Is there a place for conservative treatment of a Vancouver B2 fracture around a cemented polished tapered stem?

BackgroundRevision of the unstable stem of a total hip replacement following a peri-prosthetic fracture of the femur is a complex procedure with a high complication rate. With this study we aim to describe the radiologic findings of a specific fracture around polished tapered stems.MethodsEight male patients presented with a painful hip replacement after a fall. Standard radiographs did not show any signs of a fracture. CT scans showed a complex burst fracture in all cases. Conservative treatment was initiated for at least 6 weeks. A cement-in-cement revision was conducted at 3 months in case the patient was not pain free.ResultsAfter 3 months none of the fractures had displaced, neither had the stem subsided. Five patients were pain free and did not require surgical intervention. One patient underwent a cement-in-cement stem revision because of persistent pain.ConclusionNormal radiographs of a post-traumatic and painful polished tapered stem do not exclude a Vancouver type B2 fracture and should be followed by a CT-scan. Cement cracks, eccentric gaps and subsidence are highly suspicious signs for a non-displaced fracture pattern. Conservative treatment remains an option for these fractures and can be followed by a cement-in-cement stem revision after fracture healing, if this is still required

Inflammatory Neuropathy of the Lumbosacral Plexus following Periacetabular Osteotomy

Introduction. During periacetabular osteotomy (PAO), the sciatic, femoral, and obturator nerves are at risk. Most frequently nerve lesions can be attributed to a mechanical cause; however, in the absence of a clear mechanical cause surgeons are faced with a diagnostic problem and in many cases no diagnosis will be established. We report a case of inflammatory neuropathy of the lumbosacral plexus following a PAO. Case Presentation. A 31-year-old female developed weakness of ankle and knee flexion and extension 6 months after a PAO. Electrophysiological studies revealed damage to the obturator, femoral, and sciatic nerve consistent with an inflammatory lumbosacral plexopathy. MRI of the lumbosacral plexus was normal. The patient was treated with multimodal pain therapy and prolonged physiotherapy; nevertheless, symptoms worsened over time. At 2-year follow-up, there were no signs of recovery. Discussion. Inflammatory neuropathy of the lumbosacral plexus is a potential cause of pain and weakness after ipsilateral orthopaedic procedures. It should be distinguished from more frequently encountered mechanical causes of postsurgical neuropathy based on clinical suspicion, electrophysiological studies, MRI, and nerve biopsy. It is important that the orthopaedic community is aware of this complication since there is some evidence that early recognition and initiation of immunosuppressive therapy can lead to improved clinical outcome

Relative femoral neck lengthening in Legg-Calv\ue9-Perthes total hip arthroplasty

Abstract: Background Total hip replacement (THR) in patients with a history of Legg-Calv\ue9-Perthes disease can be a technically challenging procedure due to the distorted hip morphology. We propose a technique in which THR is preceded by a modified relative femoral neck lengthening (RFNL) procedure. Hereby, we aim to restore the biomechanical parameters. Methods Twenty-eight patients underwent RFNL in preparation of a second-stage THR between December 2011 and September 2019. The mean age was 38.1 \ub1 11.4 years. Radiographs were analyzed for centrotrochanteric distance, lateral displacement of the greater trochanter, and leg length discrepancy to assess the biomechanical restoration. Complication rate, reoperation rate, and patient-reported outcome measures were measured. Results Mean centrotrochanteric distance increased from 1218.7 \ub1 6.7 mm preoperatively to 1.9 \ub1 9.0 mm (P < .001) after RFNL and to 11.4 \ub1 10.4 mm after THR (P < .001). Mean lateral displacement of the greater trochanter increased from 34.2 \ub1 8.1 mm preoperatively to 42.4 \ub1 5.2 mm (P < .001) after RFNL and to 49.9 \ub1 8.3 mm after THR (P < .001). Leg length discrepancy decreased from 17.5 \ub1 10.5 mm to 2.7 \ub1 2.2 mm after THR (P < .001). Mean Harris Hip Score improved from 56.9 \ub1 17.6 preoperatively to 89.4 \ub1 10.7 at the latest follow-up (P < .001). Eight patients (8 hips) postponed THR because of sufficient clinical improvement, at a mean follow-up of 4.2 \ub1 2.1 years. Two hips needed a revision RFNL due to non-union (7.1%), and 1 hip replacement was revised due to a deep infection (5.0%). Conclusions RFNL prior to THR in patients with end-stage osteoarthritis following Legg-Calv\ue9-Perthes disease allows for utilizing regular implants with straight access to the femoral canal, with restored biomechanics and restoration of leg length. The prominent overhanging greater trochanter is reduced to prevent postoperative extra-articular impingement

Case Reports: A Stener-like Lesion of the Medial Collateral Ligament of the Knee

When the superficial fibers of the medial collateral ligament of the knee are torn without tearing of the deep fibers, the anterior superficial fibers may displace over the pes anserinus tendons, so that healing back to the tibial insertion site may be jeopardized. As only the anterior superficial and not the posterior superficial or deep fibers are disrupted, the knee will not have increased valgus laxity in extension whereas there is not a firm end point in 30° flexion. The clinical findings could be confused with those of a Grade 2 medial collateral ligament sprain that generally is not associated with displacement of the anterior fibers over the pes anserinus tendons. We describe the diagnostic findings confirmed with surgical exploration of two Stener-like disruptions of the medial collateral ligament of the knee

Hip loading in patients pre- and post- total hip arthroplasty

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Is there a place for conservative treatment of a Vancouver B2 fracture around a cemented polished tapered stem?

Revision of the unstable stem of a total hip replacement following a peri-prosthetic fracture of the femur is a complex procedure with a high complication rate. With this study we aim to describe the radiologic findings of a specific fracture around polished tapered cemented stems and we present the results of a two- stage treatment plan for non-displaced Vancouver type B2 fractures. Eight male patients with a cemented polished, tapered stem presented after a fall. Standard radiographs did not show any direct signs of a fracture. CT scans showed a complex burst fracture with cement mantle cracks in all cases. Partial weight bearing with 2 crutches was initiated for at least 6 weeks. A cement- in-cement revision was conducted at 3 months in case the patient was not pain free. After 3 months of weight bearing as tolerated, none of the fractures had displaced any further, neither had the stem further subsided. Five patients were pain free and did not require surgical intervention. One patient underwent a cement-in-cement stem revision because of persistent pain. Normal radiographs of a post-traumatic and painful polished tapered stem do not exclude a Vancouver type B2 fracture and should be followed by a CT-scan. Cement cracks, eccentric gaps and subsidence are highly suspicious signs for a non-displaced fracture pattern. Conservative treatment remains an option for these fractures and can be followed by a cement- in-cement stem revision after fracture healing, if this is still required.status: publishe

Perioperative operating room efficiency can make simultaneous bilateral total hip arthroplasty cost-effective : a proposal for a value-sharing model

Abstract: Background Increasing demand for total hip arthroplasty (THA) and rising health-care costs have led hospitals to improve operating room (OR) efficiency. We compare the cost-effectiveness of a simultaneous bilateral THA to that of staged unilateral procedures following the implementation of OR efficiency strategies. Methods Between 2017 and 2019, 446 simultaneous and 238 staged bilateral primary THA patients (mean age 61.3 \ub1 12.0 years; 41.8% males/58.2% females; mean body mass index 27.2 \ub1 4.8 kg/m2) were treated by a single surgeon using an efficient, standardized workflow for efficient direct anterior approach THA on a standard operating table. There were no differences in inclusion criteria between both groups. From this cohort, 16 simultaneous bilateral THAs and 34 unilateral THAs were prospectively compared for cost-effectiveness using detailed timestamp measurements and data on personnel and material usage. Outcome was assessed based on complication and reoperation rate and patient-reported outcome measures. Results There was a complication rate of 1.2%, without a difference between patients who underwent a simultaneous THA vs those who underwent a staged primary THA (5/446; 1.1% vs 3/238; 1.3% P = .386). The mean OR time (patient in/out and turnover time) was 109.4 \ub1 19.8 minutes for bilateral THAs and 133.8 \ub1 12.8 minutes for 2 unilateral THAs (P < .001). An 18% time-saving and 14% cost-saving was achieved per procedure. Sharing 5% of the cost-saving with the surgeon brings benefit to both the hospital and surgeon. Conclusions Implementing OR efficiency improves cost-effectiveness of simultaneous bilateral THA compared to unilateral procedures. A new value-sharing model could be a solution to align incentives

Towards automatic computer-aided knee surgery by innovative methods for processing the femur surface model

BACKGROUND: The femoral shaft (FDA) and transepicondylar (TA), anterior-posterior (WL) and posterior condylar (PCL) axes are fundamental quantities in planning knee arthroplasty surgery. As an alternative to the TA, we introduce the anatomical flexion axis (AFA). Obtaining such axes from image data without any manual supervision remains a practical objective. We propose a novel method that automatically computes the axes of the distal femur by processing the femur mesh surface. METHODS: Surface data were processed by exploiting specific geometric, anatomical and functional properties. Robust ellipse fitting of the two-dimensional (2D) condylar profiles was utilized to determine the AFA alternative to the TA. The repeatability of the method was tested upon 20 femur surfaces reconstructed from CT scans taken on cadavers. RESULTS: At the highest surface resolutions, the relative median error in the direction of the FDA, AFA, PCL, WL and TA was < 0.50 degrees , 1.20 degrees , 1.0 degrees , 1.30 degrees and 1.50 degrees , respectively. As expected, at the lowest surface resolution, the repeatability decreased to 1.20 degrees , 2.70 degrees , 3.30 degrees , 3.0 degrees and 4.70 degrees , respectively. The computed directions of the FDA, PCL, WL and TA were in agreement (0.60 degrees , 1.55 degrees , 1.90 degrees , 2.40 degrees ) with the corresponding reference parameters manually identified in the original CT images by medical experts and with the literature. CONCLUSIONS: The proposed method proved that: (a) the AFA can be robustly computed by a geometrical analysis of the posterior profiles of the two condyles and can be considered a useful alternative to the TA; (b) higher surface resolutions leads to higher repeatability of all computed quantities; (c) the TA is less repeatable than the other axes. Copyright (c) 2010 John Wiley & Sons, Ltd.status: publishe

Degenerative changes of the hip following in situ fixation for slipped capital femoral epiphysis: a minimum 18-year follow-up study

INTRODUCTION: In situ fixation (ISF) is currently still the 'gold standard' treatment for slipped capital femoral epiphysis (SCFE) and has shown acceptable results at mid-term follow-up. This study aims to evaluate functional, clinical and radiographic long-term outcomes after this procedure. METHODS: We reviewed 64 SCFE patients (76 SCFE hips) treated with ISF between 1983 and 1998. 82.9% were stable hips and 17.1% unstable according to Loder's definition. Initial radiographs demonstrated a mild slip in 50%, moderate in 41.3% and severe in 8.7% based on the Southwick angle. Long-term outcomes were assessed using the modified Harris Hip Score (mHHS), University of California at Los Angeles (UCLA) and Tegner activity scores, visual analogue scale (VAS) pain, VAS function, flexion-adduction-internal rotation (FADIR) test, extent of internal-rotation at 90° of hip flexion and Tönnis classification for hip osteoarthritis (OA). RESULTS: 10 (15.6%) SCFE hips were converted to a total hip replacement (THR) after a mean of 16 years. 38 (59.4%) patients underwent a clinical and radiographic examination after a mean follow-up of 23 (range 18-33) years. 12 (18.8%) patients were lost to follow-up. 74% of SCFE hips demonstrated degenerative change on radiography or were converted to THR (Tönnis 1: 33.3%, 2: 18.5%, 3 or THR: 22.2%). There were 3 cases of avascular necrosis (AVN) all in unstable hips. Mean mHHS was 86.8/100, UCLA activity score 7.5/10, Tegner activity score 3.8/10, VAS pain 1.7/10 and VAS function 1.5/10. 20% of SCFE hips were found to have a positive FADIR-test and a limited internal-rotation of 19.7° versus 36.1° (p < 0.001) in contralateral normal hips. DISCUSSION: This long-term follow-up study of ISF for SCFE shows that although complication rates in terms of AVN are low, a high number of patients become symptomatic and have a limited function. Degenerative changes are common with 22.2% of hips developing end-stage hip OA (Tönnis 3 or THR). It is important that patients and parents are informed about these risks.status: publishe