Aims

Rotational acetabular osteotomy (RAO) is an effective joint-preserving surgical treatment for acetabular dysplasia. The purpose of this study was to investigate changes in muscle strength, gait speed, and clinical outcome in the operated hip after RAO over a one-year period using a standard protocol for rehabilitation.

Flexion contracture sometimes occurs after primary total knee arthroplasty (TKA). In most cases, flexion contracture after TKA gradually improves over time. However, some severe cases require manipulation or revision surgery.

We searched our clinical database for patients who underwent primary TKA at our institution between 2008 and 2015. By reviewing patient records, we identified three patients (one man and two women) with a severe flexion contracture 30° after primary TKA. Although all three patients gained more than 120° in flexion intraoperatively, they developed flexion contracture after discharge from our institution. We performed manipulation under anaesthesia (MUA) for all three cases several months later. The two female patients had improved range of motion (ROM) right after the manipulation. However, one of them regained flexion contracture 1 year after the MUA.

We report the details of the male patient, who had the worst flexion contracture (−60°). An 80-year-old man had right knee osteoarthritis. His history indicated only hypertension. The right knee ROM before the TKA was −20° extension and 135° flexion. His radiographs showed advanced-stage osteoarthritis. We performed cemented TKA (posterior stabiliser design). Three weeks after the operation, his right knee pain improved. The right knee ROM was −10° extension and 100° flexion just before discharge. However, he returned to our institution because of right knee pain and flexion contracture 31 months after the surgery. The flexion contracture gradually worsened without any trauma. When he returned, the right knee ROM was −60° extension and 135° flexion. Manipulation under general anaesthesia was not effective. Therefore, we performed revision TKA immediately. We excised the scar tissue of the posterior knee joint. Then, we shortened the distal femoral end by 1 cm and reduced the size of the femoral component. After the operation, the right knee ROM was improved to −10° flexion and 130° extension.

The reported prevalence of stiffness after TKA was from 1.3% to 13%. Although the deleterious effects of persistent flexion contractures > 15° is well understood, whether they resolve with time or need surgical intervention is controversial. MUA is generally the initial option for patients with flexion contractures, with the possibility of some improvement. If severe flexion contracture remains after manipulation, revision TKA, which may be considered as a useful treatment option, should be considered.

Introduction

Pelvic osteotomy such as Chiari osteotomy and rotational acetabular osteotomy (RAO) have been used successfully in patients with developmental dysplasia of the hip (DDH). However, some patients are forced to undergo total hip arthroplasty (THA) because of the progression of osteoarthritis. THA after pelvic osteotomy is thought to be more difficult because of altered anatomy of the pelvis. We compared six THAs done in dysplastic hips after previous pelvic osteotomy between 2008 and 2015 with a well-matched control group of 20 primary procedures done during the same period.

Purpose

Proximal femoral osteotomy is an attractive joint preservation procedure for osteonecrosis of the femoral head. The purpose of this study was to investigate the cause of failure of proximal femoral osteotomy in patients with osteonecrosis of the femoral head.

Permanent patellar subluxation is treated with surgeries such as proximal realignment and distal realignment, however, it is difficult to cure this condition by using any methods. We performed mobile-bearing total knee arthroplasty (TKA) in a case of severe knee osteoarthritis complicated with permanent patellar subluxation since childhood, and obtained good results without performing any additional procedures.

The patient was an 82-year-old woman with severe pain in the left knee. During the initial examination, the range of motion of the left knee joint was -10°of extension to 140°of flexion, and the Japanese Orthopaedic Association (JOA) score for knee osteoarthritis was 40 points (maximum score: 100). Preoperative radiographs showed a varus deformity in the left lower extremity with a femorotibial angle (FTA) of 188°, the axial view showed luxation of the patella.

We performed TKA using a mobile-bearing implant. Intraoperative findings revealed that the central articular surface of the distal femur had disappeared, and that the patellar articular surface was concave and dome-shaped. The lateral patellofemoral ligament was released; this procedure was identical to that performed in conventional TKA.

Postoperative radiographs showed good alignment, with an FTA of 173°. In the axial view, the patella was located in a reduced position at any angle of knee joint flexion.

The postoperative range of motion of the left knee joint was 0°of extension to 130°of flexion. The patient was able to walk without the support of a T-shaped cane.

There are many surgical treatments for permanent patellar subluxation. The appropriate treatment is selected according to the type and seriousness of the dislocation and the age of the patient.

From the findings of the present case, we believe that in a case of knee osteoarthritis complicated with permanent patellar subluxation, surgery performed using a mobile-bearing implant would eliminate the necessity of performing additional proximal realignment and distal realignment.

Background

The bearing surface is one of the important factors that affect the longevity of total hip replacement (THR). The ceramic on ceramic bearing decreases the rate of dislocation event and the amount of wear debris. We encountered cases of incomplete seating of the liner with the TriAD acetabular system.

Objective: The number of hip prostheses replacement surgeries particularly in elder people with osteoporosis, has been increasing every year; given this scenario, treatment of postoperative periprosthetic femoral fracture has become a critical problem. Osteosynthesis is generally selected as the procedure of choice for the surgical treatment of fractures, provided the stem prostheses do not show loosening. Stable fixation of periprosthetic femoral fracture is difficult in the elderly because they have osteoporotic bone and most of the intramedullary space is occupied by the metal stem implanted in the proximal femoral shaft. With a view to solving this problem, we developed a new surgical treatment for postoperative periprosthetic femoral fracture; this procedure use a trimming intramedullary nail, which we have termed “docking nail.” [Materials] The subjects were 3 patients (81, 75 and 76 years old) who had suffered a femoral shaft fracture around the femoral prosthesis after total hip replacement; in all 3 patients, there was no apparent sign of loosening of the stem prosthesis. The implanted stem was cemented in one patient and uncemented in the other two.

Method: Using information on the size and shape of the stem prosthesis as well as information from the pre-operative radiographs, we cut the docking nail till the proper length was achieved and trimmed it to suit the cutting site in order to ensure that it was compatible with tip of the stem. We then performed osteosynthesis using instruments of an ordinary supracondylar type intramedullary nail. In cases where it was difficult to reposition or where it was necessary to remove excessive cement and bone from around the tip of stem and graft a free bone in the bony defect, we exposed the fracture site as minimally as possible. The major difference between our procedure and the conventional procedure is that in our procedure, the docking nail is connected to the tip of the implanted stem to ensure proper alignment. Postoperative immobilization was not used in any of the patients except for the 81-year-old patient, for whom partial weight-bearing was allowed at 4 weeks, and full weight bearing at 12 weeks. The mean follow up period was 22 months (range, 6–48 months).

Result: Within 3 months, bony union with good alignment was achieved in all 3 patients without malunion or infection. The clinical and radiographic examinations conducted during the follow-up period showed good results.

Conclusion: The advantages of this method are that it is less invasive and simple compared to the conventional methods. Its only disadvantage is that it requires considerable, preoperative planning and minor trimming of the nail. Although this series is small, we think that this new treatment can be recommended and will be beneficial for treating periprosthetic femoral fractures without a loose stem. However, these preliminary findings need to be confirmed by further investigations.

The effect of rheumatoid arthritis on the anatomy of the cervical spine has not been clearly documented. We studied 129 female patients, 90 with rheumatoid arthritis and 39 with other pathologies (the control group). There were 21 patients in the control group with a diagnosis of cervical spondylotic myelopathy, and 18 with ossification of the posterior longitudinal ligament. All had plain lateral radiographs taken of the cervical spine as well as a reconstructed CT scan. The axial diameter of the width of the pedicle, the thickness of the lateral mass, the height of the isthmus and internal height were measured. The transverse diameter of the transverse foramen (d1) and that of the spinal canal (d2) were measured, and the ratio d1/d2 calculated.

The width of the pedicles and the thickness of the lateral masses were significantly less in patients with rheumatoid arthritis than in those with other pathologies. The area of the transverse foramina in patients with rheumatoid arthritis was significantly greater than that in the other patients. The ratio of d1 to d2 was not significantly different. A high-riding vertebral artery was noted in 33.9% of the patients with rheumatoid arthritis and in 7.7% of those with other pathologies. This difference was statistically significant. In the rheumatoid group there was a significant correlation between isthmus height and vertical subluxation and between internal height and vertical subluxation.