Femur is one of the bones in humans that exhibit ethnic, racial, and gender difference. Several basic and clinical studies were conducted to explore these variations. Clinical anthropological studies have dealt with the compatibility of femoral prostheses and osteosythesis and materials with the femur. If there is a misalignment between the Total Knee Arthroplasy (TKA) femoral comportment installation position, Range of Motion (ROM) failure and several problems may arise. The aim of this study was to evaluate anterior bowing of the Japanese femur and to assess the adequacy of TKA femoral comportment installation position. We analyzed 76 normal Japanese and 97 TKA patients. (June 2014-June 2015) The average age of the normal subjects was 62.0±20.90 (24–88) years old and the average of TKA subjects was 73.6±7.9 (53–89) years old. First we defined and measured the anterior curvature and the posterior condylar offset (PCO) in normal japanese femurs. Then in TKA patients we set the implant as same angle of the component. Third, we measured the post operative anterior curvature and PCO. Then calculated the anterior curvature difference and PCO differences and preformed statistical analysis with ROM.INTRODUCTION
METHODS
We occasionally come across cortical atrophy of the femur with cemented collarless polished triple-taper stem, a short time after the operation. This study aimed to estimate the radiographs of cemented collarless polished triple-taper stem taken at three, six, twelve, and twenty-four months after the initial operation. Between May 2009 and April 2011, 97 consecutive patients underwent primary total hip arthroplasty and hemiarthroplasty using a SC-stem or C-stem implant. During the 24 month follow-up, radiographic examination was performed on a total of 95 patients (98 hips). Out of those 95 patients, 52 hips had total hip arthroplasty, 45 had osteoarthritis, 5 had idiopathic osteonecrosis, there were two 2 other cases and 46 hips had hemiarthroplasty for femoral neck fractures. The cementing grade was estimated on the postoperative radiographs. The 24 month postoperative radiographs were analyzed for changes in stem subsidence, cortical atrophy and cortical hypertrophy. According to the Gruen zone, cortical atrophy and cortical hypertrophy were classified on the femoral side. We defined no cortical atrophy as grade 0, cortical atrophy less than 1 mm as grade 1, more than 1 mm and less than 2 mm as grade 2, and more than 2 mm as grade 3. We defined Grade 1 as 1 point, Grade 2 as 2 points, and Grade 3 as 3 points. The points in every zone were calculated, and the average per zone was determined.Background
Methods
In total knee arthroplasty extramedullary tibial guides could not to be as accurate as requested in obtaining proper alignment perpendicular to the mechanical axis. The aim of this study was to determine the accuracy of an accelerometer-based system (KneeAlign 2; OrthAlign Inc, Aliso Viejo, California) as evaluated by post-op X-rays analysis. Between March 2012 and May 2012 thirty consecutive patients with primary gonarthrosis were selected for unilateral total knee arthroplasty (TKA) using a handheld surgical navigation system to perform the tibial resection.
Postoperatively, standing anteroposterior hip-to-ankle radiographs and lateral knee-to-ankle radiographs were performed to determine the varus/valgus alignment and the posterior slope of the tibial components relative to the mechanical axis in both the coronal and sagittal planes. The difference between the intraoperative reading of the tibial varus/valgus alignment and posterior slope provided by the system was compared to the radiographic measurements obtained postoperatively for each respective case. Differences were analysed via standard t test. The critical level of significance was set at P <0.05.Introduction
Methods
Avascular necrosis of the femoral head (AVN) is associated with collapse of the femoral head and arthritic degeneration of the joint. The combination of an implant inserted into the femoral head that provides mechanical support and bone grafting to promote bone formation may offer a possible joint-preserving solution1. Seventeen such procedures were performed between November 2012 and March 2014 during an IRB approved clinical trial. Thirteen out of 18 patients remained unrevised at a minimum of 12 months; the results of radiographic and histological analysis of four revisions are presented. The investigational device (Figure 1) was developed as a joint preserving treatment for AVN with a clinical grade of IIC or less according to the ARCO grading system2. The device consisted of a braided spherical Nitinol cage with a Titanium / Nitinol orientation feature. It was implanted using fluoroscopic navigation into a spherical cavity cut into the femoral head via an 11mm diameter access tunnel. Once deployed, the implant was filled with a lightly impacted mixture of autologous bone graft and bone marrow soaked Conduit TCP (DePuy CMW, Blackpool, UK). The implant's purpose was to provide mechanical support to the weakened subchondral surface while the bone graft mixture re-integrated with the host bone. The retrieved femoral heads were trimmed to leave approximately 3mm of bone around the implant, dehydrated, embedded in methacrylate resin, sectioned and thinned into 50–70µm coronal slices for histological analysis. The following observations were made (Figure 2): Case 1 (Female, age 70, ARCO IIB, revised after 2 days): The patient was revised for spontaneous sub-trochanteric fracture secondary to osteoporosis. Contact between the native bone and bone graft was observed. Marrow elements and repair tissue were visible within the pores in the graft (Figure 2a). Case 2 (Male, age 67, ARCO IIIC, revised after 82 days): Two wires were broken but retained within the braided structure. A radiolucent gap caused by the presence of fibrous tissue between the graft mixture and native bone was evident suggesting that the implant was unable to prevent progression in this case. Case 3 (Female, age 70, ARCO IIC, revised after 482 days): The cavity penetrated the subchondral surface; at revision the implant was found to have breached the articular cartilage. There was partial separation of the proximal osteonecrotic fragment and no evidence of graft revascularisation or remodelling within the implant. Case 4 (Male, age 42, ARCO IIC, revised after 469 days): There was no indication of bone graft re-integration. Collapse of the necrotic bone and deformation of the implant was diagnosed from 1 year follow-up x-rays. This treatment has preserved the joints of fourteen patients. Of the four revised, two patients had clinical grades or bone quality contra-indicated for the device and three had lesions occupying more than 30% of the femoral head: Improved criteria for patient selection may be required. The device is only partially load-bearing and incapable of stabilising fractures: The radiolucent band associated with fibrous tissue formation may be an early indication of failure.Conclusion
We occasionally came across cortical atrophy of femurs with cemented collarless polished triple-taper stem in a short term period. This study aimed to estimate radiographs of cemented collarless polished triple-taper stem taken 6 months after the initial operation. Between May 2009 and April 2011, 97 consecutive patients underwent primary total hip arthroplasty and hemiarthroplasty using SC-stem or C-stem implants. At the 6 month follow-up, a radiographic examination was performed on 70 patients (71 hips). 44 hips had Total Hip Arthoplasty, 35 had osteoarthritis, 5 had idiopathic osteonecrosis, 2 had other diseases and 27 hips had hemiarthroplasty for femoral neck fractures. The postoperative radiographs were used to estimate the cementing grade. Then the 6 month postoperative radiographs were analyzed for changes in stem subsidence, cortical atrophy and cortical hypertrophy. According to the system of Gruen- cortical atrophy and cortical hypertrophy were classified on the femoral side. We defined no cortical atrophy as grade 0, cortical atrophy less than 1 mm as grade 1, more than 1 mm and less than 2 mm as grade 2, more than 2 mm as grade 3.Background
Methods
Acetabular bone loss during revision total hip arthroplasty (THA) poses a challenge for reconstruction as segmental and extensive cavitary defects require structural support to achieve prosthesis stability. Trabecular metal (TM) acetabular augments structurally support hemispherical cups. Positive short-term results have been encouraging, but mid- to long-term results are largely unknown. The purpose of this study was to determine the continued efficacy of TM augments in THA revisions with significant pelvic bone loss. Radiographs and medical records of 51 patients who had undergone THA revision with the use of a TM augment were retrospectively reviewed. Acetabular defects were graded according to the Paprosky classification of acetabular deficiencies based on preoperative radiographs and operative findings. Loosening was defined radiographically as a gross change in cup position, change in the abduction angle (>5°), or change in the vertical position of the acetabular component (>8 mm) between initial postoperative and most recent follow-up radiographs (Figure 1).Purpose:
Methods:
The advantages of the direct anterior approach (DAA) for total hip arthroplasty include the preservation of external rotators and hip abductors thus leading to quicker recovery times. To our knowledge, there is no objective method in the literature to predict the level of difficulty for femoral exposure through the DAA. It would be beneficial to the surgeon learning the DAA to assess difficulty pre-operatively to avoid prolonged operative times. The purpose of this study was to develop a predictive model of femoral exposure difficulty in the DAA using a combination of demographic data and radiographic measurements. 305 post-operative radiographs of consecutive THA's in patients (184 female, 120 male) with primary or secondary osteoarthritis, mean age 64.6 (range 26–91, SD=11.43) performed through the DAA by one of the co-investigators from 12/2005 to 12/2009 were retrospectively reviewed by two separate observers. The observers were blinded to the difficulty level of femoral exposure. Standard post-operative AP pelvis films were assessed with TraumaCad software (TraumaCad 2.2, Voyant Health, Columbia, MD) to make radiographic measurements as shown in Figure 1–2. Each radiograph was calibrated using the size of the femoral head implant. Exclusion criteria included films that had inadequate coverage of the entire pelvis, mal-rotation, or poor exposure. Statistical analysis was performed using STAT 9.1 (StatCorp; College Station, Texas, USA). A two-sided Kruskal–Wallis test was utilized for non-parametric data. Chi-squared tests and Fisher's Exact Test were used to compare proportions. Statistically significant associations were then added to a multivariate model predicting an outcome of difficult exposure.Introduction
Methods
Degenerate chondral surfaces can be assessed in many ways, but arthroscopy is often performed without proper categorisation, mapping, zoning or sizing of lesions. Progression of disease in un-resurfaced compartments is well-recognised to occur, but is only one of several failure mechanism in partial knee replacement. A validated ‘Functional Zone’ mapping method was used to document articular surface damage in 250 sequential cases of knee arthroscopy in patients over the age of 40. Size, shape, location and severity of each chondral lesion were noted using the Outerbridge classification. Analysis determined rates of involvement of particular compartments and assessed potential for partial replacement or local treatment and also to consider the risk of future progression. Radiographs including antero-posterior standing, postero-anterior flexion views (Rosenberg), lateral and skyline views were graded (Kellgren and Lawrence) and compared with the arthroscopic findings. Our results showed that out of the 210 knees with Grade 3 or greater damage 13.3% of knees showed ‘isolated’ medial disease of Outerbridge Grade 3 or worse. Isolated lateral disease was noted in 1.4%, patello-femoral disease in 24.3%, bi-compartmental (Medial/PFJ) disease in 30.9% with tibio-femoral and tri-compartmental disease seen in 15.2%. The combination of lateral and patello-femoral disease was seen in 14.8%. Provided that Grade 1 and 2 changes (which were found in other compartments in high percentages) were ignored and ACL status considered, this information seemed to indicate that at the time these procedures were performed, 13.3% of cases were suitable for a medial uni-compartmental device, with sub-analysis of lesion sizes indicating that 17 out of 28 cases (60.7%) were suitable for a localised resurfacing. Lateral uni-compartmental replacement seemed suitable for only 1.4%, patello-femoral replacement in 24.3%, bi-compartmental in 30.9% and total knee replacement in 30%. The mean age for partial resurfacing was 53years and 59 years for total joint replacements. Radiological analysis found that the antero-posterior standing views had only 66% sensitivity and 73% specificity for the presence of Grade 3 changes or worse in the medial compartment in comparison with Rosenberg views having a sensitivity of 73% and a specificity of 83%. Skyline views had a sensitivity of 56% and 100% specificity. This study indicates that a large proportion of cases may be suited to local and limited resurfacing. Cases suitable for Patello-femoral and Bi-compartmental replacements were very common, but with the patella-femoral joint's tendency to be more forgiving in terms of symptoms, meaning that indications for uni-compartmental replacement might well be much higher than the arthroscopic findings suggested. On the other hand, the presence of high levels of Grade 1 and 2 changes in other compartments seems to indicate a need for caution particularly in younger patients. This study also indicates a need for better methods of assessing local cartilage health such as enhanced MRI scanning or spectroscopy.
Inter- and intra-observer variation has been noted in the analysis of radiographic examinations with regard to experience of surgeons, and the monitors used for conducting the evaluations. The aim of this study is to evaluate inter/intra observer variation in the measurement of mechanical alignment from long-leg radiographs. 40 patients from the elective waiting list for TKA underwent long leg radiographs pre-operatively and 6 months post-operatively (total of 80 radiographs). The x-rays were analysed by 5 observers ranging in experience from medical student to head orthopaedic surgeon. Two observers re-analysed their results 6 months later to determine intraobserver correlation, and one observer re-measured the alignment on a different monitor. These measurements were all conducted blindly and none of the observers had access to the others’ results. 80 radiographs were analysed in total, 40 pre-op and 40 post-op. The mechanical alignment was analysed using Pearson's correlation (r = 0 no agreement, r = 1 perfect agreement) and revealed that experience as an orthopaedic surgeon has little effect on the measurement of mechanical alignment from long leg radiograph. The results for the different monitor analysis were also analysed using Pearson's correlation of long leg alignment. Monitor quality does seem to affect the correlation between alignment measurements when reviewing both intra and inter observer correlation on different computer monitors. Surgical experience has little impact on the measurement of alignment on long leg radiographs. Of greater concern is that monitors of different resolution can affect measurement of mechanical alignment. As there might be a range of monitors in use in different institutions, and also in outpatient clinics to surgical theatres, close attention should be paid to the implications of these results.
Short cementless femoral stems are increasingly popular as they allow for less dissection for insertion. Use of such stems with the anterior approach (AA) may be associated with considerable per-operative fracture risk. This study's primary aim was to evaluate whether patient-specific femoral- and pelvic- morphology and surgical technique, influence per-operative fracture risk. In doing so, we aimed to describe important anatomical thresholds alerting surgeons. This is a single-center, multi-surgeon retrospective, case-control matched study. Of 1145 primary THAs with a short, cementless stem inserted via the AA, 39 periprosthetic fractures (3.4%) were identified. These were matched for factors known to increase fracture risk (age, gender, BMI, side, Dorr classification, stem offset and indication for surgery) with 78 THAs that did not sustain a fracture.
Modifiable factors contributing to stiffness include alignment, implant size, implant position and rotation, and soft tissue tightness or laxity. Less modifiable factors include genetics as in predisposition to inflammation and fibrosis, aberrations in perception and experience of emotional pain, and preoperative range of motion. We reviewed 559 knees undergoing revision between 2007 and 2014, selecting out patients with a diagnosis of stiffness and greater than one-year follow-up. Stiffness was defined as greater than 15 degrees of flexion contracture or less than 75 degrees of flexion or less than 90 degrees of active motion and a chief complaint of limited motion and pain.
INTRODUCTION. The Woodpecker pneumatic broaching system facilitates femoral preparation to achieve optimal primary fixation of the stem in direct anterior hip replacement using a standard operating table. The high-frequency axial impulses of the device reduce excess bone tension, intraoperative femoral fractures and overall operating time. The Woodpecker device provides uniformity and enhanced control while broaching, optimizing cortical contact between the femur and implant and thereby maximizing prosthetic axial stability and longevity. This study aims to describe a single surgeon's experience using the Woodpecker pneumatic broaching system in 649 cases of direct anterior approach (DAA) total hip arthroplasties to determine the device's safety and efficacy. METHODOLOGY. All consecutive patients undergoing elective anterior bikini total hip arthroplasties (THA) performed by a single surgeon between July 2013 and June 2018 were included. Patients undergoing a THA with the use of the Woodpecker device through a different surgical approach, revision THA or arthroplasties for a fractured neck of femur were excluded (n=219). The pneumatic device was used for broaching the femoral canal in all cases. Pre-operative and post-operative Harris Hip Scores (HHS) and post-operative radiographs were analyzed to identify femoral fractures and femoral component positioning at 6 weeks, 6 months and 12 months post-operative. Any intra-operative or post-operative surgical complications and component survivorship until most recent follow up were recorded in the clinical notes. RESULTS. A total of 649 patients (L THA=317, R THA=328 and bilateral=2) with a mean age of 69 (range 46–91yrs) and mean BMI of 28.3 (range = 18.4–44.0) underwent a DAA THA using a Woodpecker device were included in the study. Of these patients, 521 (80%) underwent uncemented and 128 (20%) underwent cemented femoral components. The time taken to broach the femur using Woodpecker broaching this system averaged 2.8 minutes (1.4 to 7.5 minutes) in both cemented and uncemented cases. In 91% of cases the templated broach size was achieved with the remaining 9% within +/− 1 size of the planned template.
Purpose. To evaluate the radiographic long-term result of femoral revision hip arthroplasty using impacted cancellous allograft combined with cemented, collarless, polished and tapered stem. Materials and methods. Among 28 patients with impacted cancellous allograft with a cemented stem, 28 hips from 26 consecutive patients were analyzed retrospectively. The average patient age was 59 years. The follow-up period ranged 9 years 6 months to 14 years 5 months (mean, 12, 5 years). Radiographic parameters analyzed in this study included subsidence of the stem in the cement, subsidence of the cement mantle in the femur, bone remodeling of the femur, radiolucent line, and osteolysis. Results.
Background. In the late 1980's Michael Freeman conceived the idea that knee replacement would most closely replicate the natural knee joint, if the medial Tibio-Femoral articulation was configured as a “ball-in-socket”. Over the last three decades, medial rotation and medial pivot designs have proved successful in clinical use. Freeman's final iteration of the medial ball-in-socket concept was the Medial Sphere knee. We report the three-year survivorship, clinical outcomes, patient reported outcome measures (PROMs) and radiographic analysis of this implant in a multi-centre, multi-surgeon, prospective observational study. Methods. Patients awaiting total knee replacement were recruited by four centres. They had no medical contraindication to surgery, were able to provide informed consent and were available for follow-up. Primary outcome was implant survival at six months, one, two, three and five years. Secondary outcomes were patient reported outcome measures: Oxford Knee Score (OKS), Euroqol (EQ-5D), International Knee Society Score (IKSS), IKSS Functional score and Health State score, complications and radiographic outcomes.
Introduction. Trabecular Titanium is a biomaterial characterized by a regular three-dimensional hexagonal cell structure imitating trabecular bone morphology. Components are built via Electron Beam Melting technology in aone- step additive manufacturing process. This biomaterial combines the proven mechanical properties of Titanium with the elastic modulus provided by its cellular solid structure (Regis 2015 MRS Bulletin). Several in vitro studies reported promising outcomes on its osteoinductive and osteoconductive properties: Trabecular Titanium showed to significantly affect osteoblast attachment and proliferation while inhibiting osteoclastogenesis (Gastaldi 2010 J Biomed Mater Res A, Sollazzo 2011 ISRN Mater Sci); human adipose stem cells were able to adhere, proliferate and differentiate into an osteoblast-like phenotype in absence of osteogenic factors (Benazzo 2014 J Biomed Mater Res A). Furthermore, in vivo histological and histomorphometric analysis in a sheep model indicated that it provided bone in-growth in cancellous (+68%) and cortical bone (+87%) (Devine 2012 JBJS). A multicentre prospective study was performed to assess mid-term outcomes of acetabular cups in Trabecular Titanium after Total Hip Arthroplasty (THA). Methods. 89 patients (91 hips) underwent primary cementless THA. There were 46 (52%) men and 43 (48%) women, with a median (IQR) age and BMI of 67 (57–70) years and 26 (24–29) kg/m2, respectively. Diagnosis was mostly primary osteoarthritis in 80 (88%) cases. Radiographic and clinical evaluations (Harris Hip Score [HHS], SF-36) were performed preoperatively and at 7 days, 3, 6, 12, 24 and 60 months. Bone Mineral Density (BMD) was determined by dual-emission X-ray absorptiometry (DEXA) according to DeLee &Charnley 3 Regions of Interest (ROI) postoperatively at the same time-points using as baseline the measureat 1 week. Statistical analysis was carried out using Wilcoxon test. Results. Median (IQR) HHS and SF-36 improved significantly from 48 (39–61) and 49 (37–62) preoperatively to 99 (96–100) and 76 (60–85) at 60 mo. (p≤0.0001).
Background. Peri-prosthetic humerus fractures are relatively uncommon occurrences that can be difficult to manage non-operatively. Locking plate technology has enhanced the surgical management of these fractures. We describe an osteosynthesis technique utilizing a locking plate with eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with this skive screw technique from May 2011 to September 2014. Seven patients presented with postoperative type B peri-prosthetic humerus fractures. Average follow-up was 24 months.
It is a well-known fact that total knee arthroplasty is a soft tissue operation. Soft tissue balancing is the key to success in total knee arthroplasty. It is paramount importance to preserve the maximal amount of bone on both the femur and tibial side. In Indian scenario, majority of the patients present relatively late with varus or valgus deformity. Adding to this problem is poor bone quality due to osteoporosis. Our technique of Posterior cruciate ligament (PCL) retaining TKA with tibial end plate resection facilitates soft tissue balancing, preserves PCL and maximizes bone preservation on both tibial and femoral side achieving good results in minimum seven year follow up. We retrospectively analyzed seven year outcomes of 120 knees (110 patients), mean age was 65 years (range 55 to 75 years), who received contemporary cruciate-retaining prostheses with tibial end plate resection technique. The diagnosis was osteoarthritis in 96%, Rheumatoid arthritis in 2% and posttraumatic arthritis in 2% cases. There were more number of flexible varus knees as compared to flexible valgus knees. All the patients were followed up for minimum of 84 months with average follow up of 96 months. They were followed up at 3mths, 6mths, 1,3,5,7,9 and 10 years. The functional assessment was done using knee society knee and function scores.
Purpose. This studyevaluated the results of the acetabular medial wall osteotomy to reconstruct the acetabulum in dysplastic hip during total hip athroplasty. Materials and Methods. A total of 30 hips of 30 patients who underwent THA between March 1999 and October 2002 were clinically and radiogically evaluated. The average age at the time of operation was 46.5 years (range: 17 to 73 years), and the mean follow-up period was 5 years (range: 5.3 to 8.7 years). 26 cases, a cementless hemispherical acetabular cup and 4 cases, reinforced ring were inserted in the true acetabulum. Only 2 hips needed structural bone graft. Results. The average Harris hip score improved from 56.3 points preoperatively to 93.2 points at the last follow up.
Introduction. The first highly crosslinked and melted polyethylene acetabular component for use in total hip arthroplasty was implanted in 1998 and femoral heads larger than 32mm in diameter introduced 2004. The purpose of this study was to re-assemble a previous multi-center patient cohort in order to evaluate the radiographic and wear analysis of patients receiving this form of highly crosslinked polyethylene articulating against large diameter femoral heads at a minimum of 10 years follow-up. Methods. Two centers contributed patients to this ongoing clinical study. Inclusion criteria for patients was: primary THR; femoral heads greater than 32mm; minimum 10 year follow-up. 69 hips have been enrolled with an average follow-up of 11.2 years (10–15), 32 females (50%). Wear analysis was performed using the Martell Hip
Introduction. The first highly crosslinked and melted polyethylene acetabular component for use in total hip arthroplasty was implanted in 1998. Numerous publications have reported reduced wear rates and a reduction in particle induced peri-prosthetic osteolysis at short to mid-term follow-up. The purpose of this study was to re-assemble a previous multi-center patient cohort in order to evaluate the radiographic and wear analysis of patients receiving this form of highly crosslinked polyethylene articulating against 32mm femoral heads or less at a minimum of 13 years follow-up. Methods. Inclusion criteria for patients was a primary THR with femoral heads 32mm or less and a minimum 13 year follow-up. 139 hips have been enrolled with an average follow-up of 13.7 years (13–16), 80 females (57%). Wear analysis was performed using the Martell Hip
