Why Do Patellofemoral Stabilization Procedures Fail? Keys to Success

In recent years, surgical interventions for patellofemoral joint instability have gained popularity, possibly revitalized by the recent advances in our understanding of patellofemoral joint instability and the introduction of a number of new surgical procedures. This rise in surgical intervention has brought about various complications. In this review article, we present the complications that are associated with 5 main surgical procedures to stabilize the patella-medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, trochleoplasty, lateral release/lateral retinacular lengthening, and derotation osteotomies. The key to success and potential problems with these surgical techniques are highlighted in the form of "expert takeaways.

مناسبترین زاویه والگوس استئوتومی هیپ برای درمان عدم جوش خوردن شکستگی گردن فمور با شبیه‌سازی رایانه‌ای

زمینه و هدف: شکستگی گردن فمور یکی از پرعارضه¬ترین شکستگی¬ها است و عارضه شایع آن عدم جوش خوردن است. یکی از روش¬های درمان این عارضه در صورت زنده بودن سر استخوان فمور تغییر زاویه خط شکستگی و تبدیل نیروی جابجا کننده به نیروی فشاری در محل شکستگی است که سبب جوش خوردن محل شکستگی می¬شود ولی از طرف دیگر با بر هم زدن بیومکانیک هیپ، این مفصل را مستعد تخریب زودرس می¬کند. لذا هدف ما به دست آوردن زاویه ای است که از یک طرف سبب تسریع در جوش خوردن شود و از طرف دیگر مفصل را به سمت آرتروز و تخریب سوق ندهد. مواد و روش‌ها: با تحلیل بیومکانیکی و استفاده از شبیه¬سازی رایانه¬ای، نیروی لغزاننده و جابجا کننده شکستگی گردن استخوان ران و نیروی وارد شده به سر فمور را در زوایای مختلف والگوس با در نظر گرفتن فاکتورهای هندسی و بیولوژیکی فرد بررسی شد. جهت ایجاد شکستگی در فمور و مدل¬سازی Blade از نرم‌افزار Solidworks استفاده شد‌ و سپس Blade در موقعیت مناسب برای استئوتومی قرار داده شد، سپس جهت انجام شبیه‌سازی هندسه‌ مسئله به نرم افزار انسیس وارد شد. یافته‌ها: شبیه¬سازی برای زوایا مختلف شکستگی (از ۳۰ تا ۷۰ درجه) و زوایای مختلف اصلاح (از ۰ تا ۴۰ درجه) انجام شد. با توجه به هدف کاستن از تنش برشی در سطح شکست پارامتر شدت تنش (Stress Intensity) در این سطح برای قضاوت بهترین زاویه استیوتومی استفاده شده است. لازم به ذکر است در زوایای ۵۰ و ۵۵ درجه پاول، تغییر چندانی در مقادیر تنش برشی با تغییر زاویه اصلاح دیده نشد. نتیجه‌گیـری: بر اساس نتایج این مطالعه مقادیر شدت تنش به دست آمده از شبیه¬سازی¬های انجام شده و مقادیر زوایای پیشنهادی استئوتومی بر اساس کمینه میزان تنش برشی ارایه شد. در محدوده اصلاحی 0 تا 40 درجه افزایش درجه والگوس، تغییر زاویه تأثیر چندانی در نیروی وارد شده به سر فمور ندارد

The role of valgus osteotomy with DHS fixation in the management of fracture nonunion of the neck of femur

Background: Management of fracture non-union of the neck of femur is age specific and is quite demanding. There is a need to salvage the femoral headin younger individuals which demands a procedure which suits the requirements. The aim of this study was to evaluate the role of valgus osteotomy with dynamic hip screw fixation(DHS) in the management of these fractures and to compare the results with studies of other authors as available in literature.Methods: This was a prospective study of 15 patients with fracture nonunion of the femoral neck conducted between January 2012 to January 2013 with a follow up period of 3 years.Results: There were 9 males and 6 female patients in our study with the right side being more commonly affected. The mean age of the patients was 45.2 years ranging from 36 to 58 years. All fractures united at the end of 6 months. Post operatively the mean Pauwels angle was 340 while the neck shaft angle was 135.20. There was a significant increase in the Oxford score from a mean of 20.4 preoperatively to 37.9 in the postoperative period. All patients were happy with the procedure and the functional outcome. Conclusions: Valgus osteotomy with DHS fixation is a good option for the management of fracture nonunion of the neck of femur in younger patients where there is a need to salvage the femoral head and it gives good functional results

Update on pediatric hip imaging

Hip disorders are common in children. Prompt diagnosis and treatment are important because of the potential complications. Symptoms are frequently nonspecific, and clinical examination can be difficult and unreliable, especially in smaller children. Therefore, imaging can be valuable. Radiography and ultrasound remain the initial imaging modalities of choice. Increasingly, magnetic resonance imaging is obtained for assessing the pediatric hip, although the long imaging time and need for sedation may limit its use in daily practice. Because of the exposure to ionizing radiation, the use of computed tomography and bone scintigraphy in children is limited to selected cases. Pediatric hip pathology varies depending on patient age. This article provides an overview of common hip pathologies in children including congenital and developmental pathologies, trauma, infectious processes, inflammatory disease, and neoplasm. The age of the child, history, and clinical examination are essential to narrow down the differential diagnosis and subsequent selection of the appropriate imaging modality

Osteotomy, compression and other modifications of surgical techniques for internal fixation of extracapsular hip fractures

Background: Many different surgical techniques have been described for the internal fixation of extracapsular hip fractures. Objectives: To compare different aspects of surgical technique used in operations for internal fixation of extracapsular hip fractures in adults. Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, CINAHL, Current Controlled Trials, orthopaedic journals, conference proceedings and reference lists of articles. Date of last search was January 2008. No language restriction was applied. Selection criteria: All randomised and quasi-randomised trials investigating operative techniques used in operations for the treatment of extracapsular hip fractures in adults. Data collection and analysis: Two review authors independently selected trials, assessed trial quality and extracted data. Wherever appropriate, data were pooled. Main results: Predominantly older people with trochanteric fractures were treated in the 11 included trials. One trial (65 participants undergoing fixation with a fixed nail-plate) found no statistically significant differences between osteotomy versus anatomical reduction. Four trials, involving 465 participants undergoing fixation with a sliding hip screw (SHS), compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There were no statistically significant differences for mortality, morbidity or measures of anatomical deformity. Two trials (138 participants) compared SHS fixation of a trochanteric hip fracture augmented with cement against a standard fixation. There were no reoperations even for the four cases of fixation failure in the cement group. The cement group had significantly better quality of life scores at six months. One trial (200 participants) comparing compression versus no compression of a trochanteric fracture in conjunctionwith SHS fixation found no significant differences between the two groups. One trial (120 participants) found a tendency to improved outcomes with a hydroxyapatite coated lag screw, but none reached statistical significance. One trial (19 participants) reported reduced temperatures when using a modified reaming method. Another trial (50 participants) found reduced bone marrow intravascular embolism, detected by oesophageal ultrasound, when a Gamma nail was inserted with a distal pressure venting hole in the femur. Authors' conclusions: There is inadequate evidence to support the use of osteotomy for internal fixation of a trochanteric hip fracture. Similarly, there is insufficient evidence to support the use of the other techniques examined in the trials included in this review

Management of Neglected Fracture Neck of Femur by Pauwels Osteotomy: A Prospective and Retrospective study

INTRODUCTION: Fracture neck of femur is aptly called as “the unsolved fracture”. This is because even with so much of advances in orthopedic field, there is no simple method of treatment which can give consistently successful results for this fracture. Management of this fracture especially in younger patients is a really demanding and challenging task for any orthopaedic surgeon. Fracture neck of femur is common in old people as many of them are osteoporotic. With improvement in quality of life leading to increased life expectancy, the incidence is even more common nowadays. Due to the congested vehicular traffic, it is also commonly seen in young patients after road traffic accidents and many a times they are polytraumatized. The best end result after fracture neck of femur treatment is the patients own healed femoral head and neck and every attempt must be made to achieve that goal. AIM: The aim of this study is to analyse the role of valgus osteotomy in neglected fracture neck of femur. MATERIALS AND METHODS: Study conducted at the department orthopedics , Kilpauk medical college hospital, Chennai. Period of study –1998 – 2006 Both retrospective & prospective study. We operated 19 cases neglected fracture neck of femur and one case after implant failure. Totally 20 patients included for study. Inclusion Criteria - 1. Age group less than 60 years, 2. Duration of fracture more than 3 weeks old, 3. Pauwels type II & III, 4. Garden TYPE III & IV, 5. Active individuals. Exclusion Criteria - 1. Age group more than 60 years, 2. Duration of fracture less than 3 weeks old, 3. Pauwels type I, 4. Garden TYPE I & II, 5. Osteoporosis, 6. AVN with severe collapse. RESULTS: All the 20 cases were followed up our follow up period ranges from 4 months to 8 years. All patients were assessed by clinical, functional & radiological evaluation using Harris hip scoring system. 1. PAIN - 3 out of 20 patients had persistent pain in the hip because of avascular necrosis of femoral head. 2. UNION - All but one patient had good consolidation of both osteotomy site and fracture at the end of 6 months. One patient had implant cut out partly due to inadequate fracture reduction and partly due to premature weight bearing. Planning for redo of surgery. One patient had union with retroversion. 3. GAIT - 14 of 20 patients had normal gait. 3 had minimal limp and one had moderate limp. 4. SUPPORT - All of 20 patients walked without any support. 5. HIP FUNCTION - 16 patient more than 75 % of range movements & 4 had 50 -75 % of ROM. 17 of our 20 patients were able do normal day to day activities like walking, cycling, squatting & sitting cross legged. 3 patients has difficulty in squatting & sitting cross legged. 6. LIMB LENGTH DISCREPANCY - 15 patients had no limb length discrepancy. One patient had lengthening 1cm. 4 patients had shortening 1-2 cm. 7. INFECTION - One of our patient superficial wound infection which was controlled with antibiotics and dressings. CONCLUSION: Our Indian patients require squatting and sitting cross legged for normal day to day activities. Therefore in a patient with neglected fracture neck of femur, we can not achieve this by prosthetic replacement as it has its own limitations. One must aim to preserve the natural head of femur. Though many methods for treating neglected fracture neck of femur, valgus osteotomy is a very effective procedure. The other procedures like Meyer’s muscle pedicle grafting and free or vascularised fibular grafting are more extensive, expensive and high morbidity to the patient. Meticulous pre operative planning regarding placement of blade and level of osteotomy along with early stable fixation is essential for fracture union. We conclude that for the patients under 55 years of age with neglected fracture of the femoral neck, the Pauwels osteotomy produces many good results, even in the presence of avascular necrosis of femoral head providing the head has not collapsed