Dislocation is a serious complication to be avoided in total hip arthroplasty (THA) and its incidence risk increases in revision surgery. Combined anteversion (CA) of the cup and stem is a concept for appropriate implant positioning; however, the effect of functional changes in femoral rotation has not been well investigated. The aim of this study was to investigate whether functional CA, considering femoral rotation, is associated with dislocation in patients undergoing revision THA.

Seventy-three patients who underwent revision THA and had at least one year of follow-up with pre- and postoperative supine CT imaging were included. Cup and stem were placed with a target combined angle of 37.3° using Widmer's formula. Anatomical and functional CA was calculated postoperatively using the following formula: Anatomical CA: cup anteversion + 0.7 × anatomical stem anteversion; Functional CA: cup anteversion + 0.7 × (anatomical stem anteversion + femoral rotation). Patient demographics, cup and stem angles, CA and their relationship to dislocation were statistically evaluated.

Dislocation was observed in 12 patients. In these dislocated cases, there were no significant differences in cup angle, stem angle and anatomical CA compared to non-dislocated cases. However, dislocated cases showed significantly higher values of functional CA [52.7 ± 17.5° (range, 5.9–69.3) vs. 36.0 ± 12.5° (range, 8.6–68.8), p=0.009] and significant deviation from identical CA [17.3 ± 9.6° (range, 2.8–32) vs. 7.5 ± 7.1° (range, 0.1–28.7), p=0.010].

Functional CA considering femoral rotation was associated with dislocation in revision THA patients. This finding suggests that consideration of femoral rotation may be necessary for implant positioning in revision THA.

Aims

This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

SL-PLUS MIA stem (Smith & Nephew Orthopaedics AG) is a modified implant of Zweymuller type SL-PLUS standard stem (Smith & Nephew Orthopaedics AG). We constructed finite element (FE) models and analysed equivalent stresses in the femur. In addition, we measured bone mineral density (BMD) in the femur by dual-energy X-ray absorptiometry (DEXA) after THA. The purpose of this study was to investigate the equivalent stress and to compare the results of the FE analyses with changes in BMD after THA. Twenty-one patients (18 women and 3 men) who underwent primary cementless THA with SL-PLUS MIA or SL-PLUS formed the basis of this study. Eleven patients received SL-PLUS MIA and ten patients received SL-PLUS. Zones were defined according to Gruen's system (zones 1∼7). Computed-tomography (CT) images of the femur were taken before and at 1 week after THA. FE models of the femur and prosthesis were obtained from CT data by Mechanical Finder (Research Center of Computational Mechanics Inc., Tokyo, Japan), software that creates FE models showing individual bone shape and density distribution. Equivalent stresses were analysed in zones 1 to 7 and compared to the DEXA data. FE studies revealed that there was no significant difference in equivalent stress between SL-PLUS MIA and SL-PLUS. BMD was maintained after THA in zones 3, 4, and 5, whereas BMD decreased in zones 2, 6, and 7. In zone 1, BMD decreased in SL-PLUS MIA stem group by 14%, while BMD was maintained in SL-PLUS standard stem.

The pathology of the posterior acetabular legion in femoroacetabular impingement (FAI) syndrome, so called “contre-coup region”, is still unclear. ¹⁸F-fluoride positron emission tomography (PET) is a functional imaging modality, which reflects the osteoblast activity. Recent technological advances in PET combined with computed tomography (CT) imaging allowed us to obtain detailed 3-dimensional (3D) morphological information. We evaluated the abnormal uptake of ¹⁸F-fluoride PET/CT on posterior acetabular lesion in FAI syndrome cases. We enrolled forty-one hips from 41 patients who were diagnosed as FAI syndrome and were performed ¹⁸F-fluoride PET/CT between October 2014 and October 2016. In each hip, the maximum standardized uptake value (SUV_max) on the posterior acetabular was measured. The cases were divided into 4 groups; cam-type (11 cases), pincer-type (7), combined-type (11), dysplastic developmental hip (DDH) with cam morphology (12). The average SUV_max of the pincer-type was significantly smaller than that of the other 3 groups (p < .05). The percentage of the cases with SUV_max ≥ 6 was 81.8% in cam-type, 28.6% in pincer-type, 90.9% in combined-type, 91.7% in DDH with cam morphology. Furthermore, the average degree of α angle of the cases of SUV_max ≥ 6 was significantly higher than that of the cases of SUV_max < 6 (p = .005). Although actual biomechanical mechanism in contre-coup region is still controversial, this result indicated that the cam morphology related to the posterior acetabular lesion with accelerated bone metabolism.

In this study, we evaluated the labrum tear using radial sequence 3D Multiple Echo Recombined Gradient Echo (MERGE) MRI without arthrography based on modified Czerny's classification, comparing with actual arthroscopic findings. A total of 61 hips including 27 hips of femoroacetabular impingement (FAI), 19 hips of borderline development dysplasia of the hip (BDDH) and 15 hips of early stage osteoarthritis (OA) were enrolled this retrospective study. MRI findings evaluated in each three regions of interest; anterior region, anterolateral region, and lateral region. The cases with severe degeneration that is not concordant with any original Czerny's classification is defined as stage4. We compared MRI findings with arthroscopic findings and calculated the sensitivity, specificity, and likelihood ratio in terms of the existence of labrum tear. MRI findings revealed labrum tear more frequently in anterolateral than lateral (p<0.001). Especially in FAI group, labrum tear was more frequently observed by MRI in anterolateral than lateral (p=0.006). In comparison with MRI findings and arthroscopic findings, the sensitivity was 97%, specificity was 79% and likelihood ratio was 4.59 as average of all regions in terms of the existence of labrum tear. In each region, sensitivity and specificity was 97% and 50% in anterior, 97% and 100% specificity in anterolateral, 94% and 81% in lateral, respectively. Thus, MERGE MRI revealed excellent sensitivity and specificity for diagnosis of labrum tear, especially in anterolateral region. The cases with severely degenerated labrum were classified as newly defined stage 4, which was recognized frequently in OA cases.

Infection is one of the most serious complications of orthopedic surgery, particularly in implant-related procedures. Minimum inhibitory concentration (MIC) for identified bacteria is an important factor for successful antibiotic treatment. We investigated the MIC of antibiotics in Staphylococcus species from orthopedic infections, comparing with isolates from respiratory medicine. Staphylococcus species isolated in our laboratory from January 2013 to July 2016 were retrospectively reviewed. The MIC of vancomycin (VCM), arbekacin (ABK), teicoplanin (TEIC), linezolid (LZD), and rifampicin (RFP) was reviewed. Differences in the MIC of each antibiotic in orthopedic and respiratory samples were determined. A total of 259 isolates were evaluated (89 orthopedic, 170 respiratory). Staphylococcus aureus was the most commonly identified species (58%). In comparison with orthopedic samples, the number of isolates with a VCM MIC <0.5 μg/ml in methicillin sensitive staphylococcus aureus (MSSA) was significantly higher in respiratory isolates, while a MIC of 2 μg/ml was significantly lower (P = 0.0078). The proportion of isolates with a VCM MIC of 2 μg/ml in methicillin-resistant coagulase-negative staphylococci (MRCNS) was significantly higher in orthopedic isolates than that seen in respiratory isolates of methicillin-resistant staphylococcus aureus (MRSA; P < 0.001). When comparing MRCNS and other orthopedic Staphylococci, the rate of RFP MIC >2 μg/ml in MRCNS isolates was significantly higher (P = 0.0058). The MIC of VCM in Staphylococcus species from orthopedic infection was higher than that of respiratory samples, particularly in MRCNS from implant-related samples. MRCNS showed a significantly higher rate of resistance for RFP versus other orthopedic isolates.

While stable long-term clinical results have been achieved in total joint arthroplasty, periprosthetic joint infection (PJI) has been actualized as difficult issue in this decade. For accurate diagnosis, it is important to establish standard criteria such as MSIS criteria, and it is prevailing now. As an issue involving PJI, however, the existence of viable, but non-culturable (VNC) bacteria must be noticed. It is difficult to identify the VNC state infection, because microbiologic culture result shows negative and other markers tend to be negative. Here, molecular diagnosis based on polymerase chain reaction (PCR) has certain role as potential diagnostic tools for such VNC infection. We have applied a real-time PCR system for the diagnosis of PJI, which is able to detect methicillin-resistant Staphylococcus (MRS) and distinguish gram-positive from gram-negative bacteria. The prominent advantage is that PCR is the singular way to identify MRS in such culture negative cases. Recent development of full-automatic PCR system may improve the time efficiency for routine application. In this presentation, we will show the overall sensitivity and specificity of our PCR system for diagnosing PJI and discuss the current problem and future prospect.

Objectives

In total hip arthroplasty (THA), the cementless, tapered-wedge stem design contributes to achieving initial stability and providing optimal load transfer in the proximal femur. However, loading conditions on the femur following THA are also influenced by femoral structure. Therefore, we determined the effects of tapered-wedge stems on the load distribution of the femur using subject-specific finite element models of femurs with various canal shapes.

Introduction

Resorptive bone remodeling secondary to stress shielding has been a concern associated with cementless total hip arthroplasty (THA). At present, various types of cementless implants are commercially available. The difference in femoral stem design may affect the degree of postoperative stress shielding. In the present study, we aimed to compare the difference in bone mineral density (BMD) change postoperatively in femurs after the use of 1 of the 3 types of cementless stems.

Objective

It is known that stress shielding frequently occurs after total hip arthroplasty (THA). However, the status of bone metabolism in stress shielding region is not still clear. ¹⁸F-fluoride positron emission tomography (PET) is a useful tool for the quantitative evaluation of bone metabolism, which uptake relates with the activity of bone formation by osteoblast. In this study, we evaluated the status of bone turnover in stress shielding region using ¹⁸F -fluoride PET.

INTRODUCTION

Implantation of total hip arthroplasty (THA) components caused a significant alteration in stress environment. Several studies have reported that bone mineral density (BMD) decreases after THA, especially in the proximal femur. This phenomenon is explained as an adaptive remodeling response of bone tissue to a significant alteration in its stress environment.

SL-PLUS MIA stem (Smith & Nephew Orthopaedics AG) is a modified implant of Zweymuller type SL-PLUS standard stem (Smith & Nephew Orthopaedics AG). The major change is an omission of the trochanteric wing, which enables a bone-sparing and may lead to changes of femoral stress distribution and rotational stability. The change of stress distribution in the femur could affect BMD after THA.

In the present study, we constructed finite element (FE) models of femurs and stems before and at 1week after THA and analyzed equivalent stresses in the femur. In addition, we measured BMD in the femur by dual-energy X-ray absorptiometry (DEXA) after THA. The purpose of this study was to investigate the equivalent stress in the femur and to compare the results of the FE analyses with changes in BMD after THA.

Periprosthetic bone loss is one of the major concerns in total hip arthroplasty (THA). Several studies have reported that bone mineral density (BMD) decreases after THA especially in the proximal femur. The phenomenon is explained as an adaptive remodeling response of bone tissue to a significant alteration of its stress environment. The purpose of this study was to evaluate the pattern of load transfer after stem implantation, and to compare the stress of finite element (FE) studies to BMD in the proximal femur after THA.

Forty-eight consecutive patients who received a primary cementless THA with implantation of the same femoral prosthesis (VerSys, Zimmer Inc, Warsaw, Idaho) between January 2007 to December 2007 were identified. Twenty-nine patients were excluded for administration of alendronate or alfacalcidol, and four patients were lost to follow-up or had incomplete computed tomography (CT) or dual-energy X-ray absorptiometry (DEXA) data. The remaining 15 patients formed the basis of this study. The average age of the patients at the time of THA was 64 years (range, 44 to 82 years). BMD were measured with DEXA at 1 week and 12 months after THA. Regions of interest (ROIs) were defined according to Gruen’s system (ROIs 1–7). FE models of the femur and stem were obtained from pre-and postoperative CT data by “Mechanical Finder (Research Center of Computational Mechanics Inc.)” that was a software to make FE models considering individual bone shape and density distribution. FE model of the femur consisted of approximately 600,000 elements and that of the stem consisted of 200,000 elements. The shaft was restrained and force was applied to the femoral head and directed within the coronal plane at 20° to the shaft axis. Stress distribution and strain energy density were analyzed and compared to DEXA data.

BMD maintained at 1 year after THA in ROI 3,4,5, and 6, where as BMD decreased in ROI 1,2, and 7 by 17%, 16%, and 26 %, respectively. This means that BMD decreased especially in the proximal femur at 1 year after THA. FE studies revealed that the stress and the strain energy density in ROI 3,4,5, and 6 were much higher than in ROI 1,2, and 7. It was suggested that high stress and strain energy density are contributed to maintenance of BMD in the femur at 1 year after THA.