The author's experience is with a specific type of femoral stem and modular neck both fabricated from Ti alloy. Fracture of this Ti-Ti modular neck is associated with heavy weight, heavy activity, long modular necks and corrosion at the junction of the neck to the stem. Instruments have been designed that can remove the distal fragment of the fractured modular neck in most cases. After the neck is removed, the clinician is faced with the decision to remove the stem or to place another modular neck. At present MicroPort (formerly Wright Medical Technology) the company whose modular neck forms the data for this presentation, suggests that the female part of the taper (that is the part at the top of the stem) should not be reused if a modular neck (fractured or intact) has been removed. Thus the recommendation from the company is that the stem be removed. This recommendation is true across all modular neck – femoral stem combinations particularly for those that have been recalled by the manufacturer. There is no question that the female taper is changed by having had the modular neck implanted. In most cases of fracture there is severe corrosion at the junction of the neck to stem. Thus, reuse of the taper could have problems and it is understandable that the company does not sanction its reuse. On the other hand, removal of a well-fixed ingrown stem is not without morbidity. In several cases, with patient informed consent, I have left the stem and implanted a new modular neck (either CoCr or Ti alloy) in the damaged taper. We are following these patients closely and it is too soon to make recommendations as to the wisdom of this practice. My strong recommendation is to remove the stem and place a new one

Fracture of the Ti-Ti modular neck is associated with heavy weight, heavy activity, long modular necks and corrosion of the junction of the neck to the stem. Instruments have been designed that can remove the distal fragment of the fractured modular neck in most cases. These instruments will be demonstrated in this video. After the neck is removed, the clinician is faced with the decision to remove the stem or to place another modular neck. At present MicroPort (formerly Wright Medical Technology) the company whose modular neck I used, suggests that the female part of the taper (that is the part at the top of the stem) should not be reused if a modular neck (fractured or intact) has been removed. There is no question that the female taper is changed by having had the modular neck implanted. In most cases of fracture there is severe corrosion at the junction of the neck to stem. Thus, reuse of the taper could have problems and it is understandable that the company does not sanction its reuse. On the other hand, removal of a well-fixed ingrown stem is not without morbidity. In several cases, with patient informed consent, I have left the stem and implanted a new modular neck (either CoCr and Ti alloy) in the damaged taper. We are following these patients closely and it is too soon to make recommendations as to the wisdom of this practice. My strong recommendation is to remove the stem and place a new one

Trauma & Orthopaedic Department, Bronglais Hospital & Hywel Dda University Health Board, Aberystwyth, UK. Auto-CAD study is done to observe the effects of head neck ratio (HNR) in joint replacements. Total hip replacement joints were reconstructed on CAD with increasing diameter of the head keeping neck diameter constant in 1997. Simulation was done and Range of Movement (ROM), impingement and stability of the hip joint was noted. A graph was plotted with HNR on X-axis and ROM on Y-axis. It was observed that as the HNR increases the ROM of the joint is increased, impingement is reduced and stability is also increased. It is also observed that diameter of the head and neck is more important than considering only head diameter of the hip joint. The graphical analysis confirms that different diameters of the head may have same HNR depending on the neck diameter. So even in smaller diameter head the HNR may be more due to smaller diameter neck and may be more advantages than larger diameter head with bigger neck having smaller HNR. We conclude that HNR is more important than the head diameter alone in hip replacements

Modular femoral stems for total hip arthroplasty (THA) were introduced to allow additional options for surgeons in controlling leg lengths, offset and implant stability. This option is widely used in our Region, where the study was conducted, having a modular neck stem nearly 35% of primary THA in 2013. Great majority of modular neck is made of Titanium alloy. The study was designed as a retrospective descriptive case series of 67 hips in patients who underwent revision of a THA. All had a Titanium modular neck. In 44 cases revision was due to breakage of the neck, in the remaining 23 it was due to different reasons unrelated to modular neck such as bone fracture, breakage of a ceramic component, cup loosening. Mean follow up was 3.5 yrs. For all patients excised capsule and surrounding tissue were graded for presence of necrosis, inflammatory exudate, lymphocytes, and wear particles using light microscopy of routine paraffin sections stained with hematoxylin and eosin. The retrieved modular neck-body and head-neck junctions were examined for evidence of fretting and corrosion. For some patient dosage of circulating Titanium was obtained. Approval was obtained from institutional review board. It resulted that a variable amount of wear was observed in the first group of patients, with no evidence of lymphocytic reaction, but with variable notes of necrosis. Broken necks showed different patterns of damage, with different degree of corrosion, beside the fatigue fracture. In the second group wear was less evident or absent and negativity of lymphocyte reaction was substantially confirmed. Circulating Titanium ions were one order of magnitude higher in first group (mean 35 micrograms /liter). It can be concluded that fracture of Titanium modular necks occurs progressively, wear does not induce lymphocytic reaction and circulating ions increase

Auto-CAD study is done to observe effects of head neck ratio (HNR) in hip replacements. Total hip replacement joints were reconstructed on CAD with increasing diameter of the head keeping neck diameter constant in 1997. Simulation was done and Range of Movement (ROM), impingement and stability of the hip joint was noted. A graph was plotted with Head Neck Ratio (HNR) on X-axis and ROM on Y-axis. It was observed that as the HNR increases the ROM of the joint is increased, impingement is reduced and stability is also increased. It is also observed that diameter of the head and neck is more important than considering only head diameter of the hip joint. The graphical analysis confirms that different diameters of the head may have same HNR depending on the neck diameter. So even in smaller diameter head the HNR may be more due to smaller diameter neck and may be more advantages than larger diameter head with bigger neck having smaller HNR. We conclude that HNR is more important than the head diameter alone in hip replacements

Introduction. One of the objectives of total hip arthroplasty is to restore femoral and acetabular combined anteversion. It is desirable to reproduce both femoral and acetabular antevesions to maximize the acetabular cup fixation coverage and hip joint stability. Studies investigated the resultant of implanted femoral stem anteversion in western populations showed that the implanted femoral stems had only a small portion can meet the desirable femoral anteversion angle. 1. , and anteversion angle increases after the implantation of an anatomical femoral stem with anteverted stem neck comparing to anatomical femoral neck. 2. The purpose of this study was to anatomically measure the anteversion angular difference between metaphyseal long axis and femoral neck in normal Chinese population. The metaphyseal long axis represents the coronal fixation plane of modern cementless medial-lateral cortical fitting taper stem. This angular difference or torsion Δ angle provides the estimation of how much the neck antevertion angle of femoral stem would be needed to match for desirable anatomical femoral neck version. Methods. 140 (77 male and 63 female) anonymous normal adult Chinese CT data with average age of 54.6 (male 54.6, female 54.5, P=0.95) were segmented and reconstructed to 3D models in Trauson Orthopeadic Modeling and Analytics (TOMA) program. Femoral head center, femoral neck axis and center point of diaphyseal canal 100mm bellow calcar formed the femoral neck plane. The metaphyseal stem implantation plane was determined by the center point of medial calcar, proximal canal central axis formed by femoral neck plane and the center point of diaphyseal canal 100mm bellow calcar. [Fig. 1] The angle between two planes was the torsion Δ angle between femoral placement plane and anatomical femoral neck. [Fig. 2] The torsion Δ angles were measured for all 140 cases. The traditional anteversion angle for anatomical femoral neck was also measured by Murphy's method. Student T test was perform to compare the angles for male and female. The 98% confidence level was assumed. Results. The average torsion Δ angle for whole population was 4.9°(0.04°-15.6°), SD=3.52°, male: 4.6° (0.42°-13.9°), SD=3.09°; female: 5.3° (0.04°-15.6°), SD=3.98°. There was no statistical significant difference between genders. P=0.28. All metaphyseal stem placement planes were less anteverted than anatomical femoral neck plane. [Fig. 3] The average anatomical femoral neck anteversion angle for total population was 18.6° (0.27°-42.6°), SD=7.54°; male: 18.6° (0.27°-32.9°), SD=7.37°; female: 18.7° (1.74°-42.6°), SD=7.81°. There was no statistical significance between male and female P=0.92. Only 26% of study population or 37 cases with unadjusted implant neck version had normal anteversion angle of 10°-15° (Tönnis). Discussion. The study suggested femoral stem neck anteversion angle adjustments up to 11° was necessary to match anatomical femoral neck for 94% of cases in Chinese population. And the adjustments of 0°-7° represented the 76% majority of population. This finding was in agreement with the published data in western population. 2. . Significance. Variable femoral stem neck anteversion angles up to 11° are necessary to reproduce the anatomical anteversions for 94% of normal Chinese population. For any figures or tables, please contact the authors directly

In conventional DXA (Dual-energy X-ray Absorptiometry) analysis, pixel bone mineral density (BMD) is often averaged at the femoral neck. Neck BMD constitutes the basis for osteoporosis diagnosis and fracture risk assessment. This data averaging, however, limits our understanding of localised spatial BMD patterns that could potentially enhance fracture prediction. DXA region free analysis (RFA) is a validated toolkit for pixel-level BMD analysis. We have previously deployed this toolkit to develop a spatio-temporal atlas of BMD ageing in the femur. This study aims first to introduce bone age to reflect the overall bone structural evolution with ageing, and second to quantify fracture-specific patterns in the femur. The study dataset comprised 4933 femoral DXA scans from White British women aged 75 years or older. The total number of fractures was 684, of which 178 were reported at the hip within a follow-up period of five years. BMD maps were computed using the RFA toolkit. For each BMD map, bone age was defined as the age for which the L2-norm between the map and the median atlas at that age is minimised. Next, bone maps were normalised for the estimated bone age. A t-test followed by false discovery rate (FDR) analysis was applied to compare between fracture and non-fracture groups. Excluding the ageing effect revealed subtle localised patterns of loss in BMD oriented in the same direction as principal tensile curves. A new score called f-score was defined by averaging the normalised pixel BMD values over the region with FDR q-value less than 1e–6. The area under the curve (AUC) was 0.731 (95% confidence interval (CI)=0.689–0.761) and 0.736 (95% CI=0.694–0.769) for neck BMD and f-score. Combining bone age and f-score improved the AUC significantly by 3% (AUC=0.761, 95% CI=0.756–0.768) over the neck BMD alone (AUC=0.731, 95% CI=0.726–0.737). This technique shows promise in characterizing spatially-complex BMD changes, for which the conventional region-based technique is insensitive. DXA RFA shows promise to further improve fracture prediction using spatial BMD distribution

Distal neck modularity places a modular connection at a mechanically critical location which is also the location that confers perhaps the greatest clinical utility. Assessment of femoral anteversion in 342 of our total hip replacement (THR) patients by CT showed a range from −24 to 61 degrees. The use of monoblock stems in some of these deformed femurs therefore must result in a failure to appropriately reconstruct the hip and have increased risks of impingement, instability, accelerated bearing wear or fracture, and adverse local tissue reaction (ALTR). However, the risks of failing to properly reconstruct the hip without neck modularity must be weighed against the additional risks introduced by neck modularity. There are several critical design, material, and technique variables that are directly associated with higher or lower incidences of problems associated with modular neck femoral components. Unfortunately, in vitro testing of the fatigue strength of these constructs has failed to predict their behavior in vivo. Designs predicted to tolerate loads that far exceed those experienced in vivo still fail at unacceptably high rates. Titanium alloy neck components subjected to the stresses at the neck-stem junction continue to fail at an unacceptable incidence. CoCr alloy neck components, while theoretically stronger, still fracture and are further compromised by mechanically assisted crevice corrosion, metal hypersensitivity, and rarely, adverse tissue reaction. Designs that have proven clinical strength and utility universally have larger, more robust junctions that extend into the metaphysis of the femur. While these designs are primarily designed for revision THR, they are occasionally indicated for primary THR. Overall, however, while design options at the neck-stem junction have unmatched clinical utility, no design that does not extend into the metaphysis has proven to be universally reliable. While routine use for primary THR does not appear clinically indicated based on current evidence, modular designs with proven successful proximal junctions appear to be indicated for extreme version or anatomical circumstances

Introduction. Failure of the neck-stem taper in one particular bi-modular primary hip stem due to corrosion and wear of the neck piece has been reported frequently1, and stems were recalled. A specific pattern of material loss on the CoCr neck-piece taper in the areas of highest stresses on the proximal medial male taper was observed in a retrieval study of 27 revised Rejuvenate implants revised after 3 to 38 month time in situ (Stryker, Kalamazoo, MI, USA) (Figure 1). One neck piece exhibited additionally wear marks at the distal end of the flat male neck taper indicating contact with the female taper of the stem. The purpose of this study was to understand the observed failure scenario of bottoming-out by investigating the stem taper morphologies. Materials and Methods. The geometry of taper contact surfaces was determined using a Coordinate Measurement Machine (BHN 805, Mitutoyo, Japan). An algorithm based on the individual unworn areas of the respective taper surfaces was applied to all retrievals. One retrieval is additionally investigated by infinite focus microscopy (G4, Alicona, Austria) in the main wear areas on the neck piece taper, and the bottom, facing each other inside the junction (surfaces of the distal end of the male and the bottom of the female taper). Results. The bottom of the male neck piece taper showed a prominent patch surrounded by a corrosion area (Figure 2), similar to the pattern observed in the proximal taper articulation medial- proximally and lateral-distally (Figure 1). The bottom of the female titanium stem taper did not show material loss to this extent, but only slight scratches. The proximal male taper of the neck piece showed the usual corrosion pattern, with an elevated patch protruding inside the corrosion cavity (Figure 3, left). Contrarily to observations on other retrievals (Figure 3, right), the height of this patch did not reach the original surface level. The wear depth at the patch of the bottomed out taper was 93µm with wear reaching as deep as 170µm. Discussion. Only one of 27 retrieved neck pieces showed bottoming out. It can be speculated that the other retrievals were revised before this situation could occur. In the assembled situation, the initial space between the bottom faces of the stem taper is expectedly in the order of a few 100µm. During the observed wear process, permanent contact at patches on the neck piece prevents its reseating, until these localized structures give in to mechanical and electrochemical exposure. This end stage of failure only occurring in one explant indicates high clinical risks of the implants during earlier stages of intact patches, that are usually observed in retrievals. The formation of such patches has not been reported before, and might be characteristic for the wear and corrosion mechanism of the employed TMZF-CoCr combination, possibly due to the reduced stiffness of the TMZF Titanium. Acknowledgements. The research received funding from the European Union's Seventh Framework Program (FP7/2007-2013) under grant agreement GA-310477 (LifelongJoints)

The use of shorter humeral stems in reverse shoulder arthroplasty has been reported as safe and effective. Shorter stems are purported to be bone preserving, easy to revise, and have reduced surgical time. However, a frequent radiographic finding with the use of uncemented short stems is stress shielding. Smaller stem diameters reduce stress shielding, however, carry the risk of varus or valgus malalignment in the metadiaphyseal region of the proximal humerus. The aim of this retrospective radiographic study was to measure the true post-operative neck-shaft (N-S) angle of a curved short stem with a recommended implantation angle of 145°. True anteroposterior radiographs of patients who received RTSA using an Ascend Flex short stem at three specialized shoulder centres (London, ON, Canada, Lyon, France, Munich, Germany) were reviewed. Radiographs that showed the uncemented stem and humeral tray in orthogonal view without rotation were included. Sixteen patients with proximal humeral fractures or revision surgeries were excluded. This yielded a cohort of 124 implant cases for analysis (122 patients, 42 male, 80 female) at a mean age of 74 years (range, 48 – 91 years). The indications for RTSA were rotator cuff deficient shoulders (cuff tear arthropathy, massive cuff tears, osteoarthritis with cuff insufficiency) in 78 patients (63%), primary osteoarthritis in 41 (33%), and rheumatoid arthritis in 5 (4%). The humeral component longitudinal axis was measured in degrees and defined as neutral if the value fell within ±5° of the humeral axis. Angle values >5° and < 5 ° were defined as valgus and varus, respectively. The filling-ratio of the implant within the humeral shaft was measured at the level of the metaphysis (FRmet) and diaphysis (FRdia). Measurements were conducted by two independent examiners (SA and TW). To test for conformity of observers, the intraclass correlation coefficient (ICC) was calculated. The inter- and intra-observer reliability was excellent (ICC = 0.965, 95% confidence interval [CI], 0.911– 0.986). The average difference between the humeral shaft axis and the humeral component longitudinal axis was 3.8° ± 2.8° (range, 0.2° – 13.2°) corresponding to a true mean N-S angle of 149° ± 3° in valgus. Stem axis was neutral in 70% (n=90) of implants. Of the 34 malaligned implants, 82% (n=28) were in valgus (mean N-S angle 153° ± 2°) and 18% (n=6) in varus position (mean N-S angle 139° ± 1°). The average FRmet and FRdiawere 0.68 ± 0.11 and 0.72 ± 0.11, respectively. No association was found between stem diameter and filling ratios (FRmet, FRdia) or cortical contact with the stem (r = 0.39). Operative technique and implant design affect the ultimate positioning of the implant in the proximal humerus. This study has shown, that in uncemented short stem implants, neutral axial alignment was achieved in 70% of cases, while the majority of malaligned humeral components (86%) were implanted in valgus, corresponding to a greater than 145° neck shaft angle of the implant. It is important for surgeons to understand that axial malalignment of a short stem implant does influence the true neck shaft angle

A-70-year old woman underwent uncomplicated total hip arthroplasty using a titanium modular stem with a 46mm CoCr femoral head, a titanium shell, and a metal linear (Wright Medical Technology). Eight years after implantation, she presented with a painful left hip. A pelvic radiograph revealed adequate positioning of both hip implants without any signs of wear of loosening. CT scanning confirmed the presence of a 5 × 5 cm soft tissue mass in the ilium above the cup component accompanied by the iliac fracture. The patient was diagnosed as having an adverse reaction to metal debris (ARMD) after a metal-on-metal THA and revision was performed. Perioperatively?tissue necrosis and partial destruction of the abductor mechanism were found in the absence of any macroscopic infection. Both the neck trunnion and bore of the head showed slight signs of corrosion. The modular neck was revised with a ceramic 28mm head and a new dual-mobility liner(Zimmer Biomet). The iliac fracture was fixed with a porous trabecular metal augment(Zimmer Biomet). The histopathology of tissue sample revealed extensively necrotic material with focal cellular areas of inflammatory cells containing macrophages and neutrophilas. Metalic debris was also scattered in the necrotic materials. After the revision, the patient was recovered without pain or dislocation, and iliac fracture was well fixed. Instability is a substantial problem in the revision of ARMD. Extensive necrosis with gross deficiency of the abductor mechanism is associated with postoperative dislocation. Revision of failed MoM THA a dual-mobility device an effective strategy

Increased modularity of total hip arthroplasty components has occurred, with theoretical advantages and disadvantages. Recent literature indicates the potential for elevated revision rates of modular neck systems and the potential for metallosis and ALVAL (Aseptic Lymphocyte dominated Vasculitis Associated Lesion) formation at the modular neck/stem site. Retrieval analysis of one modular neck implant design including SEM (Scanning Electron Microscopy) assessment was done and correlated to FEA (Finite Element Analysis) as well as clinical features of patient demographics, implant and laboratory analysis. Correlation of the consistent corrosion locations to FEA indicates that the material and design features of this system may result in a biomechanical reason for failure. The stem aspect of the modular neck/stem junction may be at particular risk

Femoral stems with exchangeable necks are a recent development in hip arthroplasty. They are proposed to be better in restoring offset and leg length while not compromising the fixation in the femoral canal. Few studies have been published on the clinical and functional outcome of modular neck hip system. The Australian Joint registry data was analysed to evaluate the outcome after modular neck hip arthroplasties with the diagnosis of primary osteoarthritis. Only prostheses with data for more than 50 patients were studied. The indications for revision were identified. A comparison of outcomes with conventional hip arthroplasties was done. The analysis confirmed that femoral stems with exchangeable necks have a significantly higher risk of revision compared to all other primary total conventional hip replacement (adj HR=2.13; 95% CI (1.88, 2.42), p<0.001). With the exception of three, all femoral stems with exchangeable necks have a higher rate of revision compared to primary total conventional hip replacement. The three exceptions have a short follow up. There is an increased incidence of revision for loosening and dislocation. The recent registry data suggests that with end point being revision, the outcome of exchangeable neck hips are worse than conventional hips in patients with primary osteoarthritis of hip

Introduction. One of the major concerns in the use of modular hip prostheses is the structural failure of one or more components of the prosthesis, with total mechanical failure. In literature there are sporadic cases of breakage of the prosthetic neck in patients with high functional demand. Material and methods. In our experience we have implanted a model of modular hip prostheses in 38 patients. In 17 of these patients it was implanted a neck made of titanium alloy, while in the remaining 21 was utilised a CrCo neck. In 5 of the 17 patients with neck titanium it has been a spontaneous rupture of the neck in a time ranging from 12 to 24 months. We proceeded with the replacement of the titanium neck with similar neck made of CrCo alloy in 5 patients with failed neck, and we decided to call the remaining 12 patients with titanium neck, offering them the revision of the system. All patients accepted the revision surgery. Results. implants explanted and subject to breakage of the neck were analyzed by an independent metallurgical laboratory which has produced a document in which were found the main signs of wear which led to the deterioration of metal involved. Conclusions. The rupture of the modular hip prostheses is a possible event both because of the high functional loads required by some types of patients, that of the building materials and design of the modular components. In this study we are presented the results of the laboratory tests that allow us to pose hypotheses about the causes and failure mechanisms of modular hip prostheses

Background. Scapular notching is a complication after reverse shoulder arthroplasty with a high incidence up to 100%. Its clinical relevance remains uncertain; however, some studies have reported that scapular notching is associated with an inferior clinical outcome. There have been no published articles that studied positional relationship between the scapular neck and polyethylene insert in vivo. The purpose of this study was to measure the distance between the scapular neck and polyethylene insert in shoulders with Grammont type reverse shoulder arthroplasty during active external rotation at the side. Methods. Eighteen shoulders with Grammont type prosthesis (Aequalis Reverse, Tornier) were enrolled in this study. There were 13 males and 5 female, and the mean age at surgery was 74 years (range, 63–91). All shoulders used a glenosphere with 36mm diameter, and retroversion of the humeral implant was 10°in 4 shoulders, 15°in 3 shoulders, and 20°in 11 shoulders. Fluoroscopic images were recorded during active external rotation at the side from maximum internal to external rotation at the mean of 14 months (range, 7–24) after surgery. The patients also underwent CT scans, and three-dimensional glenosphere models with screws and scapula neck models were created from CT images. CT-derived models of the glenosphere and computer-aided design humeral implant models were matched with the silhouette of the implants in the fluoroscopic images using model-image registration techniques (Figure 1). Based on the calculated kinematics of the implants, the closest distance between the scapular neck and polyethylene insert was computed using the scapular model and computer-aided design insert models (Figure 2). The distance was computed at each 5° increment of glenohumeral internal/external rotation, and the data from 20°internal rotation to 40°external rotation were used for analyses. One-way repeated-measures analysis of variance was used to examine the change of the distance during the activity, and the level of significance was set at P < 0.05. Results. The mean glenohumeral abduction during the activity was 17°-22°. The mean distance between the neck and insert was approximately 1mm throughout the activity (Figure 3). The distance tended to become smaller with the arm externally rotated, but the change was not significant. Discussion. The reported incidence of scapular notching after Grammont type reverse shoulder arthroplasty is generally higher than the newer design prosthesis with the lateralized center of rotation. This may be associated with the design of the prosthesis, and the results of this study that the distance between the neck and insert was approximately 1mm throughout active external rotation at the side will support the high incidence of notching. We may need to analyze the distance with the newer design reverse shoulder prosthesis to prove the architectural advantage of the newer systems. Conclusion. The distance between the scapular neck and polyethylene insert was approximately 1mm throughout active external rotation activity in shoulders with Grammont type prosthesis

Introduction:. The complex 3D geometry of the scapula and the variability among individuals makes it difficult to precisely quantify its morphometric features. Recently, the scapular neck has been recognized as an important morphometric parameter particularly due to the role it plays in scapular notching, which occurs when the humeral component of a reverse shoulder arthroplasty (RSA) prosthesis engages the posterior column of the scapula causing mechanical impingement and osseous wear. Prosthetic design and positioning of the glenoid component have been accepted as two major factors associated with the onset of notching in the RSA patient population. The present image-based study aimed to develop an objective 3D approach of measuring scapular neck, which when measured pre-operatively, may identify individuals at risk for notching. Materials and Methods:. A group of 81 subjects (41 M, 69.7 ± 8.9 yrs.; 40 F, 70.9 ± 8.1 yrs.) treated with RSA were evaluated in this study. The 3D point-cloud of the scapular geometry was obtained from pre-operative computed tomography (CT) scans and rendered in Mimics. Subsequently, a subject-specific glenoid coordinate system was established, using the extracted glenoid surface of each scapula as a coordinate reference. The principal component analysis approach was used to establish three orthogonal coordinate axes in the geometric center of the glenoid. Utilization of glenoid-specific reference planes (glenoid, major axis, and minor axis plane) were selected in order to remove subjectivity in assessing “true” anterior/posterior and profile views of the scapula. The scapular neck length was defined as the orthogonal distance between the glenoid surface and the point on the posterior column with the significant change of curvature (Fig. 1). In addition, the angle between the glenoid plane, area center of the glenoid, and the point of significant change of the curvature were assessed (Fig. 2). This new parameter was developed to serve as a predictive critical value for the occurrence of notching. The incidence of notching increases as the value of the notching angle decreases. In order to evaluate relationships between glenoid and scapular neck, the glenoid width and height was also measured at the glenoid plane. Results:. Glenoid neck length and notching angle within the population were normally distributed with mean values of 7.8 ± 2.3 mm and 19.6 ± 4.8°, respectively (Fig. 3). No gender difference was found (p = 0.676). In one subject, a glenoid neck length of less than 1 mm was measured with the notching angle less than 2.5°. No association between glenoid neck length and glenoid size were identified (vs. glen. height r. 2. = 0.001, and vs. glen. width r. 2. = 0.05). Conclusion:. The present study reported on the scapular neck length and notching angle as measureable morphometric parameters that follow a normal distribution throughout the population and that are not correlated to the subject's glenoid size. Pre-operative acquisition of these novel and unique CT-based measurements may promote more appropriate RSA prosthesis selection to account for subject-specific anatomy in an effort to avoid scapular notching. Inferior placement of a baseplate or lateralization of glenoid component center of rotation (either biologically or mechanically) both serves to theoretically increase the notching angle

The NDI is a simple 10-item questionnaire used to assess patients with neck pain. The original validation was performed on 52 patients with neck pain and the test-retest on 17 whiplash patients with a 2-day interval. The SF36 measures functional ability, wellbeing and the overall health of patients. It is used in health economics to assess the health utility, gain and economic impact of medical interventions. Objectives were to independently validate the NDI in patients with neck pain and to draw comparison between the NDI and SF36. 160 patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks. The internal consistency of the NDI and SF36 was calculated using Cronbach alpha. The test-retest reliability was assessed using the Bland and Altman method and the concurrent validity between the two questionnaires was assessed using Pearson correlation. Both questionnaires showed robust internal consistency: SF36 alpha = 0.878 (se=0.014, 95%CI=0.843 to 0.906) and NDI = 0.864 (se=0.017, 95%CI=0.825 to 0.894). The NDI had significant correlation to all eight domains of the SF36 (p<0.001). The individual scores for each of the ten items had significant correlation with the total disability score (p<0.001). The test-retest reliability of the NDI was acceptable. We have shown irrefutably that the NDI has good reliability and validity and that it stands up well to the SF36

INTRODUCTION:. Proximally coated femoral stems have been designed to address the shortcomings of fully coated femoral stems including proximal femoral stress shielding. The design improvements leading to more optimized proximal femoral loading condition in the “Neck preserving stems” have increased the popularity of such implants (e.g., Minihip). Neck preserving stems depict better biological outcomes compared to more traditional stems . 1. by utilizing more natural mechanical stress/strain distribution over the femur. These stems provide significant reduction in both torsional and bending moments at the stem/bone interface. This reduction may result in decreasing the micromotion and failure of osseointegration . 1. Figure 1 demonstrates the differences between the cutting areas of a neck preserving versus traditional stem. The Minihip stem demonstrate a curved structure that is designed to match the shape of the femoral neck. The stability of the implant is achieved in the femoral neck and intertrochanteric area of the proximal femur. Further investigations are needed to establish a solid ground for the outcome of these stem in total hip arthroplasty (THA). OBJECTIVES:. The current study was conducted to report the short-term clinical outcome of the THA by using Minihip neck preserving stem. METHODS:. In the current study the short-term clinical outcomes of the patients in the patients who were treated by Minihip THA is analyzed. All patients were evaluated via Hip Disability and Osteoarthritis Outcome Score (HOOS). In addition we explored the effect of obesity on the perceived difficulty of surgery performance. A multinomial logistic regression was used in addition to a multivariate repeated ANCOVA was performed to determine significance of the demographics (i.e., BMI, Height, Weight, Age, and Gender). The signed consent was obtained from each participant. RESULTS:. 26 of the patients reported their symptoms to evaluate the HOOS (20 male, 6 female, Age 61.7 ± 8.5 years and BMI of 27.5 ± 3.88). Six patients demonstrated obesity (BMI>30). Post-operative data were collected at a mean followup time of 3 months. The results indicated significantly higher HOOS in individuals during postop depicting better quality of life (F(1, 25) = 186.695, p < .001), lower pain (F(1,25) = 249.317, p < .001), and higher activity level (F(1,25) = 202.233, p < .001). The increase in the performance of the patients however was not affected by the obesity of the individuals. We have also explored the effect of BMI on the difficulty of the surgery perceived by the surgeon and found that the surgeries were more difficult in obese patients (p = .023). CONCLUSION:. In this pilot study we have demonstrated that Minihip has the potential to exhibit excellent short-term clinical outcome in THA. In our study all individuals reported better quality of life after receiving the surgery. Future study should be conducted on comparing the differences in the outcome of the THA between commonly used implants and neck preserving stems

Introduction. Hip-Spine syndrome has various clinical aspects. For example, schoolchild with severe congenital dislocation of the hip have unfavorable standing posture and disadvantageous motions in ADL. Hip-Spine syndrome is closely related closely as the adjacent lumbar vertebrae and the hip joint. Furthermore, not only the pelvis and the lumbar spine, but also the neck position might influence on the maximum hip flexion angle. In this study, we examined the maximum hip flexion angle and pelvic movement angle by observing the lumbar spine, the pelvis and the neck in three different positions. Subjects and Methods. The participants were five healthy volunteers (three males and two females) and ranged in age from 16 to 49 years. We measured the hip flexion angle (=∠X) and the pelvic tilt angle (=∠Y), using Zebris WinData and putting the six markers on skin. The positions of the marker are Femur lateral condyle (M1), Greater trochanter (M2), Lateral margin of 10th rib (M3), Anterior superior iliac spine (M4), Superior lateral margin of Iliac (M5), and Acromion (M6). We performed maximum hip flexion three times in three positions and measured ∠X (=∠M1,2,3) and ∠Y (=∠M4,5,6) and calculated the mean and SD of each position. The first position (P1) that we investigated is the regular position specified by the Japanese Orthopedics Association and Rehabilitation Medical Association. The second position (P2) is performed in the limited position of the posterior pelvic tilt and lumbar movement, by placing the tube under the subject's lower back. The third position (P3) is the altered limited position of P2 added by placing the 500ml PET bottle filled water under the back of the subject's neck. Analysis. A two way factorial analysis of variance was used for statistical analysis to examine the difference among three different positions (P1, P2 and P3) in ∠X and ∠Y. A significance level was set at P < 0.05. We also calculated Spearman rank correlation coefficients to determine the correlation between ∠X and ∠Y. Results. There was a statistically significant difference among three different positions (P1, P2 and P3) in both ∠X and ∠Y (p < 0.01). Slight strong correlations were found between ∠X and ∠Y in three different positions. (r =0.5178571). The smallest values of ∠X and ∠Y were obtained in P1. The values of ∠X and ∠Y in P3 were all smaller than those in P2. Conclusions. The limited movement of pelvic and lumbar spine, and neck different positions give the limit to a maximum hip joint flexion angle

Background. There are numerous concerns associated with femoral stems that feature a modular neck design, including the potential for corrosion, modular neck fracture, and adverse local tissue reactions. These stems have a higher-than-anticipated rate of failure in registry results, but large single-center cohort studies are lacking. Methods. This is a retrospective, single-surgeon cohort of 133 hips in 119 patients implanted with a single dual-tapered titanium alloy stem with a modular titanium alloy neck (Profemur® Z; Wright Medical Technology, Arlington, TN). Several bearing surface combinations were used, including metal-on-polyethylene, ceramic-on-polyethylene, metal-on-metal, and ceramic-on-ceramic couples. Patients were evaluated at a mean of 4.5 years (range 2.0–9.0 years) with Harris Hip scores (HHS), radiographic analysis, and metal ion testing. Results. Mean HHS were 84.8 points at latest follow-up (range, 30 to 100 points). Five hips were revised during the study period, for an overall Kaplan-Meier survival of 0.881 at 8 years. There was only one modular neck fracture (0.75%), but others demonstrated ALTR or corrosion at the neck-body interface. Mean serum titanium levels were 4.3 ng/dL (range, < 1 to 46 ng/dL), mean serum cobalt levels were 2.5 ng/dL (range, < 0.1 to 30 ng/dL), and mean serum chromium levels were 1.8 ng/dL (range, < 0.1 to 28.4 ng/dL). Overall 9% of hips had serum titanium levels greater than 7 ng/dL, 10% had serum cobalt levels greater than 7 ng/dL, and 4% had serum chromium levels greater than 7 ng/dL. There was substantial variation in serum metal levels among different bearing surface combinations. Conclusions. The Profemur® Z stem offers good clinical results in the majority of patients with a low rate of modular neck fracture, however there is an increased rate of femoral revision at mid-term follow-up consistent with registry results. We urge caution in the use of stem designs with a modular neck as this additional interface creates a site for unique failure mechanisms that do not occur with monolithic stem designs