Introduction

During THA in lateral position, keeping accurate lateral position is very important for obtaining good cup position. We normally use two kinds of hip positioner, but sometimes we can only use universal positioner provided with operational table. The pelvic tilt can be changed by surgical procedures such as traction, dislocation, reduction and so forth. In the present study, pre-op and post-op pelvic tilt was assessed using Kinect (Xbox 360′s sensor) as 3D scanner.

Periprosthetic fractures around the femur during and after total hip arthroplasty (THA) remain a common mode of failure. It is important therefore to recognise those factors that place patients at increased risk for development of this complication. Prevention of this complication, always trumps treatment. Risk factors can be stratified into: 1. Patient related factors; 2. Host bone and anatomical considerations; 3. Procedural related factors; and 4. Implant related factors. Patient Factors. There are several patient related factors that place patients at risk for development of a periprosthetic fracture during and after total hip arthroplasty. Metabolic bone disease, particularly osteoporosis increases the risk of periprosthetic fracture. In addition, patients that smoke, have long term steroid use or disuse, osteopenia due to inactivity should be identified. A metabolic bone work up and evaluation of bone mineralization with a bone densitometry test can be helpful in identifying and implementing treatment prior to THA. Pre-operative Host Bone and Anatomic Considerations. In addition to metabolic bone disease the “shape of the bone” should be taken into consideration as well. Dorr has described three different types of bone morphology (Dorr A, B, C), each with unique characteristics of size and shape. It is important to recognise that not one single cementless implant may fit all bone types. The importance of templating a THA prior to surgery cannot be overstated. Stem morphology must be appropriately matched to patient anatomy. Today, several types of cementless stem designs exist with differing shape and areas of fixation. It is important to understand via pre-operative templating which stem works best in what situation. Procedural Related Factors. There has been a resurgence in interest in the varying surgical approaches to THA. While the validity and benefits of each surgical approach remains a point of debate, each approach carries with it its own set of risks. Several studies have demonstrated increased risk of periprosthetic fractures during THA with the use of the direct anterior approach. Risk factors for increased risk of periprosthetic fracture may include obesity, bone quality and stem design. Implant Related Factors. As mentioned there are several varying cementless implant shapes and sizes that can be utilised. There is no question that cementless fixation remains the most common mode of fixation in THA. However, one must not forget the role of cemented fixation in THA. Published results on long term fixation with cemented stems are comparable if not exceeding those of press fit fixation. In addition, the literature is clear that cemented fixation in the elderly hip fracture patient population is associated with a lower risk of periprosthetic fracture and lower risk of revision. The indication and principles of cemented stem fixation in THA should not be forgotten

Introduction. We have investigated middle-term clinical results of total hip arthroplasty (THA) cemented socket with improved technique using hydroxyapatite (HA) granules. IBBC (interfacial bioactive bone cement method, Oonishi) (1) is an excellent technique for augmenting cement-bone fixation in the long term. However, the technique is difficult and there are concerns over some points, such as bleeding control, disturbance of cement intrusion to anchoring holes by granules, difficulty of the uniform granular dispersion to the acetabular bone. To improve the original technique, we have modified IBBC (M-IBBC), and investigated the middle-term clinical results and radiographic changes. Materials and Methods. K-MAX HS-3 THA (Kyocera, Japan), with tapered cemented stem with small collar and all polyethylene cemented socket, was used for THA implants (Fig.1). Basically the third generation cementing technique was used for THA using bone cement. The socket fixation was performed with bone cement (Endurance, DePuy) and HA granules (Ca10(PO4)6(OH)2, Boneceram P; G-2, 0.3–0.6mm in size, Olympus, Japan) (Fig.2). In original IBBC technique, HA granules were dispersed on reamed acetabulum before cementing. In M-IBBC technique, HA granules were attached to bone cement on plastic plate, then inserted to reamed acetabulum and pressurized (Fig.3). 112 hip joints (95 cases) were operated between June 2010 and March 2014, and followed. The average follow-up period was 6.5 years, and average age at operation was 66.5 years. The clinical results were evaluated by Japan Orthopaedic Association Hip Score (JOA score), and X-p findings were evaluated using antero-posterior radiographs. The locations of radiolucent lines were identified according to the zones described by Delee and Charnley for acetabular components, and Zone 1 was divided into two parts, outer Zone 1a and inner Zone 1b. Results and Discussion. Revision was not performed. JOA score improved from 47 to 88. Socket and stem loosening was not observed. X-p findings of sockets demonstrated radiolucent line in Zone 1a/1b/2/3 in 0.9/0/0/0% immediately after the operation, 6.3/1.8/0/0.9% at 2 years postoperatively. After 2 years there was no progressive change, however, improvement of radiolucent line in Zone 1a was observed in two cases after 3 years postoperatively. Accordingly, at 5 years radiolucent line in Zone 1a/1b was observed in 4.4/1.8%. Oonish has reported excellent clinical results of THA with IBBC (1). To easily perform IBBC, we have modified the technique, improving the problems of IBBC. In this study, radiolucent line was observed at the margin of the socket in a small number of cases, and there was no progressive change. In addition, improvement of radiolucent line was observed in M-IBBC in this study, which was not observed in conventional cementing technique. Conclusions. It is demonstrated that M-IBBC provides stable socket cement fixation for THA. The interesting finding in M-IBBC cases was the improvement of radiolucent line, suggesting osteoconductive property of hydroxyapatite granules at the interface after the operations. The promising long-term clinical results of M-IBBC method, were expected. For any figures or tables, please contact the authors directly

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

The main causes of total hip arthroplasty (THA) revisions are loosening and instability. Use of a dual mobility cup cemented in a acetabular reconstruction cage device limits the risk of instability and does not hinder the acetabular fixation during THA revisions. The objective of this study was to analyse a retrospective series of 123 THA revisions with antiprotusio cage and dual mobility socket. Patients and methods: At a mean follow-up of 10 years, we analysed a continuous series of 123 revisions using a reconstruction device (87 Kerboull cross-plates, 12 Burch-Schneider antiprotrusio cages, 24 custom-fit Novae ARM cages associated in all cases with a Novae Stick dual mobility cup cemented into the cage). There were 80 women and 43 males. The mean age at the surgery was 69.2 years old. PMA score increased from 9.6 +/− 3.06 preoperatively to 14.2 +/− 2. at the follow-up. 9 early dislocations occurred and one late dislocation. At the last follow-up, the X-rays showed nine hardware failures, including one cross-plate fracture, one hook fracture, and one flange fracture. Analysis of the radiological position of the cup showed a mean lowering of 13 mm and a 7 mm lateralisation compared to the preoperative position. 2 revisions for aseptic loosening and 3 for septic loosening were performed. This study confirms the advantage of dual mobility cups during acetabular reconstruction cemented in antiprotrusio cages as a way to limit, without eliminating, the risk of dislocation. Therefore cemented fixation of dual mobility cups in cages appears to be a reliable short-term option

The femoral diaphysis presents the best opportunity for fixation during revision THA. Both fully coated cylindrical and modular fluted tapered titanium stems have demonstrated excellent results. Cylindrical stems have demonstrated concerning rates of failure when used in larger, osteopenic canals or in canals with post-isthmal divergent morphologies. Modular stems offer the advantage of separating distal fixation needs from proximal version, leg length, and offset needs via a modular junction. Although early designs demonstrated some breakages at the taper or through thin proximal bodies, newer generation implants have not demonstrated such mechanical concerns. Additionally, the modular junctions do not appear to be having any problems with corrosion. Mid- to long-term data with various designs now support the safety and efficacy of these constructs that can handle a wide variety of challenges during femoral revision. Careful attention to detail is necessary to minimise the risk of subsidence and intra-operative fracture or femoral perforation

There is continuing debate among orthopedists regarding the appropriate treatment of femoral neck fractures, open reduction internal fixation (ORIF), Total hip arthroplasty (THA) or hemiarthroplasty. In 2003 310,000 patients were hospitalized for hip fracture in the United States and about one-third were treated with total hip arthroplasty. Worldwide, the total number of hip fractures is expected to surpass 6 million by the year 2050. In a survey distributed by the American Association of Hip and Knee Surgeons, and of the 381 members who responded, 85% preferred hemiarthroplasty, 2% preferred ORIF and 13% preferred THA. The decision to perform internal fixation, hemiarthroplasty, or THA is based on comminution of the fracture activity level and independence, bone quality, presence of rheumatoid or degenerative arthritis, and mental status. Evidence based practice indicates that in a young patient with good bone stock and a fracture with relatively low comminution an ORIF is the treatment of choice. If the patient has a comminuted fracture with poor bone quality, minimal DJD, no RA, and low activity demand a hemiarthroplasty is a reasonable choice. If the patient has a comminuted fracture with poor bone quality, DJD and high activity demand a total hip replacement is a reasonable choice

We report an intertrochanteric fracture in a patient who had undergone hip arthrodesis 30 years previously. A 53-year-old man was injured in a head-on car crash and was referred to our hospital for treatment. Plain radiographs showed an intertrochanteric fracture of the right proximal femur and deformity of the right hip joint. He had undergone hip arthrodesis surgery 30 years previously at another hospital. Computed tomography scan showed marked atrophy of the gluteus and iliopsoas muscles. He preferred undergoing total hip arthroplasty (THA) to internal fixation. THA was performed using the anterolateral approach with the patient in the supine position as he had undergone hip arthrodesis through the Smith–Petersen approach, and we were concerned about damaging the gluteus muscle and dislocation if we took the posterolateral approach. The femoral head was removed using curved chisels under fluoroscopy. A cementless THA (J Taper stem, Aquala polyethylene liner; Kyocera Medical Corporation, Osaka, Japan) was inserted and fixed appropriately. Full weight-bearing using a walking frame was allowed 2 weeks after the surgery. Six months after the operation, he was able to walk independently and had good range of movement of the hip joint but continued to have weakness in the abductor muscles. Very few cases of proximal femur fracture in a previously arthrodesed hip have been reported. Manzotti et al. reported a similar case but they performed open reduction and internal fixation. No previous reports in the literature describe THA for intertrochanteric fracture in an arthrodesed hip. The conversion of an arthrodesed hip to THA is technically challenging. It has a high risk of complications such as nerve injuries and hip instability. We were able to treat the patient successfully, but surgeons should carefully decide the treatment method depending on the case

Fracture of the acetabulum can result in damage to the articular surface that ranges from minimal to catastrophic. Hip arthroplasty may be required for more severe injuries due to marked articular surface damage, post traumatic degenerative changes, persistent malunion or nonunion, or occasionally avascular necrosis and destruction of the femoral head. These problems may be seen following both closed and open fracture treatment, but prior open reduction and internal fixation often makes subsequent THA more difficult due to soft tissue scarring and retained hardware. In select acute acetabular fracture cases with severe initial comminution of the joint, open reduction and fixation can be technically impossible or so clearly destined to early failure that initial fracture treatment with combined limited fixation and simultaneous THA is the best option, especially in osteoporotic elderly fracture patients. Problems which may be encountered during any THA in a patient with a prior acetabular fracture include: difficult exposure due to soft tissue defects and scarring, presence of heterotopic ossification, and nerve palsy from the original fracture or subsequent osteosynthesis. Retained hardware can present significant challenges and frequently is left in place or removed in part or completely, when intraarticular in location or blocking preparation of the acetabular cavity and placement of the cup. Additional potential problems include residual deformity and malunion, persistent pelvic dissociation or nonunion of fracture fragments, cavitary or segmental bone loss from displaced or resorbed bone fragments, and occasionally occult deep infection. Preoperative assessment and planning should include careful consideration of the most appropriate surgical approach, which may be impacted by the need for hardware removal. Screening laboratory studies and aspiration of the hip may prove helpful in excluding associated deep infection. Intraoperative sciatic nerve monitoring may be of assistance in patients with partial residual nerve deficits or where extensive posterior exposure and mobilization of the sciatic nerve is needed for hardware removal or excision of heterotopic ossification. Metal cutting tools to allow partial removal of long plates and adjunctive equipment for removal of broken or stripped screws should be routinely available during these cases. Careful preoperative planning regarding implant and reconstructive options can also ensure availability of proper components and equipment. Often implants and techniques developed for revision surgery for management of major bone deficiencies are needed. Reported results suggest that surgery is frequently prolonged, can be associated with greater blood loss and may result in increased risk of post-arthroplasty heterotopic ossification when compared to routine primary procedures. Bone stock and fracture union may be better in patients with prior internal fixation than in those with nonoperative treatment of major displaced acetabular fractures. Available long-term results document more durable results with lower rates of aseptic loosening with uncemented acetabular fixation compared to cemented acetabular components. These patients are at higher risk of revision and failure than patients undergoing THA for simple osteoarthritis, though initial short-term results are comparable to conventional hip arthroplasty patients, as long as early wound healing problems and deep infection can be avoided, which is a greater risk for acute THA for initial fracture care. The application of newer implant designs, highly porous ingrowth materials, and methods for management of acetabular bone deficiency developed for revision THA have helped improve results in this challenging subset of primary THA patients

Bactericidal levels of antibiotics are difficult to achieve in infected total joint arthroplasty when intravenous antibiotics or antibiotic-loaded cement spacers are used, but intra-articular (IA) delivery of antibiotics has been effective in several studies. This paper describes a protocol for IA delivery of antibiotics in infected knee arthroplasty, and summarises the results of a pharmacokinetic study and two clinical follow-up studies of especially difficult groups: methicillin-resistant Staphylococcus aureus and failed two-stage revision. In the pharmacokinetic study, the mean synovial vancomycin peak level was 9242 (3956 to 32 150; sd 7608 μg/mL) among the 11 patients studied. Serum trough level ranged from 4.2 to 25.2 μg/mL (mean, 12.3 μg/mL; average of 9.6% of the joint trough value), which exceeded minimal inhibitory concentration. The success rate exceeded 95% in the two clinical groups. IA delivery of antibiotics is shown to be safe and effective, and is now the first option for treatment of infected total joint arthroplasty in our institution.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):31–6.