Femoral Canal Research Articles

The “Inside-Out” Anterior Osteotomy of the Proximal Femur via the Direct Anterior Approach in Revision Hip Arthroplasty

Osteotomy techniques used for wide exposure during femoral component revision include the extended trochanteric osteotomy and its modifications. We describe an anterior proximal femur osteotomy technique starting from the inside of the femoral canal at the bone-implant interface and heading outward. The technique is used in conjunction with the extended direct anterior approach and allows direct access to and visualization of the anterior, medial, and lateral bone-implant interfaces. This technique is most useful for the removal of collared, fully hydroxyapatite-coated double-tapered femoral stems, in which bone-implant interfaces need to be accessed for removal of a well-osseointegrated hip arthroplasty implant.

The degree of C-reactive protein elevation after total knee arthroplasty is related to bone and medullary injury rather than soft tissue.

First, we want to find out whether computer-assisted surgery (CAS) for total knee arthroplasty (TKA), which does not require opening the femoral medullary canal, results in a lesser C-reactive protein (CRP) level increase postoperatively compared to manual TKA. Second, they seek to examine whether the CRP reduction in CAS TKA and manual TKA follows a similar pattern within the first 2 weeks after surgery. Third, the study aims to compare and analyze the CRP levels in 3 different groups: CRP levels in CAS TKA with surgeons who started TKA surgery by CAS, CRP levels in manual TKA by surgeons with little experience, and CRP levels in skillful manual TKA performed after conducting over 200 cases. The 3 patient groups were as follows. Group 1: Patients who underwent non expertized surgeon CAS TKA (N = 63). Group 2: Patients who underwent manual TKA after surgeon CAS TKA experience (N = 108). Group 3: Patients who underwent manual TKA after surgeon 200 cases or more of either CAS TKA or manual TKA experience (more skillful manual TKA) (N = 66). CRP levels were analyzed using electronic medical records for 3 time points: within 3 months before surgery, 5 days after surgery, and 11 days after surgery. There were no statistically significant differences in pre operative CRP values among the 3 groups. At 5 days after surgery, the CRP level were 48.59 ± 32.75 for CAS TKA, 69.82 ± 42.76 for early manual TKA, and 67.73 ± 44.00 for skillful manual TKA, indicating a statistically significant lower CRP level in the CAS TKA group compared to the manual TKA groups (P = .01). At 11 days after surgery, there were no statistically significant differences in CRP level among the 3 groups, with was 12.12 ± 9.74 for CAS TKA, 14.07 ± 13.18 for early manual TKA, and 11.43 ± 11.45 for skillful manual TKA. The degree of CRP elevation after TKA is related to bone and medullary injury rather than soft tissue.

An in vivo study to investigate an original intramedullary bone graft harvesting technology

BackgroundHarvesting bone graft (BG) from the intramedullary canal to treat bone defects is largely conducted using the Reamer–Irrigator–Aspirator (RIA) system. The RIA system uses irrigation fluid during harvesting, which may result in washout of osteoinductive factors. Here, we propose a new harvesting technology dedicated to improving BG collection without the potential washout effect of osteoinductive factors associated with irrigation fluid. This novel technology involves the conceptual approach of first aspirating the bone marrow (BM) with a novel aspirator prototype, followed by reaming with standard reamers and collecting the bone chips with the aspirator (reaming–aspiration method, R–A method). The aim of this study was to assess the harvesting efficacy and osteoinductive profile of the BG harvested with RIA 2 system (RIA 2 group) compared to the novel harvesting concept (aspirator + R–A method, ARA group).MethodsPre-planning computed tomography (CT) imaging was conducted on 16 sheep to determine the femoral isthmus canal diameter. In this non-recovery study, sheep were divided into two groups: RIA 2 group (n = 8) and ARA group (n = 8). We measured BG weight collected from left femur and determined femoral cortical bone volume reduction in postoperative CT imaging. Growth factor and inflammatory cytokine amounts of the BGs were quantified using enzyme-linked immunosorbent assay (ELISA) methods.ResultsThe use of the stand-alone novel aspirator in BM collection, and in harvesting BG when the aspirator is used in conjunction with sequential reaming (R–A method) was proven feasible. ELISA results showed that the collected BG contained relevant amounts of growth factors and inflammatory cytokines in both the RIA 2 and the ARA group.ConclusionsHere, we present the first results of an innovative concept for harvesting intramedullary BG. It is a prototype of a novel aspirator technology that enables the stepwise harvesting of first BM and subsequent bone chips from the intramedullary canal of long bones. Both the BG collected with the RIA 2 system and the aspirator prototype had the capacity to preserve the BG’s osteoinductive microenvironment. Future in vivo studies are required to confirm the bone regenerative capacity of BG harvested with the innovative harvesting technology.

The influence of hip revision stem spline design on the torsional stability in the presence of major proximal bone defects.

Despite the success of primary total hip arthroplasty, the number of revisions remains high. Infection, aseptic loosening, periprosthetic fractures and dislocations are the leading causes of hip revision. Current revision stem designs feature a tapered body with circumferential placed longitudinal thin metal splines that cut into the femoral cortex of the diaphysis to provide axial and rotational stability. Modifications to the spline design may help improve primary stability in various bone qualities. The purpose of this study was to evaluate whether the rotational stability of a revision hip stem can be improved by an additional set of less prominent, wider splines in addition to the existing set of splines. It is hypothesized that the additional splines will result in greater cortical contact, thereby improving torsional strength. The ultimate torsional strength of an established modular revision stem (Reclaim®, DePuy Synthes) was compared to a Prototype stem design with two sets of splines, differing in prominence by 0.25 mm. Five pairs of fresh-frozen human femurs (n = 10) were harvested and an extended trochanteric osteotomy was performed to obtain common bone defects in revision. Stems were implanted using successive droptower impacts to omit variability caused by mallet blows. The applied energy was increased from 2 J in 1 J increments until the planned implantation depth was reached or seating was less than 0.5 mm at 5 J impact. The ultimate torsional strength of the bone-to-implant interface was determined immediately after implantation. Image superposition was used to analyze and quantify the contact situation between bone and implant within the femoral canal. Cortical contact was larger for the Prototype design with the additional set of splines compared to the Reclaim stem (p = 0.046), associated with a higher torsional stability (35.2 ± 6.0 Nm vs. 28.2 ± 3.5 Nm, p = 0.039). A second set of splines with reduced prominence could be shown to improve primary stability of a revision stem in the femoral diaphysis in the presence of significant proximal bone loss. The beneficial effect of varying spline size and number has the potential to further improve the longevity of revision hip stems.

Treatment of Femoral Neck Fractures in the Elderly: A Survey of the Korean Hip Society Surgeons.

This study examined the methods for treatment of femoral neck fracture (FNF) preferred by members of the Korean Hip Society (KHS) and identified factors that influence decisions regarding the surgical intervention of choice. A total of 97 members of the KHS responded to the 16-question survey which included questions about the mean number of surgeries performed each month for treatment of femoral neck fractures, the cut-off age for deciding between internal fixation and arthroplasty, the implant used most often, usage of cement, and factors influencing each decision. The mean cut-off age used when deciding between internal fixation and arthroplasty was 64 years old. Hemiarthroplasty (HA) (70%) was the most preferred option for treatment of displaced FNFs in cases where arthroplasty was indicated (total hip arthroplasty [THA] 19% and dual mobility THA 11%). The main reasons for selection of arthroplasty over reduction with internal fixation were age and pre-fracture ambulatory status. Pre-trauma ambulatory status and/or sports activity were the main factors in selection of HA over THA. Cement was used by 33% of responders. Poor bone quality and a broad femoral canal were factors that influenced the usage of cement. Management of FNFs in the elderly is a major health problem worldwide; thus, remaining alert to current trends in treatment is essential for surgeons. The mean cut-off age used in deciding between internal fixation and arthroplasty was 64 years old. HA is the preferred method for treatment of displaced FNFs for members of the KHS.

Intramedullary Fibular Strut Allograft and a Small Fragment Nonlocking T-plate for Periprosthetic Lateral Femoral Condyle Fracture: A Case Report

Intramedullary Fibular Strut Allograft and a Small Fragment Nonlocking T-plate for Periprosthetic Lateral Femoral Condyle Fracture: A Case Report

970 A Parisian Pain in the Groin; a Case of De Garengeot’s Hernia

Abstract Introduction 77-year-old gentleman presented with a four-day history of a painful right sided irreducible groin swelling. Background of previous bilateral mesh inguinal hernia repair thirty years prior. Differential diagnosis- recurrent incarcerated inguinal hernia. Description Emergency presentation with a painful right sided groin lump with history of previous inguinal hernia repair. Past medical history of AF on rivaroxaban, HTN and BPH. Patient systemically well with an irreducible lump in the right groin. CTAP showed recurrence of hernia in right inguinal region containing fat stranding and a 2cm-sized fluid-filled structure (suspected appendix). Taken to theatre the following day - oblique incision in right groin. Obvious femoral hernia identified. Haemorrhagic fluid and a necrotic appendix contained in hernia sac. Open appendicectomy performed through groin incision and femoral canal plicated using 2.0 prolene. No mesh used due to risk of contamination. Discharged day 2 post-op. Pathology confirmed acute appendicitis. Discussion Extremely rare case presentation. Femoral hernias account for 3% of all hernias and De Garengeot hernias only 1% of all femoral hernias. Furthermore, De Garengeot hernia with acute appendicitis accounts for only 0.01% of femoral hernias and are much more common in females than males with a 4:1 ratio. Femoral hernias are fifteen times more common in patients who have undergone previous inguinal hernia repair with 33% of men and 4% of women with De Garengeot hernia having undergone previous right inguinal hernia repair. Difficult pre-operative diagnosis given rarity with only 30% of cases diagnosed on pre-operative imaging-initial diagnosis Amyand hernia on CT imaging.

Bone Cement Fumes Generated in Laminar Airflow Versus Conventionally Ventilated Operating Rooms: Does the Mixing System Matter?

Bone cement is commonly utilized in a variety of orthopaedic procedures and contains methylmethacrylate (MMA) monomer. MMA is a colorless, clear, flammable liquid of intense odor. Its vapor concentration in the immediate breathing zone can vary considerably in the operative setting and, in higher concentrations, can become an occupational health hazard. Therefore, reducing MMA vapor is desirable. The aim of this study was to compare the MMA vapor levels emitted during mixing among 5 commercially available cement-mixing systems across 2 operative settings: an operating room (OR) with conventional ventilation (CV) and an OR with laminar airflow (LAF). A prospective, in vitro study was conducted at a single hospital in an OR with LAF and in an OR with CV. MMA vapor release during the cement preparation of a SAWBONES femoral canal was measured with use of a calibrated MiniRAE 3000. A total of 5 different vacuum cement-mixing systems were utilized to mix the same cement type according to the manufacturer instructions of each system. MMA vapor concentrations were measured during 5 phases of mixing, and each mixing system was randomly utilized 10 times in each OR. When comparing the MMA concentration levels of each system between the 2 settings, emissions remained generally higher in the CV setting for every system and in nearly every phase. Among the 5 systems analyzed, System #5, the only entirely closed system, had the lowest overall emissions for each of the 5 phases in the CV setting. This study demonstrated that an operative environment with LAF is conducive to clearing the fumes of MMA during mixing as well as limiting the amount of time that residual fumes linger after mixing. Additionally, the entirely closed cement-mixing system was the most effective in minimizing fume levels within the CV setting. Utilizing this closed system, especially in an OR with CV, may reduce exposure to MMA fumes from bone cement, potentially creating a more favorable working environment. This study provides evidence that a closed cement-mixing system utilized under vacuum in both an OR with CV and an OR with LAF is effective in keeping MMA fume levels below those considered harmful by the U.S. Occupational Safety and Health Administration.

Surgical approach had minor association with femoral stem migration in total hip arthroplasty: radiostereometric analysis of 61 patients after 5-year follow-up.

Total hip arthroplasty (THA) is usually performed using 1 of 3 surgical approaches: direct lateral (DLA), posterior (PA), or anterior (AA). AA is different from DLA and PA owing to limited intraoperative visibility of the femoral canal. This could affect stem positioning and therefore migration. We aimed to perform an exploratory radiostereometric analysis (RSA) study with 3 groups for surgical approach assessing stem migration up to 5 years postoperatively. 61 patients with unilateral osteoarthritis of the hip were included. 21 patients were allocated to the DLA, 20 to the PA, and 20 to the AA group. All patients received an uncemented, collarless, double-tapered, fully hydroxyapatite-coated Profemur Gladiator stem. Migration was measured with model-based RSA. Baseline RSA was on day 1 postoperatively. The follow-ups were at day 8, at 5 weeks, and at 3, 6, 12, 24, and 60 months after surgery. Generalized linear mixed models were used to analyze maximum total point motion (MTPM) migrations. Group mean differences in MTPM were 0.4 mm (95% confidence interval [CI] -1.5 to 2.4) for DLA vs. PA, 1.1 mm (CI -1.0 to 3.3) for AA vs. DLA, and 1.6 mm (CI -0.8 to 3.9) for AA vs. PA, when adjusted for sex and age as covariates. 2 stems in the AA group had excessive early migration. For all stems the migrations occurred mainly within 5-week follow-up and then stabilized. At 5-year follow-up, there were no statistically significant differences in stem migration associated with the 3 surgical approaches used in this study.

Is Posterior Femoral Neck Cortex an Obstacle in Achieving Sagittal Plane Balance of Uncemented Straight Femoral Stem?

There is a paucity of the literature that aims to improve sagittal plane balance of femoral stem in hip arthroplasty. We have comparatively evaluated the effect of trimming the posterior cortex left in situ after femoral neck osteotomy and counter-clockwise rotation of starting awl with respect to their ability to achieve neutral alignment of femoral stem in sagittal plane. (1) Which of the two techniques under reference is more reliable in achieving a sagittal plane balance of the femoral stem in the femoral canal? (2) Does either of the two techniques have the potential to adversely affect other parameters for the optimum placement of femoral stem? This prospective study involved a total of 60 patients (age group of 18 to 60years) who underwent primary total hip arthroplasty (THA) through a standard posterolateral approach. They were randomized into groups (1) PNCT (n = 30): femoral canal preparation was done by posterior neck cortex trimming method; (2) CCRA (n = 30): femoral canal preparation was done by counter-clockwise rotation of starting awl. Postoperatively, radiographs and computed tomography were obtained and angle of femoral stem with the femoral canal in coronal and sagittal plane, femoral stem tip deviation in coronal and sagittal plane, anteversion of the femoral stem, duration of canal preparation and blood loss were analyzed between the two groups. Based on our results, there is a significantly better sagittal alignment of the femoral stem within the femoral canal, both in terms of angle of the femoral stem with the femoral canal (p < 0.001) and the deviation of the femoral stem tip from the center of the medullary canal (p < 0.001) when the posterior neck cortex was trimmed. Canal preparation by trimming the posterior neck cortex took a mean of 11.93min (range 8-15min) against the mean duration of 6.87min (range; 5min to 9min) in the other group (p < 0.001). Trimming the posterior femoral neck cortex after neck osteotomy results in better sagittal plane balance of uncemented straight femoral stem. III.

Radiographic parameters of pelvic and proximal femoral morphology do not predict outcomes for direct anterior total hip arthroplasty

BackgroundRadiographic predictors of outcomes associated with direct anterior approach (DAA) total hip arthroplasty (THA) are largely unknown. Anecdotally, some surgeons limit surgery to patients with low body mass index (BMI) or “favorable” bony morphology. Objective data on the impact of these factors is limited. We sought to determine radiographic and demographic predictors of outcomes after DAA arthroplasty. MethodsA consecutive series of patients undergoing unilateral, elective DAA THA, who had linked pre- and post-operative patient reported outcome scores, from January 1, 2017 to March 30, 2019 were included. Radiographic measurements, including proxies for pelvic overhang, femoral canal access, acetabular morphologic changes, and markers of disease severity, were performed on calibrated radiographs. Intra-observer consistency was also evaluated. Outcome measures included disease specific and general health patient-reported outcomes scores, while surgical difficulty was approximated by estimated blood loss and surgical time. Multivariate analyses were performed to determine statistically significant correlations. Results168 patients were included. Overall, patients experienced significant improvement in outcome scores (mean ∆ HOOS-JR 39.4, PROMIS-physical 12.3). There were two reoperations (1.2%), for recurrent dislocation. Female sex (p = 0.015) and increasing age (p == 0.019) were associated with shorter surgical times. No statistically significant correlations were found between the radiographic parameters and outcome measures. Intraclass correlation coefficients of the radiographic measurements were overall strong (0.73–1.0). ConclusionWe demonstrated consistent results in this series of patients despite variation in bony morphology. Our findings suggest that DAA THA can be safely performed on a broader patient population.

Effect of bone cement sealing of the intramedullary femoral canal on coagulation status after total knee arthroplasty: a retrospective thromboelastography study

BackgroundThe main objective of this study was to investigate whether the use of bone cement in total knee arthroplasty (TKA) has an effect on postoperative coagulation status and bleeding.Methods153 patients who underwent unilateral TKA between September 2019 and February 2023 were collected and divided into Bone and Cement&Bone groups according to whether bone cement was used to seal the bone medullary canal intraoperatively. Routine blood and thromboelastography (TEG) examinations were performed on the day before, the first day and the seventh day after surgery; postoperative bleeding, drainage, transfusion rate and the number of people suffering from deep venous thrombosis (DVT) were recorded.ResultsThere were no significant differences between the two groups in terms of baseline clinical characteristics before surgery (P > 0.05). In terms of TEG indicators, the coagulation index (CI) of the Bone&Cement group was lower than that of the Bone group on the first postoperative day and on the seventh postoperative day (P < 0.05). The CI of patients in the Bone group on the first postoperative day was lower than that of the preoperative day (P < 0.05); in terms of blood loss, the total blood loss and occult blood loss were lower in the Bone&Cement group than in the Bone group (P < 0.05). In addition, there was no significant difference in postoperative drainage,transfusion rate and the incidence of DVT between the two groups.ConclusionBlocking the intramedullary canal of the femur with bone cement during TKA improves relative postoperative hypocoagulation and reduces postoperative blood loss, although there is no significant effect on transfusion rates, drainage and DVT.

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point.

Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN. A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured. On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1mm (SD, 1.7mm) medial to the intercondylar notch. The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

Effectiveness of anterior cruciate ligament reconstruction with personalized femoral locator based on apex of deep cartilage

To investigate the effectiveness of anterior cruciate ligament (ACL) reconstruction assisted by personalized femoral locator based on the apex of deep cartilage (ADC) combined with patient imaging data. Between January 2021 and January 2022, a total of 40 patients with primary ACL rupture were selected and randomly divided into study group (ACL reconstruction assisted by personalized femoral locator based on ADC) and control group (ACL reconstruction assisted by intraoperative fluoroscopy and traditional femoral locator), with 20 cases in each group. There was no significant difference in gender, age, body mass index, affected side, cause of injury, and preoperative International Knee Documentation Committee (IKDC) score, Lyshlom score, and Tegner score between the two groups ( P>0.05). IKDC score, Lyshlom score, and Tegner score were used to evaluate the functional recovery of the affected knee before operation and at 3, 6, and 12 months after operation. CT scan and three-dimensional reconstruction were performed before and after operation to measure the horizontal distance from ADC to the anterior cartilage margin (L) and the horizontal distance from ADC to the center of the femoral canal (I), and the anteroposterior position of the bone canal (R) was calculated by I/L; the distance from the center to the distal cartilage margin (D) was measured on the two-dimensional cross section; the R value and D value were compared between the two groups. The operation time of the study group was significantly less than that of the control group [ MD=-6.90 (-8.78, -5.03), P<0.001]. The incisions of the two groups healed by first intention, and no complication such as intra-articular infection, nerve injury, and deep vein thrombosis of lower limbs occurred. There was no significant difference in the R value and D value between the preoperative simulated positioning and the actual intraoperative positioning in the study group [ MD=0.52 (-2.85, 3.88), P=0.758; MD=0.36 (-0.39, 1.11), P=0.351]. There was no significant difference in the actual intraoperative positioning R value and D value between the study group and the control group [ MD=1.01 (-2.57, 4.58), P=0.573; MD=0.24 (-0.34, 0.82), P=0.411]. The patients in both groups were followed up 12-13 months (mean, 12.4 months). The IKDC score, Lysholm score, and Tegner score of the two groups increased gradually with time, and there were significant differences between pre- and post-operation ( P<0.05). There was no significant difference in the scores between the two groups at each time point after operation ( P>0.05). The personalized femoral locator based on ADC can accurately assist the femoral tunnel positioning in ACL reconstruction, which can shorten the operation time when compared with traditional surgical methods, and achieve satisfactory early effectiveness.

Comparison of canal fill and radiolucent line formation between two fully coated, hydroxyapatite tapered stems: a 2-year follow-up after total hip arthroplasty.

Comparison between fully hydroxyapatite (HA)-coated stems with differing geometry are lacking in the total hip arthroplasty (THA) literature. This study aimed to compare femoral canal fill, radiolucency formation, and 2-year implant survivorship between two commonly used, HA-coated stems. All primary THAs performed with two fully HA-coated stems (Polar stem, Smith&Nephew, Memphis, TN and Corail stem, DePuy-Synthes, Warsaw, IN) with a minimum 2-year radiographic follow-up were identified. Radiographic measures of proximal femoral morphology based on the Dorr classification and femoral canal fill were analyzed. Radiolucent lines were identified by Gruen zone. Perioperative characteristics and 2-year survivorship were compared between stem types. A total of 233 patients were identified with 132 (56.7%) receiving the Polar stem (P) and 101 (43.3%) receiving the Corail stem (C). No differences were observed with respect to proximal femoral morphology. Femoral stem canal fill at the middle third of the stem was greater for P stem patients than for C stem patients (P stem; 0.80 ± 0.08 vs. C stem; 0.77 ± 0.08, p = 0.002), while femoral stem canal fill at the distal third of the stem and presence of subsidence were comparable between groups. A total of six and nine radiolucencies were observed in P stem and C stem patients, respectively. Revision rate at 2-year (P stem; 1.5% vs C stem; 0.0%, p = 0.51) and latest follow-up (P stem; 1.5% vs C stem; 1.0%, p = 0.72) did not differ between groups. Greater canal fill at the middle third of the stem was observed for the P stem compared to the C stem, however, both stems demonstrated robust and comparable freedom from revision at 2-year and latest follow-up, with low incidences of radiolucent line formation. Mid-term clinical and radiographic outcomes for these commonly used, fully HA-coated stems remain equally promising in THA despite variations in canal fill.

Revision Total Hip Arthroplasty with a Modular Fluted Tapered Stem for a Periprosthetic Femoral Fracture.

As the number of primary total hip arthroplasty procedures performed each year continues to rise, so too do the number of complications, including periprosthetic femoral fracture1-9. Vancouver B2 and B3 periprosthetic femoral fractures are difficult to treat because they require the surgeon to simultaneously manage a femoral fracture and gain new implant fixation. Fluted tapered stems have advanced the treatment of periprosthetic femoral fractures by providing immediate axial and rotational implant fixation distal to the fracture10-18. Modular fluted tapered stems provide the added practical advantage of allowing length and anteversion adjustment after implantation of the distal fixation portion of the stem. In this technique, a modified extended trochanteric osteotomy incorporating the fracture is utilized to gain access to the loose femoral implant and femoral diaphyseal canal. The femoral diaphyseal canal is then sequentially reamed in 1-mm increments. A fluted tapered stem with the appropriate length, diameter, and axial and rotational stability is inserted into the canal. A proximal body is then chosen that establishes the appropriate leg length, femoral offset, and version. The final proximal body is engaged into the fluted tapered stem. Finally, the fracture is fixed around the implant with a combination of cables or wires. Historically, implants such as extensively porous coated stems were utilized to treat Vancouver B2 or B3 periprosthetic femoral fractures. Unfortunately, these implants were associated with high rates of failure and revision7,9. The introduction of a fluted tapered stem provided a more reliable implant that achieves immediate axial and rotational stability. In addition, utilizing a fluted tapered stem allowed for a more soft-tissue-preserving approach to these complex injuries, in turn allowing the fracture to be reduced around the implant proximally with cerclage cables and or wires. Modular fluted tapered stems provide the additional advantage of allowing the surgeon to modify leg length, offset, and femoral version, independently of the fluted tapered stem. As a result of these unique advantages, these stems were introduced several years ago for the treatment of Vancouver B2 or B3 periprosthetic femoral fractures. Contemporary series have demonstrated that the use of a modular fluted tapered stem leads to improved implant survivorship and clinical outcomes with lower complication rates for Vancouver B2 and B3 periprosthetic femoral fractures1,10-12,14-19. Template both the fluted tapered stem and proximal body preoperatively. The proximal body should be templated at the ideal hip center of rotation that appropriately restores leg lengths and offset. Template the fluted tapered stem so that it provides appropriate isthmic fit and bypasses the most distal extent of the fracture by at least 2 cortical diameters.Utilize a modified extended trochanteric osteotomy for your exposure in order to facilitate visualization of the fracture and to provide direct access to the femoral canal.Place a prophylactic cable prior to preparing the femur for the implant in order to help prevent iatrogenic fracture.Place a trial stem and obtain intraoperative anteroposterior and lateral radiographs in order to assess the position of the implants and the risk of anterior cortical perforation.When placing the final implants, be sure the fluted tapered stem has both axial and rotational stability.Reduce and fix the fracture after the final implants are placed and the hip is reduced. AP = anteroposteriorMFT = modular fluted tapered (stem)ETO = extended trochanteric osteotomyTHA = total hip arthroplastyCT = computed tomographyPJI = periprosthetic joint infection.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.

Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty.

Clinical, radiological and surprise diagnosis of femoral hernia

The author has treated three cases of femoral hernias over the years. Femoral hernias are rare compared to inguinal hernias. Here, there were varied clinical presentations of all femoral hernias. Obstruction, strangulation and groin swelling were the presentations observed. Management of all varies according to presentation. Because of narrow neck and stiff femoral canal chances of complications are more. Use of minimal access techniques may reduce the morbidity of surgical treatment in emergency.

THE OUTCOME OF 394 CONSECUTIVE CEMENTED EXETER SHORT STEMS USED IN PRIMARY TOTAL HIP ARTHROPLASTIES WITH A MAXIMUM FOLLOW-UP OF 28 YEARS

Although data on uncemented short stems are available, studies on cemented short-stemmed THAs are limited. These cemented short stems may have inferior long-term outcomes and higher femoral component fracture rates. Hence, we examined the long-term follow-up of cemented short Exeter stems used in primary THA.Within the Exeter stem range, 7 stems have a stem length of 125 mm or less. These stems are often used in small patients, in young patients with a narrow femoral canal or patients with anatomical abnormalities. Based on our local database, we included 394 consecutive cemented stems used in primary THA (n=333 patients) with a stem length ≤125 mm implanted in our tertiary referral center between 1993 and December 2021. We used the Dutch Arthroplasty Registry (LROI) to complete and cross-check the data. Kaplan-Meier survival analyses were performed to determine 20-year survival rates with stem revision for any reason, for septic loosening, for aseptic loosening and for femoral component fracture as endpoints.The proportion of male patients was 21% (n=83). Median age at surgery was 42 years (interquartile range: 30–55). The main indication for primary THA was childhood hip diseases (51%). The 20-year stem survival rate of the short stem was 85.4% (95% CI: 73.9–92.0) for revision for any reason and 96.2% (95%CI: 90.5–98.5) for revision for septic loosening. No stems were revised for aseptic femoral loosening. However, there were 4 stem fractures at 6.6, 11.6, 16.5 and 18.2 years of follow-up. The stem survival with femoral component fracture as endpoint was 92.7% (CI: 78.5–97.6) at 20 years.Cemented short Exeter stems in primary THA show acceptable survival rates at long-term follow-up. Although femoral component fracture is a rare complication of a cemented short Exeter stem, orthopaedic surgeons should be aware of its incidence and possible risk factors.

Proximal radiolucent lines around fully hydroxyapatite-coated tapered femoral stems: should we be concerned?

Radiolucent lines occasionally develop around the proximal aspect of fully hydroxyapatite (HA)-coated tapered femoral stems after total hip arthroplasty (THA). It was hypothesised that distal wedging of stems may predispose to proximal radiolucent line formation, which may negatively impact clinical outcome. All primary THA performed with a collarless fully HA-coated stem that had a minimum of 1 year of radiographic follow-up were identified in a surgical database (n = 244). Radiographic measures of proximal femoral morphology and femoral canal fill at the middle and distal thirds of the stem were analysed for association with the presence of proximal radiolucent lines. Linear regression was used to explore any association between radiolucent lines and patient reported outcome measures (PROMs), available in 61% of patients. Proximal radiolucent lines developed in 31 cases (12.7%) at final follow-up. Dorr A femoral morphology and increased canal-fill at the distal ⅓ of the stem correlated with the development of radiolucent lines (p < 0.001). No correlation was observed between pain or PROMs and the presence of proximal radiolucent lines. We observed an unexpectedly high incidence of proximal femoral radiolucent lines about collarless fully HA coated stems. Distal-only implant wedging in Dorr A bone may compromise proximal fixation. Although this finding did not correlate with short-term outcomes, the long-term clinical impact requires further study.