenia. These survey questions were used to calculate the SARC-F score. Measurements, including appendicular muscle mass, were taken using dual-energy X-ray and grip strength using a dynamometer. Classification using the SARC-F score was compared using the consensus panel criteria from the international, European, and Asian sarcopenia working groups. The performance of all four methods was compared by examining the predictive ability using a ROC curve. RESULTS: A total of 115 subjects were included and the sarcopenia prevalence rate (SARC-F score ≥ 4) was 63.5 percent. The sensitivity, specificity, positive predictive value, negative predictive value PPV with the EWGSOP-2 criteria in Older People as the reference standard were 95.35 %, 56.94 %, 56.94%, 95.35%, and 71.3%, respectively. In addition, we found similar results for sensitivity and specificity as studies using the EWGSOP and AWGS criteria. CONCLUSIONS: The SARC-F questionnaire is a useful screening tool for elderly patients with hip fractures. This finding supports the recommendation of SARC-F as a screening tool for sarcopenia from the EWGSOP2.

Validity of the intra-operative measurement of stem anteversion and factors for the erroneous estimation in cementless total hip arthroplasty using postero-lateral approach.

BACKGROUND: Intra-operative estimation of stem anteversion in total hip arthroplasty (THA) using postero-lateral approach is made by the surgeon's visual assessment, using the tibia as a guide, with the assumption that tibial axis is vertical to the trans-epicondylar axis. However, the accuracy of the intra-operative estimation has rarely been verified with postoperative CT-scans, with controversies regarding these measurements particularly in case of knee osteoarthritis. Therefore we performed a prospective study to: (1) determine the accuracy of the intra-operative measurement and (2) investigate factors affecting the discrepancy between the surgeon's estimation and the real stem anteversion. HYPOTHESIS: Intra-operative estimation of stem anteversion correlated with the real stem anteversion on CT-scan. PATIENTS AND METHODS: Sixty-seven THAs using cementless straight stems (65 patients) without ipsilateral total knee arthroplasty were prospectively evaluated to compare the intra-operative measurement of stem anteversion with the real stem anteversion on computed tomography (CT) scans. There were 33 men and 34 women with a mean age of 59.7years (range, 27-84years) at the time of surgery. Age, tibia plateau angle, native femoral anteversion, femoro-tibial angle, body mass index, operative site, gender, coronal and sagittal tilt of the stem, stem type, ipsilateral knee osteoarthritis, and preoperative diagnosis were analyzed to evaluate the factors affecting the discrepancy between the intra-operative and CT measurements. RESULTS: The intra-operative estimation (mean, 21.5°±8.5°; range, 5.0°-39.0°) was greater than the CT measurement (mean, 19.5°±8.7°; range, 4.5°-38.5°) by 2.0°. The mean absolute value of discrepancy was 4.5°. The correlation coefficient between intra-operative and CT measurements was 0.837. The femoro-tibial angle was associated with the discrepancy between the two measurements. In the presence of genu varum deformity, the intra-operative measurement underestimated the stem anteversion. DISCUSSION: Although intra-operative estimation of stem anteversion was slightly greater than the real stem anteversion, there was an excellent correlation between the two. The femoro-tibial angle should be considered to optimize the stem anteversion during cementless THA using postero-lateral approach. LEVEL OF EVIDENCE: Level III, prospective case control study.

Mid-term results of the BIOLOX delta ceramic-on-ceramic total hip arthroplasty.

AIMS: We conducted a prospective study of a delta ceramic total hip arthroplasty (THA) to determine the rate of ceramic fracture, to characterise post-operative noise, and to evaluate the mid-term results and survivorship. PATIENTS AND METHODS: Between March 2009 and March 2011, 274 patients (310 hips) underwent cementless THA using a delta ceramic femoral head and liner. At each follow-up, clinical and radiological outcomes were recorded. A Kaplan-Meier analysis was undertaken to estimate survival. RESULTS: Four patients (four hips) died and 18 patients (20 hips) were lost to follow-up within five years. The remaining 252 patients (286 hips) were followed for a mean of 66.5 months (60 to 84). There were 144 men (166 hips) and 108 women (120 hips) with a mean age of 49.7 years (16 to 83) at surgery. The mean pre-operative Harris Hip Score of 47.1 points improved to 93.8 points at final follow-up. Six patients reported squeaking in seven hips; however, none were audible. Radiolucent lines involving Gruen zones one and/or seven were seen in 52 hips (18.2%). No hip had detectable wear, focal osteolysis or signs of loosening. One hip was revised because of fracture of the ceramic liner, which occurred due to an undetected malseating of the ceramic liner at the time of surgery. One hip was revised for a periprosthetic fracture of the femur, and one hip was treated for periprosthetic joint infection. The six-year survivorship with re-operation for any reason as the endpoint was 99.0% (95% confidence interval 97.8% to 100%). DISCUSSION: The rate of delta ceramic fracture was 0.3% (one of 286). While ceramic head fracture was dominant in previous ceramic-on-ceramic THA, fracture of the delta ceramic liner due to malseating is a concern. Cite this article: Bone Joint J 2017;99-B:741-8.

Total hip arthroplasty using a monobloc cementless femoral stem for patients with childhood Perthes' disease.

AIMS: Modular or custom-made femoral components have been preferred for total hip arthroplasty (THA) in patients with a history of Perthes' disease because of the distortion in the anatomy of the proximal femur. However, it has not been established whether a monobloc cementless stem will fit the distorted proximal femur or whether the results of the procedure are satisfactory in this group of patients. PATIENTS AND METHODS: We reviewed 68 consecutive patients who had undergone THA for childhood Perthes' disease between June 2003 and December 2008. There were 35 men and 33 women with a mean age of 48 years (16 to 73) at the time of index arthroplasty. Their mean body mass index was 24.4 (18.3 to 32.9). Of the 68 hips, 32 were classified as Stulberg class III and 36 as class IV. The mean pre-operative shortening of the affected leg was 17.2 mm (5 to 34). The minimum follow-up was five years (mean 8.5 years; 5.2 to 10). RESULTS: An intra-operative calcar fracture occurred in eight hips (11.8%) and was successfully treated by cerclage wiring. The mean stem version was 14.6° (-2.3 to 30; standard deviation (sd) 7.3). The mean acetabular component abduction was 40.2° (23.7 to 56.0; sd 6.5) and the mean anteversion 28.3° (6.4 to 43.0; sd 7.6), respectively. The mean follow-up was 8.5 years (5.2 to 10). No dislocations occurred and no hips were revised during the course of the study. At final follow-up, the mean Harris Hip Score was 91 points (59 to 100) and the mean University of California, Los Angeles activity score was 3.2 (2 to 8). CONCLUSION: Monobloc cementless stems reliably restore the anatomy in Perthes' disease at THA without the need for custom-made or modular implants. Cite this article: Bone Joint J 2017;99-B:440-444.

Human apolipoprotein A-I forms small high density lipoprotein particles in rats in vivo.

The effects of injection of purified human or rat apolipoprotein (apo) A-I (1.7 mg/100 g body weight) on the size and composition of rat high density lipoprotein (HDL) particles have been investigated. The injection of human apo A-I results in the formation (over a period of 3 to 6 h) of a population of smaller HDL particles resembling human HDL3. This population of smaller particles contains human apo A-I and rat apo A-IV but lacks rat apo A-I and rat apo E. Small HDL3-like particles are not detected in rat plasma following the injection of rat apo A-I. Associated with the injection of either human or rat apo A-I is a gradual increase of plasma cholesterol levels of 20 to 50% (over 24 h) and the appearance of larger HDL particles. The results suggest that the smaller HDL particles in human plasma compared to rat plasma are not simply due to the action of lipid modifying enzymes or lipid transfer proteins but a specific property of human apo A-I.

Effects of injecting exogenous lipid transfer protein into rats.

Rats were injected intravenously with preparations of partially purified lipid transfer protein isolated from human plasma. Cholesteryl ester transfer activity disappeared from the plasma of recipient rats with a t1/2 of about 10 h and after 24 h had fallen to a level comparable to that in human plasma. By contrast there was no measurable cholesteryl ester transfer activity in the plasma of control rats. Plasma collected from rats 24 h after the injection was subjected to ultracentrifugation at 1.225 g/ml; lipoproteins in the 1.225 g/ml supernatant were subsequently separated by both gel filtration chromatography and gradient gel electrophoresis. The major change in the treated animals was a total loss of the large, cholesteryl ester-rich, apolipoprotein E-rich high-density lipoproteins, HDL1, which are prominent in the plasma of control rats. This loss of HDL1 unmasked an obvious peak of low-density lipoproteins that had been obscured in the control rats. Other changes in the treated rats included an increase in the relative cholesteryl ester content of very-low-density lipoproteins and the emergence of a peak of triacylglycerol in the high-density lipoproteins.