Introduction. Osteonecrosis of the femoral head occurs in young patients. The preservation of the hip joint is vitally important, because hip arthroplasty does not guarantee satisfactory long-term results in young and active patients.
Introduction: Osteonecrosis of the femoral head occurs in young patients. The preservation of the hip joint is vitally important because hip replacement arthroplasty is associated with high rates of failure in young and active patients.
Introduction.
Several studies have reported the assessment of the femoral head coverage on plane radiograph and CT data in supine position, though young patients with the dysplastic hip often have symptoms during activities such as standing, walking, and running. On the other hand, some investigators have used a method of CT which allows standardization of the femoral head coverage against an anterior pelvic plane based on the anterior superior iliac spines and the pubic tubercle. We believe both the weight-bearing position and the standardized position to be more relevant for diagnosis and preoperative surgical assessment. So, we show the femoral head coverage in standardized position using 3D-CT method and in weight-bearing position using the plane radiograph and the three-dimensional lower extremity alignment assessment system before and after
Transtrochanteric curved varus osteotomy is one of the effective joint-preserving operations for osteonecrosis (ON) of the femoral head. We correlated various factors with the radiological outcome of this procedure. We reviewed 74 hips in 63 patients who had a minimum follow-up of 5 years after transtrochanteric curved varus osteotomy for the treatment of ON. There were 28 men and 35 women who had a mean age of 33 years (range, 15 to 68 years) at the time of surgery. Clinical assessment was made based on the Harris hip score (HHS). Radiographically, we investigated various factors; affected lesion, stage and type (localization of the necrotic lesion) of ON, varus degree, post-operative intact ratio, progression of collapse, and joint-space narrowing. On the basis of postoperative radiographs, the hips were divided into 2 groups (Group I: either the progression of collapse or joint-space narrowing, Group II: neither progression of collapse or joint-space narrowing). The related factors with radiological outcome were analyzed by using multivariate analysis (Stepwise discriminant analysis).Introduction
Methods
In total hip arthroplasty (THA), the importance of preserving muscle is widely recognized. It is important to preserve the short external rotator muscles because they contribute to joint stability and prevent postoperative dislocation. However, despite careful capsular release and femoral rasping, damage to the short external rotator muscles may occur. The Optymis Shot Stem preserves more bone and surrounding tissue than does a traditional primary stem. We investigated the usefulness of the stem in terms of the extent of preservation of the tendon attachment on the greater trochanter. In this study, we enrolled 31 consecutive patients (39 hips; 6 males, 25 females) who underwent THA. Simultaneous bilateral THA was performed in 8 patients. The patients’ mean age was 56.1 years. Diagnoses included developmental dysplasia in 35 hips (Crowe group 1: 31 hips, group 2: 4 hips), and sequel of Perthes disease in 4 hips. All THAs were performed via the direct anterior approach without traction tables. The femoral procedure was performed with the hip hyperextended, and posterior capsular release was performed if the femoral procedure became technically difficult. We compared the following among patients: the operative time, intraoperative blood loss, length of hospital stay, rate of posterior capsular release, postoperative radiographic findings, WOMAC score before and after surgery, and any complications.Background
Method
Rotational alignment is important for the long-term success and good functional outcome of total knee arthroplasty (TKA). While the surgical transepicondylar axis (sTEA) is the generally accepted landmark on the distal femur, a precise and easily identifiable anatomical landmark on the tibia has yet to be established. Our aim was to compare five axes on the proximal tibia in normal and osteoarthritic (OA) knees to determine the best landmark for determining rotational alignment during TKA. One hundred twenty patients with OA knees and 30 without knee OA were recruited for the study. Computed tomography (CT) images were obtained and converted through multiplanar reconstruction so the angles between the sTEA and the axes of the proximal tibia could be measured. Five AP axes were chosen: the line connecting the center of the posterior cruciate ligament(PCL) and the medial border of the patellar tendon at the cutting level of the tibia (PCL-PT), the line from the PCL to the medial border of the tibial tuberosity (PCL-TT1), the line from the PCL to the border of the medial third of the tibia (PCL-TT2), the line from the PCL to the apex of the tibia (PCL-TT3), and the AP axis of the tibial prosthesis along with the anterior cortex of the proximal tibia (anterior tibial curved cortex, ATCC).Background
Methods
This study has evaluated the results of plantar fascia release through a plantar incision. Materials and Methods A 4cm curved incision on the plantar surface of the heel, was used to release the plantar fascia in children. The incision allowed complete visualisation of the entire origin of the plantar fascia. The procedure was performed as part of treatment for pes cavus or resistant clubfoot. There were 27 feet in 17 patients. The ages ranged from three to sixteen years. The minimum follow up was six months after surgery. The wound was assessed for pain, numbness, and problem scarring as well as heel pad symptoms. A modified functional score was used. (American Orthopaedic Foot and Ankle Society Ankle/ Hindfoot Scale)
All wounds healed within two weeks. The scar was clearly visible in seven patients, and visible only on close inspection in 10 patients. None had heel tenderness, hypersensitivity or numbness and there were no signs of pad atrophy. Fifteen patients had no pain, while two had minimal pain score of two on the visual analogue scale. The functional score was more than 90. All the patients were satisfied with the cosmetic appearance of the scar.
The plantar incision is safe, effective and provides excellent visualisation of the plantar fascia for complete release with minimal morbidity.
Previous in vivo fluoroscopic studies have documented that subjects having a PS TKA experience a more posterior condylar contact position at full extension, a high incidence of reverse axial rotation and mid flexion instability. More recently, a PS TKA was designed with a Gradually Reducing Radius (Gradius) curved condylar geometry to offer patients greater mid flexion stability while reducing the incidence of reverse axial rotation and maintaining posterior condylar rollback. Therefore, the objective of this study was to assess the in vivo kinematics for subjects implanted with a Gradius curved condylar geometry to determine if these subjects experience an advantage over previously designed TKA. In vivo kinematics for 30 clinically successful patients all having a Gradius designed PS fixed bearing TKA with a symmetric tibia were assessed using mobile fluoroscopy. All of the subjects were scored to be clinically successful. In vivo kinematics were determined using a 3D-2D registration during three weight-bearing activities: deep-knee-bend (DKB), gait, and ramp down (RD). Flexion measurements were recorded using a digital goniometer while ground reaction forces were collected using a force plate as well. The subjects then assessed for range of motion, condyle translation and axial rotation and ground reaction forces.Background
Methods
Dysfunction of acetabular dysplasia is a complex problem which includes excessive stresses on the cartilage, dynamic instability and muscular fatigue eventually leading to degenerative osteoarthrosis if left uncorrected. The most physiologic solution for a young adult with this problem is to redirect the acetabulum into a normal position. Rotational acetabular osteotomy developed in Japan aims to transfer the position of the acetabulum en bloc by circumacetabular osteotomy using the curved osteotome. Because of same curvatures of osteotomy surfaces, this osteotomy produces the greater contact among bony surfaces, stable fixation and early solid union. However, this osteotomy requires abductors splitting, leaves acetabular teardrop in its original position, and has the risk of postoperative avascular necrosis of the transferred acetabulum. Bernese periacetabular osteotomy developed by Ganz also provides good coverage of the femoral head by redirecting the acetabulum. This osteotomy preserves the vascular supply of the transferred acetabulum and allows medialization of the hip joint. On the other hand, it poses the risk of considerable morbidities due to extensive exposure, and major and/or moderate complications, such as bleeding complications, reflex sympathetic dystrophy, motor nerve palsy and heterotopic ossification are reported. In order to reduce these disadvantages, we developed a curved periacetabular osteotomy (CPO), for the treatment of hip dysplasias and have performed CPO on more than 400 hips since 1995. Both an imaging of the margin of the hip presumed to be on the quadrilateral surface and a sophisticated operative technique are needed for CPO. However, the extent of soft tissue dissection is limited with abductors left intact, and the osteotomy surfaces retain their original curvature. There have been no major or moderate complications. These advantages seem to reduce postoperative complications and promote early postoperative rehabilitation. Recently, we compared surgical invasion and complications in patients aged over 40 years who underwent CPO (n=30) or total hip arthroplasty (THA; n=30) using postoperative levels of interleukin (IL)-6 and C-reactive protein (CRP). The mean IL-6 levels were 55.4 pg/ml and 89.5 in the CPO and THA groups, respectively (p<
0.001). The mean CRP levels were 4.5 mg/dl and 5.8 in the CPO and THA groups, respectively (p<
0.01). No major or moderate complications were encountered in either group. CPO appears to be a less invasive and safer surgical procedure for middle-aged patients than THA.
We originally performed metal-on-metal hip resurfacing using a Townley designed Vitallium Total Articular Replacement Arthroplasty (TARA) curved stemmed prosthesis. Neither the acetabular or femoral components were cemented or had porous coating. The bearing surfaces were consistently polar bearing. The surgical objectives were to preserve bone stock, maintain normal anatomy and mechanics of the hip joint and to approximate the normal stress transmission to the supporting femoral bone. The functional objectives were better sports participation, less thigh pain and limp, less perception of a leg length difference and a greater perception of a normal hip. Metal-on-metal was selected to conserve acetabular bone and avoid polyethylene associated osteolysis. Relatively few cases were performed until the Conserve Plus and later the Birmingham Hip Resurfacing systems became available. We examined the results of metal-on-metal hip resurfacing in patient with at least 10 years of follow-up and an age less than 50 at the time of surgery. We did not have access to the Birmingham Prosthesis until 2006. We performed 101 TARA procedures and 397 Conserve Plus procedures for 357 patients. For the combined series the mean age was 43 and 62% of patients were male. 34 patients had a conventional total hip replacement on the contralateral side. We used both the anterolateral and posterior approaches. All acetabular components were placed without cement and all the Conserve Plus Femoral Components were cemented.BACKGROUND
METHODS
Architectural changes occurring in the proximal femur after THA continues to be a problem. Stress shielding occurs regardless of fixation method. The resultant bone loss can lead to implant loosening and breakage of the implant. A new novel tissue sparing neck-stabilised stem has been designed to address these concerns. Over 1,200 stems have been implanted since April 2010 and 2012. Patient profile showed two-thirds being female with an age range between 17 to early 90s. 90% were treated for OA. This stem has been used in all Dorr bone classification (A, B, & C). Two surgical approaches were utilised (single anterior incision and standard posterior incision). All were used with a variety of cementless acetabular components and a variety of bearing surfaces (CoC, CoP, MoM, MoP). Complications were track by surgeon Members of the Tissue Sparing Study Group of the Joint Implant Surgery and Research Foundation. Complications include first year of limited clinical release. No surgeon was permitted usage without specific cadaver / surgical training. No head diameters below 32 mm were used.Introduction
Methods
A transtrochanteric curved varus osteotomy (TCVO) is an excellent joint preserving surgical modality if the necrotic lesion can be moved to the non-weight bearing area as assessed by maximum abduction antero-posterior radiographs. The purpose of this article was to elucidate whether TCVO can reduce the volume of osteonecrosis after an index osteotomy as assessed by magnetic resonance imaging (MRI). Twenty patients (twenty hips) with non-traumatic osteonecrosis of the femoral head were followed for more than three years after an index operation and MRI examinations both before and at two years after surgery were retrospectively investigated. The average age at the time of operation was 40 years (range, 18 to 60 years), consisting of 13 men (13 hips) and 7 women (7 hips). The etiology and/or associated risk factors was steroid-associated osteonecrosis in 11 hips, alcohol associated in 7 hips, and idiopathic in 2. According to the classification of the Japanese Investigation Committee there was Type B in one hip, Type C-1 in 17 hips, and Type C-2 in 2 hips. Eight hips were in Stage 2, 10 in Stage 3A, and 2 in Stage 3B. Average follow-up was 4 years (range, 3 to 5 years).Introduction
Methods
Cutaneous nerve injury occurs commonly with knee arthroplasty, causing altered skin sensation and, infrequently, the formation of painful neuromas. The infrapatellar branch of the saphenous nerve is the structure most commonly damaged. The aim of this study was to establish the frequency of cutaneous nerve injury with three incisions commonly used in knee arthroplasty. Ten knees from five cadavers were studied. Skin strips representing three different incisions, were excised and examined for number and thickness of nerves. There were more nerve endings found in the dermis layer than the subcutaneous fatty layer. There was no significant difference in the total number of nerves when the 3 studied incisions were compared. The lower part of all incisions was found to have more thick and a higher number of nerves than the upper part (P=0.005). Careful incision placement is required to avoid damage to cutaneous nerves during knee arthroplasty. This may be of long-term advantage to patients especially those for whom kneeling is important.
Our centre has used a specially designed custom-made endoprostheses with curved stems to reconstruct femoral defects in patients with residual short proximal femur after excision of primary bone sarcoma over the last 18 years. Two designs of endoprostheses with curved intramedullary stems were used: the rhinohorn stem type and the bifid stem type. We report the safety, survival and functional outcome of this form of reconstruction. Twenty six patients who had these special endoprosthesis reconstruction were studied. The median age was 16 years (range 7 to 60 years). Prostheses with rhino horn stems were used in 15 patients and bifid-stem in 1 1 patients. Twenty patients had the prostheses inserted as a primary procedure after excision of primary bone sarcoma, and in six patients the prostheses were inserted after revision surgery of failed distal femur endoprostheses. Seventeen patients (65%) were alive and free of disease at a median follow-up of 98 months (12 to 203 months) and nine patients had died of metastatic disease. Local recurrence developed in two patients (1 0%) out of the 20 patients. Surgical complications occurred in five patients (191/o). Deep infections occurred in two patients (8%) requiring revision surgery in one patient. Prosthetic failure, occurred in nine patients (35%). The cumulative survival of prostheses was 69% at five years and 43% at 10 years. Musculoskeletal Tumour Society mean functional score was 83% (53% to 97%). In conclusion, preservation of a short segment of the proximal femur and the use of endoprostheses with curved stems for reconstruction of the femur is technically possible. There is an increased risk of fracture of the prostheses decreasing the survival rate. Functional outcome of patients with this form of reconstruction is not significantly different from the functional outcome of patients who have proximal femur or total femur endoprosthetic reconstruction. This operation is particularly desirable in skeletally immature patients and allows normal development of the acetabulum.
Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle. We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire. Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group. Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated.
Tibiofemoral motions are fundamental to the function (strength, stability, ROM) and longevity of total knee replacements (TKR). Although a wide range of TKR kinematics have been reported, few studies have reported kinematics of a single TKR design utilising a variety of tibial articular surfaces. We hypothesised that increased articular constraint, from four different tibial inserts, would result in reduced tibio-femoral translations during dynamic activities. We tested 22 knees with excellent early clinical outcomes after primary TKR. All knees received the same PCL retaining arthroplasty; with six curved tibial inserts, six flat inserts, six laterally pivoting inserts and four translating/rotating mobile bearing inserts. Fluoroscopic images of knees were acquired during gait, stair, and deep flexion activities. CAD model based shape matching was performed to determine 3D knee kinematics. There were significant differences in medial condy-lar translations for all activities, none for the lateral condyle. The medial condyle in knees with flat and mobile bearing inserts translated more anterior with flexion than knees with curved or pivoting inserts. Medial condyle translations were greater in mobile bearing knees than knees with flat inserts. Our results indicate that condylar motions in TKR’s during dynamic activities can be modulated in a reasonably predictable manner by varying the degree of tibio-femoral constraint. Furthermore, the results show that significant control of translation can be achieved through asymmetric tibial insert conformity. These findings suggest it is possible to achieve a particular pattern of tibio-femoral translations and rotations in vivo through careful selection or design of the articular geometry.
