The purpose of this study was to identify factors that predict implant cut-out after cephalomedullary nailing of intertrochanteric and subtrochanteric hip fractures, and to test the significance of calcar referenced tip-apex distance (CalTAD) as a predictor for cut-out. We retrospectively reviewed 170 consecutive fractures that had undergone cephalomedullary nailing. Of these, 77 met the inclusion criteria of a non-pathological fracture with a minimum of 80 days radiological follow-up (mean 408 days; 81 days to 4.9 years). The overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex distance (TAD) (p <  0.001), CalTAD (p = 0.001), cervical angle difference (p = 0.004), and lag screw placement in the anteroposterior (AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507), fracture type (AO classification) (p = 0.381), Singh Osteoporosis Index (p = 0.575), lag screw placement in the lateral view (p = 0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575). In the multivariate analysis, CalTAD was the only significant measurement (p = 0.001). CalTAD had almost perfect inter-observer reliability (interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD is a predictor of cut-out. The finding of CalTAD as the only significant parameter in the multivariate analysis, along with the univariate significance of Parker’s ratio index in the AP view, suggest that inferior placement of the lag screw is preferable to reduce the rate of cut-out. Cite this article: Bone Joint J 2014; 96-B:1029–34

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed. Cite this article: Bone Joint J 2014;96-B:1198–1201

Aims

Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures.

Aims

The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes.

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening.

These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.

Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies.

Cite this article: Bone Joint J 2013;95-B, Supple A:7–10.

We undertook a multicentre, prospective study of a series of 112 unstable trochanteric fractures in order to evaluate if internal fixation with a sliding screw device combined with augmentation using a calcium phosphate degradable cement (Norian SRS) could improve the clinical, functional and radiological outcome when compared with fractures treated with a sliding screw device alone. Pain, activities of daily living, health status (SF-36), the strength of the hip abductor muscles and radiological outcome were analysed.

Six weeks after surgery, the patients in the augmented group had significantly lower global and functional pain scores (p < 0.003), less pain after walking 50 feet (p < 0.01), and a better return to the activities of daily living (p < 0.05). At follow-up at six weeks and six months, those in the augmented group showed a significant improvement compared with the control group in the SF-36 score. No other significant differences were found between the groups. We conclude that augmentation with calcium phosphate cement in unstable trochanteric fractures provides a modest reduction in pain and a slight improvement in the quality of life during the course of healing when compared with conventional fixation with a sliding screw device alone.

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.

Cite this article: Bone Joint J 2013;95-B, Supple A:11–16.

The dysplasia cup, which was devised as an adjunct to the Birmingham Hip Resurfacing system, has a hydroxyapatite-coated porous surface and two supplementary neutralisation screws to provide stable primary fixation, permit early weight-bearing, and allow incorporation of morcellised autograft without the need for structural bone grafting.

A total of 110 consecutive dysplasia resurfacing arthroplasties in 103 patients (55 men and 48 women) performed between 1997 and 2000 was reviewed with a minimum follow-up of six years. The mean age at operation was 47.2 years (21 to 62) and 104 hips (94%) were Crowe grade II or III.

During the mean follow-up of 7.8 years (6 to 9.6), three hips (2.7%) were converted to a total hip replacement at a mean of 3.9 years (2 months to 8.1 years), giving a cumulative survival of 95.2% at nine years (95% confidence interval 89 to 100). The revisions were due to a fracture of the femoral neck, a collapse of the femoral head and a deep infection. There was no aseptic loosening or osteolysis of the acetabular component associated with either of the revisions performed for failure of the femoral component. No patient is awaiting a revision.

The median Oxford hip score in 98 patients with surviving hips at the final review was 13 and the 10th and the 90th percentiles were 12 and 23, respectively.

Many tumors metastasise to bone, therefore, pathologic fracture and impending pathologic fractures are common reasons for orthopedic consultation. Having effective treatment strategies is important to avoid complications, and relieve pain and preserve function. Thorough pre-operative evaluation is recommended for medical optimization and to ensure that the lesion is in fact a metastasis and not a primary bone malignancy. For impending fractures, various scoring systems have been proposed to determine the risk of fracture, and therefore the need for prophylactic stabilisation. Lower score lesions can often be treated with radiation, while more problematic lesions may require internal fixation. Intramedullary fixation is generally preferred due to favorable biomechanics. Arthroplasty may be required for lesions with massive bony destruction where internal fixation attempts are likely to fail. Radiation may also be useful postoperatively to minimise construct failure due to tumor progression.

Intertrochanteric osteotomy may postpone the need for total hip replacement (THR). In young patients with an acquired deformity of the femoral head and secondary osteoarthritis, a valgus intertrochanteric osteotomy may allow better congruency but the acetabular cover may become insufficient because of subluxation of the femoral head. In patients with a spherical femoral head and acetabular dysplasia, cover can still remain insufficient after varus displacement osteotomy. We present the long-term results of intertrochanteric osteotomy combined with an acetabular shelfplasty in both these circumstances.

Sixteen hips (15 patients) with a deformed femoral head, and ten (seven patients) with a spherical femoral head, underwent an intertrochanteric osteotomy and acetabular shelfplasty. The mean age at the time of surgery was 30 and 37 years and the mean final follow-up was 15 and 19 years, respectively. Six patients in the deformed group, but only one in the spherical group, had required a THR by the time of their final follow-up. In both groups, those who had not undergone a THR had a good result.

Acetabular shelfplasty is an excellent addition to an intertrochanteric osteotomy and gives full cover of the femoral head in patients with a deformity of the head and secondary osteoarthritis.

We biomechanically investigated whether the standard dynamic hip screw (DHS) or the DHS blade achieves better fixation in bone with regard to resistance to pushout, pullout and torsional stability. The experiments were undertaken in an artificial bone substrate in the form of polyurethane foam blocks with predefined mechanical properties. Pushout tests were also repeated in cadaveric femoral heads. The results showed that the DHS blade outperformed the DHS with regard to the two most important characteristics of implant fixation, namely resistance to pushout and rotational stability.

We concluded that the DHS blade was the superior implant in this study.

Transtrochanteric curved varus osteotomy was designed to avoid some of the disadvantages of varus wedge osteotomy, such as post-operative leg-length discrepancy. In this retrospective study we investigated the leg-length discrepancy and clinical outcome after transtrochanteric curved varus osteotomy undertaken in patients with osteonecrosis of the femoral head. Between January 1993 and March 2004, this osteotomy was performed in 42 hips of 36 patients with osteonecrosis of the femoral head. There were 15 males and 21 females with a mean age at surgery of 34 years (15 to 68). The mean follow-up was 5.9 years (2.0 to 12.5). The mean pre-operative Harris hip score was 64.0 (43 to 85) points, which improved to a mean of 88.7 (58 to 100) points at final follow-up. The mean varus angulation post-operatively was 25° (12° to 38°) and the post-operative mean leg-length discrepancy was 13 mm (4 to 25). The post-operative leg-length discrepancy showed a strong correlation with varus angulation (Pearson’s correlation coefficient; r = 0.9530, p < 0.0001), which may be useful for predicting the leg-length discrepancy which can occur even after transtrochanteric curved varus osteotomy.

We have studied the placement of three screws within the femoral head and the degree of angulation of the screws in 395 patients with displaced intracapsular fracture of the hip to see if either was related to the risk of failure of the fracture to unite. No relationship between nonunion of the fracture was found regarding the position of the screws on the anteroposterior radiograph. However, we found that a reduced spread of the screws on the lateral view was associated with an increased risk of nonunion of the fracture.