Background. There are few reports including natural course of initial gap in total hip arthroplasty. The purpose of this study is to investigate the incidence of initial gap in the PSL type shells and its natural course. Methods. Total of 386 THAs with Trident or TriAD PSL shells were performed between January 2000 and December 2014. Exclusion criteria were shells with screw fixations (n=189), previous pelvic osteotomy (n=15) and less than 3 years’ follow-up (n=11). Finally, our study included 171 hips. Average age was 56.8 (17∼83) years at THA and average follow-up time was 8.3 (3∼16.3) years; 112 (66%) were women; and 120 hips (70.2%) had osteoarthrosis. As radiographic evaluation, we checked presence or absence of initial gap, maximum size of it, gap filling and cup stability. The presence of initial gap was defined as gap present on post-operative anteroposterior X-ray measuring 1mm or greater. Gap filling was defined as confirmed trabecular formation between the cup and acetabular floor without cup migration. And we determined the time to gap filling. As clinical evaluation, we retrospectively checked Harris Hip Score (HHS) at pre-operative and final follow-up period, and presence of shell revision. Furthermore, we compared clinical results with or without initial gap. Results. Initial gap was confirmed at 85 hips (49.7%) and mean maximum size was 2.1 (1∼6.3) mm. Mean gap filling occurred at 2.5 (± 1.4) years and there was no unstable cup. Comparing clinical results with or without initial gap, pre-operative HHS was not significantly associated with initial gap (57.8 and 56.3, respectively, p=0.41). HHS at final follow-up period was also not significantly associated with initial gap (88.4 and 87.5, respectively, p=0.49). There was no shell revision with or without initial gap. Discussion. Initial gap of hemispherical type shell is reported that its incidence is 16∼38% and initial gap is not associated with clinical outcome. Our results show that PSL type shell occurs initial gap more frequently than hemispherical type shells. Conclusion. Initial gap of PSL type shell was confirmed at 85 hips (49.7%) and mean gap filling occurred at 2.5 years. Initial gap did not affect shell revision and clinical outcome

Background. Although thigh pain is an annoying problem after total hip arthroplasty (THA), little information has been known about its natural course. Methods. To determine the frequency, time of onset, and duration of thigh pain after cementless THA, we evaluated 240 patients (240 hips) who underwent primary THA because of femoral head osteonecrosis with the use of a single tapered stem. Results. Twenty-seven patients (11.3%) experienced thigh pain during the follow-up of 3–11 years(mean, 84 months). The pain developed 2–78 months (median, 25 months) after THA. The 75% of pain developed within 36 months. In 25 patients, the pain disappeared postoperatively 1 month-64 months (mean, 17.4 months), and 2 patients (7.4%, 2/27) had persistent thigh pain. There were no differences in the latest Harris Hip Score between the thigh pain group and no thigh pain group. Conclusion. Our results provided basic information about the natural history of thigh pain after cementless THA with a tapered stem design

Purpose. Our primary purpose was to study the rate of occurrence and the natural course of pseudotumors in patients who had not required a revision procedure. Our secondary purpose was to see if there is a relationship between serum metal ion analysis and clinical symptoms with metal-on-metal (MOM) hip arthroplasty. Patients and Methods. We used repeated metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) to screen 17 unrevised hips (mean patient age 63.0 years, 43 to 83 years) with pseudotumors and 26 hips (mean patient age 63.2 years, 47 to 83 years) without pseudotumors. Patients with 17 MOM, 17 ceramic-on-polyethylene (COP) and 7 ceramic on ceramic (COC) who had undergone repeated MARS MRI were evaluated with or without any symptoms. We utilized MARS MRI to score the type of pseudotumors using the Hart method. The mean post-operative time to the first MARS MRI scan was 30.0 months (8 to 96), and the time between the first and the second MARS MRI scan was eleven months (6 to 12). Serum Cr and Co ion measurements were undertaken at the time of both MRIs and analyzed only after MOM total hip arthroplasty. Results. The rate of occurrence of pseudotumors was 47.5% with MOM, 33.0% with COP, and 25.0% with COC. There was a significant difference in number of abnormalities between MOM and COP and COC bearing. At the second MRI scan, the grade of severity of pseudotumors had not changed in 40 hips. Two new asymptomatic pseudotumors (MOM:1 case, COP:1 case) were detected and one pseudotumor was downgraded. In 17 patients with pseudotumors, two cases (11.7%) were symptomatic and in 26 patients without pseudotumors, 4 cases (15.3%) were symptomatic, with no significance between the two groups. In 17 patients with MOM cases, only two cases with pseudotumors were symptomatic, and both cases showed elevated blood metal ion levels. However, in these series 13 cases (6 with pseudotumors and 7 without pseudotumors) (76.4%) were overtaken baseline. So there was no significance in terms of metal ion levels with or without pseudotumors. Discussion. Overall, there was the same tendency in terms of occurrence of pseudotumors compared with our previous studies regarding MARS MRI. Pseudotumors can occur in patients with COP and COC bearing secondary to corrosion at modular femoral head neck taper. This feature is similar to pseudotumors seen in patients with a MOM bearing. In general, the characteristics of the pseudotumors hardly changed. Repeated MARS MRI scans within one year after total hip arthroplasty showed little or no variation. On the other hand, in 26 patients without pseudotumors, two new asymptomatic pseudotumors were detected. Moreover, there was no clinically useful association among symptoms, serological markers and the severity of MR findings. In conclusion, MRI abnormalities are present in normal asymptomatic THA and, regardless of the type of bearing surface, the occurrence of pseudotumors suggests that it might originate from head neck junction and indicate subclinical disease

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results.

Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.