Aims

Accurate estimations of the risk of fracture due to metastatic bone disease in the femur is essential in order to avoid both under-treatment and over-treatment of patients with an impending pathological fracture. The purpose of the current retrospective in vivo study was to use CT-based finite element analyses (CTFEA) to identify a clear quantitative differentiating factor between patients who are at imminent risk of fracturing their femur and those who are not, and to identify the exact location of maximal weakness where the fracture is most likely to occur.

In Displaced Intracapsular Hip Fractures (ICHF) in young active patients, preservation of the femoral head and its blood supply are of high importance and urgent surgical treatment with anatomic reduction and internal fixation is the preferred intervention. Due to the strong varus displacement shear forces exerted across the hip, there are relatively high complication rates after fixation. There is no consensus regarding the optimal fixation device or technique. This retrospective study compared closed reduction internal fixation method using cannulated cancellous screw (CCS) with the Targon Femoral Neck (TFN) hip fixed angle screw. Data regarding, gender, operational data, duration of surgery, complications, NAS (Numerical Analogue Scale) pain score, Modified Harris Hip Score (MHHS) and SF-12 scores were retrieved for patients younger than 65 with displaced ICHF. Eighty-two patients were included in the study, 30 patients treated with CCS were compared to 52 patients treated with TFN. Fracture configuration (Garden and Pauwel classifications), mean time to surgery and complication rate did not differ significantly. Operative time did differ significantly between groups (CCS 56 minutes, TFN 92 minutes, p<0.001). At final follow-up the CCS group reported less pain (NAS 2.3 vs 3.5, p< 0.049) and better Mental Health Composite score of SF-12 (p=0.017) compared to the TFN group. Complication rates for the treatment of displaced ICHF with TFN and CCS showed no significant differences; however, the functional outcomes, as presented by the NAS and Mental Health Composite score of SF-12, showed superiority for CCS treatment. As this fixation method is related to reduce costs, we suggest CCS for the treatment of displaced ICHF in the young population.

Introduction:

Non-hinged constrained condylar components (CCK) may be used for primary TKA in presence of severe deformity, fixed contractures and ligamentous laxity. Several authors have recommended use of stem extensions to accompany CCK type of components. However, use of stem extensions in primary TKA, not only invades the medullary canal, but may also be associated with increased surgical time, implant cost, and thigh or leg pain. The purpose of this study was to assess the short-term outcomes of primary CCK knees without stem extensions and to compare this to a control group of standard posterior stabilized (PS) knees, otherwise using the same implant design.

Background:

Dual mobility components in total hip arthroplasty have been successfully in use in Europe for greater than 25 years. However, these implants have only recently obtained FDA approval and acceptance among North American arthroplasty surgeons. Both decreased dislocation rate and decreased wear rates have been proposed benefits of dual mobility components. These components have been used for primary total hip arthroplasty in patients at high risk for dislocation, total hip arthroplasty in the setting of femoral neck fracture, revision for hip instability, and revision for large metal-on-metal (MoM) hip articulation. The literature for the North American experience is lacking.

Background

Revision surgery for failed metal-on-metal (MOM) total hip arthroplasty (THA) or hip resurfacing (HR) has been a challenge. Previous studies have reported high failure and complication rates, including dislocation, infection, aseptic loosening and lower patient satisfaction. Options for revision depend on the integrity and stability of the femoral and acetabular components. When both components fail, full revision is required; however, when the acetabular component remains well fixed and oriented, only the isolated femoral component revision can be performed. Dual mobility components can be utilized to match the size to the inner diameter of the metal cup. With the dual mobility implant, the morbidity and complications associated with cup revision are avoided while maintaining a natural femoral head size and potentially increasing range of motion and stability postoperatively compared to standard THA.

Medial transfer of the tibial Tuberosity remains the treatment of choice for skeletally mature patients with patellar malalignment (recurrent dislocation, subluxation with or without patellar tilt). As many patients with patellar malalignment have patellar articular cartilage lesion or patella alta, anteriorisation and distalisation of the tibial tuberosity is advised.

Material and Methods: Tibial tuberosity transfer was performed in our center on 80 knees in 66 patients (40 females, 26 males) during the past 13 years (mean age 23 range 15 – 52). One surgeon supervised all the operations. The average follows-up was 6.2 years (one to thirteen years). All patients were examined clinically for the purpose of this study. The Lisholm and Karlsson scoring system were used to evaluate the results. Radiographs of both knees were also taken. Fifteen knees had no dislocation of the patella prior to the operation, seventeen knees had 1 to 10 eleven knees had 10 to 50, ten knees 50 to 100, and twenty-seven knees had more than hundred dislocations of the patella prior to surgery. Ten of these knees had daily dislocations of the patella.

All operations were done either by selective epidural anesthesia (only sensory and not motor) or general anesthesia without muscle relaxant using quadriceps muscle stimulation. The mean tibial tuberosity medialisation, anteriorisation and distalisation was 1.4 cm (0–2.5 cm) 0.4cm (0–1.1cm) and 0.87cm (0–1.2cm) respectively.

Results: When interviewed by an independent examiner 87% of the patients reported improvement and only 4.3% (3 patients) reported worsening of their condition after the operation.

84% of the patients stated they would have the operation again. All patients had full active range of motion on both knees without extension lag.

At the final evaluation visit the Lisholm and Karlsson scores were good and excellent in 72% and 72.5%, 18.8% and 23.5% had fair results and only 8.7% and 4.4% had poor results respectively. The poor results correlated well with the degree of the patella cartilage damage found during surgery, poor selection of patients and extreme ligamentous laxity. There were two complications: one non-union of the tibial tuberosity treated successfully with bone grafting and one non displaced fracture bellow the osteotomy, treated conservatively. Both had excellent results.

Conclusion: We conclude that distal patella re-alignment done by tibial tuberosity transfer is a reliable technique for the treatment of patello femoral pain secondary to mal-alignment.

TOH was first described by Curtis and Kinkade in 1959, in women in the 3rd trimester of pregnancy. Later the disease was described in middle-aged males (4th-6th decade). Very rare occurrence was described in children and in females not connected to pregnancy.

Thirty-six patients with sudden hip pain with normal radiographs but increase uptake on bone scan and bone marrow edema in the head and neck on MRI were investigated by the senior author. Two patients (age 16 and 18) had Osteoid osteoma in the neck and two elderly patients (72 female and 75 male) had stress fracture in the neck were excluded from the study. The rest, 32 patients (28 males and 4 females – not connected to pregnancy) are the study group. Three male patients had bilateral involvement 1 to 3 years apart. The initial symptoms were pain, limping with minimal or no restriction in range of motion. All patients had plain radiographs, bone scan and MRI. Bone scan was positive in all and MRI showed bone edema in the neck and head in all. All patients were initially treated by non-weight bearing for six weeks followed by additional MRI every 6 weeks till the bone edema and symptoms subsided. In all patients the third MRI showed improvement in bone edema and were allowed to weight bear. None of the patients showed progression from TOH to AVN even in 7 patients with Crescent lines on T-1 images.

The mean F.U. was 51 months (4 to 131 months). Five patients still complained of mild pain in the affected hip, all with the exception of one had full range of motion. None of the patients had limping. All the plain radiographs were normal, with no signs of AVN or deformity of the head. In contrast the Dexa measurements of all patients showed decreased bone density in the affected hip compared to the other.

Conclusion: TOH is a benign disease. Even when Crescent lines are present all patients heal successfully without signs of AVN. Excellent correlation was found between subsidence of pain and improvement of bone edema on MRI. AVN and TOH are two distinct entities and therefore the treatment of TOH should always be conservative.