Sequential treatment with teriparatide and strontium ranelate in a postmenopausal woman with atypical femoral fractures after long-term bisphosphonate administration

AbstrAct ObJEctIVE: Despite the existence of numerous case series, no evidenced-based medical management for atypical fractures associated with bisphosphonate (bP) treatment has been established. DEsIGN: We report the outcome of teriparatide (trP) administration followed by strontium ranelate (sr) in a woman with a complete and an incomplete contralateral atypical fracture of the femoral diaphysis (AFF) associated with bP treatment. the spontaneous complete AFF was managed with intramedullary nailing, discontinuation of bP and initiation trP. rEsULts: Eleven months later, she suffered a contralateral incomplete AFF. At the completion of the trP treatment, she had only slight discomfort in the femur with the incomplete AFF. bMD testing revealed increase of 7.61% at the lumbar spine (Ls) and 0.8% at the hip. Following trP, 1-year sr treatment resulted in further bMD increase of 9.2% at the Ls and 1.4% in the hip, while she does not report any pain. bone markers remain within the normal range. cONcLUsION: Our case indicates that sequential therapy with trP and sr in cases of AFF might be a rational treatment option. However, there is a need for additional information concerning the effect of trP and sr, given alone or sequentially, in these patients in order to incorporate these drugs into the management of AFF

Basic science of osteoarthritis

Osteoarthritis (OA) is a prevalent, disabling disorder of the joints that affects a large population worldwide and for which there is no definitive cure. This review provides critical insights into the basic knowledge on OA that may lead to innovative end efficient new therapeutic regimens. While degradation of the articular cartilage is the hallmark of OA, with altered interactions between chondrocytes and compounds of the extracellular matrix, the subchondral bone has been also described as a key component of the disease, involving specific pathomechanisms controlling its initiation and progression. The identification of such events (and thus of possible targets for therapy) has been made possible by the availability of a number of animal models that aim at reproducing the human pathology, in particular large models of high tibial osteotomy (HTO). From a therapeutic point of view, mesenchymal stem cells (MSCs) represent a promising option for the treatment of OA and may be used concomitantly with functional substitutes integrating scaffolds and drugs/growth factors in tissue engineering setups. Altogether, these advances in the fundamental and experimental knowledge on OA may allow for the generation of improved, adapted therapeutic regimens to treat human OA.(undefined

Lessons learned from study of congenital hip disease in adults

Orthopaedic surgeons specialising in adult hip reconstruction surgery often face the problem of osteoarthritis secondary to congenital hip disease (CHD). To achieve better communication among physicians, better treatment planning and evaluation of the results of various treatment options, an agreed terminology is needed to describe the entire pathology. Furthermore, a generally accepted classification of the deformities is necessary. Herein, the authors propose the use of the term "congenital hip disease" and its classification as dysplasia, low dislocation and high dislocation. Knowledge of the CHD natural history facilitates comprehension of the potential development and progression of the disease, which differs among the aforementioned types. This can lead to better understanding of the anatomical abnormalities found in the different CHD types and thus facilitate preoperative planning and choice of the most appropriate management for adult patients. The basic principles for improved results of total hip replacement in patients with CHD, especially those with low and high dislocation, are: Wide exposure, restoration of the normal centre of rotation and the use of special techniques and implants for the reconstruction of the acetabulum and femur. Application of these principles during total hip replacement in young female patients born with severe deformities of the hip joint has led to radical improvement of their quality of life. © 2016 Baishideng Publishing Group Inc. All rights reserved

Comparison of the long-term outcome of cemented Charnley low-friction arthroplasty with hybrid arthroplasty in patients with congenital hip disease

Aims To our knowledge, no study has compared the long-term results of cemented and hybrid total hip arthroplasty (THA) in patients with osteoarthritis (OA) secondary to congenital hip disease (CHD). This is a demanding procedure that may require special techniques and implants. Our aim was to compare the long-term outcome of cemented low-friction arthroplasty (LFA) and hybrid THA performed by one surgeon. Patients and Methods Between January 1989 and December 1997, 58 hips (44 patients; one man, 43 woman; mean age 56.6 years (25 to 77)) with OA secondary to CHD were treated with a cemented Charnley LFA (group A), and 55 hips (39 patients; two men, 37 women; mean age 49.1 years (27 to 70)) were treated with a hybrid THA (group B), by the senior author (GH). The clinical outcome and survivorship were compared. Results At all timepoints, group A hips had slightly better survivorship than those in group B without a statistically significant difference, except for the 24-year survival of acetabular components with revision for aseptic loosening as the endpoint, which was slightly worse. The survivorship was only significantly better in group A compared with group B when considering reoperation for any indication as the endpoint, 15 years postoperatively (74% vs 52%, p = 0.018). Conclusion We concluded that there was not a substantial difference at almost any time in the outcome of cemented Charnley LFAs compared with hybrid THAs when treating patients with OA of the hip secondary to CHD. We believe, however, that after improvements in the design of components used in hybrid THA, this could be the method of choice, as it is technically easier with a shorter operating time. ©2019 The British Editorial Society of Bone & Joint Surgery

An attempt to throw light on congenital hip disease terminology and anticipation of clinical outcomes when treated with total hip arthroplasty

The terminology of the wide spectrum of hip deformities seen during the neonatal, infantile and adult life period remains controversial, mainly due to the indiscriminate use of the terms dysplasia, subluxation, congenital hip disease, developmental hip disease, congenital dislocation, etc. This has a serious implication on the anticipation of clinical outcomes, complications and comparison of different reconstructive techniques when these patients are treated with total hip arthroplasty in adulthood. Journals, specialising in this field, should publish homogeneous series (type of the disease, reconstruction technique, implants) in order to clarify arguments and anticipate clinical outcomes. © 2017 Wichtig Publishing

Bilateral character of total hip replacement does not change the overall survival

The purpose of this study was to compare the long-term survivorship of total hip replacement in unilaterally and bilaterally operated patents and try to answer the queston whether analyses of combined unilateral and bilateral cases could result in erroneous interpretatons. The material consisted of 266 Charnley’s low-fricton arthroplastes performed on 193 patents with osteoarthrits of the hip, followed for a minimum of 15 years. The 25-year survivorship of unilaterally operated hips was 69.2% (95% CI 57%-81.4%) and of bilaterally 66.4% (95% CI 57.6%-75.2%), respectvely (p = 0.324). Cox regression analysis of unilateral and bilateral cases for confounding factors of gender, age and primary diagnosis confrmed that there was no significant relatonship between survival of THR and whether the patent is unilaterally or bilaterally operated. Only age had a significant relatonship with the survival of THR. In bilateral cases, Cox analysis for possible predictve factors found that the primary diagnosis, tme interval between the two operatons and sequence of the operaton were not significantly correlated with the survivorship of bilateral THRs. We thus concluded that in analysing a combinaton of unilateral and bilateral cases, and presentng the long-term THR results, the bilateral character does not change the overall survival. © 2014 Wichtg Publishin

Overestimation of the risk of revision with Kaplan-Meier presenting the long-term outcome of total hip replacement in older patients

Introduction: The purpose of the present study was (i) to review the long-term outcome of cemented Charnley total hip replacements (THRs) performed by 1 surgeon (GH), 20 to 42 years ago, in patients ≥60 years, using both the Kaplan-Meier (KM) and the cumulative incidence (CI) methods, and (ii) to compare the estimations of the 2 statistical methods. Methods: We evaluated the outcome of 306 consecutive primary cemented THRs that were performed in 265 patients. The final clinical, radiographic assessment and satisfaction of living patients were also included. The survivorship was estimated with the use of KM and CI methods and the relative difference between their estimations was calculated. Results: Living patients’ final clinical results were significantly improved in comparison with respective preoperative ones, and all the acetabular and 91% of femoral components considered as well fixed. 95% of these patients reported satisfaction. The risk of revision at 25 years, with revision for aseptic loosening for 1 or both components as the endpoint, with 21 hips at risk, assessed with KM analysis was 6.9% and with CI approach was 3.9%. The relative difference between KM and CI estimations was increasing during follow-up, reaching up to 76.8% at 25 years. Conclusions: We concluded that fixation of implants with cement in older patients had satisfactory long-term results and can serve as a benchmark with which to compare newer fixation methods (hybrid and uncemented) and materials. However, KM method, in studies that include older population with long-term follow-up, may significantly overestimate the risk of revision and clinicians could consider using besides the cumulative incidence of competing risk method. © The Author(s) 2018

Overestimation of the risk of revision with Kaplan-Meier presenting the long-term outcome of total hip replacement in older patients

Introduction: The purpose of the present study was (i) to review the long-term outcome of cemented Charnley total hip replacements (THRs) performed by 1 surgeon (GH), 20 to 42 years ago, in patients ≥60 years, using both the Kaplan-Meier (KM) and the cumulative incidence (CI) methods, and (ii) to compare the estimations of the 2 statistical methods. Methods: We evaluated the outcome of 306 consecutive primary cemented THRs that were performed in 265 patients. The final clinical, radiographic assessment and satisfaction of living patients were also included. The survivorship was estimated with the use of KM and CI methods and the relative difference between their estimations was calculated. Results: Living patients’ final clinical results were significantly improved in comparison with respective preoperative ones, and all the acetabular and 91% of femoral components considered as well fixed. 95% of these patients reported satisfaction. The risk of revision at 25 years, with revision for aseptic loosening for 1 or both components as the endpoint, with 21 hips at risk, assessed with KM analysis was 6.9% and with CI approach was 3.9%. The relative difference between KM and CI estimations was increasing during follow-up, reaching up to 76.8% at 25 years. Conclusions: We concluded that fixation of implants with cement in older patients had satisfactory long-term results and can serve as a benchmark with which to compare newer fixation methods (hybrid and uncemented) and materials. However, KM method, in studies that include older population with long-term follow-up, may significantly overestimate the risk of revision and clinicians could consider using besides the cumulative incidence of competing risk method. © The Author(s) 2018

Acetabular reconstruction in patients with low and high dislocation: 20-to 32-year survival of an impaction grafting technique (named cotyloplasty)

We report the results at a mean of 24.3 years (20 to 32) of 61 previously reported consecutive total hip replacements carried out on 44 patients with severe congenital hip disease, performed with reconstruction of the acetabulum with an impaction grafting technique known as cotyloplasty. The mean age of the patients at operation was 46.7 years (23 to 68) and all were women. The patients were followed post-operatively for a mean of 24.3 years (20 to 32), using the Merle d'Aubigné and Postel scoring system as modified by Charnley, and with serial radiographs. At the time of the latest follow-up, 28 acetabular components had been revised because of aseptic loosening at a mean of 15.9 years (6 to 26), and one at 40 days after surgery because of repeated dislocations. The overall survival rate for aseptic failure of the acetabular component at ten years was 93.1% (95% confidence interval (CI) 86.5 to 96.7) when 53 hips were at risk, and at 23 years was 56.1% (95% CI 49.4 to 62.8), when 22 hips remained at risk. These long-term results are considered satisfactory for the reconstruction of an acetabulum presenting with inadequate bone stock and circumferential segmental defects. ©2013 The British Editorial Society of Bone & Joint Surgery

The twenty-year survivorship of two CDH stems with different design features

Previous studies have shown that anatomical abnormalities of the femur in dislocated hips require the application of special CDH prosthesis for the reconstruction of the proximal femur in total hip arthroplasty (THA). We have retrospectively examined the clinical records and radiographs of 50 patients (67 hips) with low and high dislocations treated with THA in our institution, between January 1987 and December 1994. For the reconstruction of the femur, the stainless steel Charnley CDH stem, with polished surface, monoblock and collarless, was used in 32 hips; the Harris CDH stem, made of CoCr, precoated at the proximal part, modular and with collar was used in 35 hips. At the time of the latest follow-up, 11 Charnley and 6 Harris CDH stems had been revised for aseptic loosening at an average of 14 years (range 6-20) and 13 years (range 2-19), respectively. The survival rate at 20 years, with failure for aseptic loosening as the end point, was 63 % for the Charnley and 78 % for the Harris CDH stems. These results provide a basis for evaluation of newer techniques and designs. Level of evidence Therapeutic study, Level IV. © 2012 Springer-Verlag France