Greater Trochanter Region Research Articles

Assessment of Superoxidized Solution Efficacy in Treating Pressure Ulcers: A Case Study of a 65-Year-Old Male with Refractory Parkinson's Disease

In the realm of pressure sore management, meticulous wound care is essential, serving not only to prevent infections but also as preparatory groundwork for potential surgical interventions. This study delves into the effectiveness of Superoxidized Solution in directly addressing pressure sores. Through a detailed case study of a 65-year-old male afflicted with refractory Parkinson's disease and presenting pressure sores in the greater trochanteric region, our findings indicate that the application of Superoxidized Solution fosters tissue regeneration while concurrently mitigating the risk of infection.

Prevention of Postoperative Skin Disorders and Pressure Injuries in the Neurosurgical Park Bench Position Surgery: A Prospective Cohort Study.

Background In neurosurgical procedures where the park bench position is employed, the risk of perioperative pressure injuries is elevated due to the limited contact surface area, with the head and part of the upper torso extending beyond the surgical table. This study aimed to examine the effects of preventative measures against such injuries, proposing a potential standard for postural fixation in these surgeries. Methods Conducted at a medical center, from January 2017 to March 2023, this prospective cohort study involved participants aged 20 and above who underwent neurosurgical procedures in the park bench position under general anesthesia. The focus was on comparing the incidence of pressure injuries between intervention and control groups. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results Out of 65 patients enrolled, 28 were assigned to each of the intervention and control groups. The control group experienced 17 instances of postoperative pressure injuries and skin disorders in areas prone to pressure, such as the axillary and greater trochanter regions. Conversely, the intervention group reported no such incidents, underscoring the efficacy of meticulous surgical positioning and management of bodily pressure, temperature, humidity, and microclimate. Conclusion Implementing preventive measures in neurosurgical park bench procedures significantly reduces the incidence of postoperative pressure injuries and skin disorders. These findings advocate for the adoption of standardized postural fixation protocols in such surgeries, potentially influencing global clinical practices in neurosurgery.

Acetabular "Fleck" Sign: Outcomes of Surgical Repair.

Traumatic, posterior hip dislocations in the pediatric population are typically managed by closed reduction to achieve a concentric hip joint. The presence of an acetabular "fleck" sign, despite concentric reduction, has been shown to signify significant hip pathology. The purpose of this study was to evaluate the outcomes of open labral repair through a surgical hip dislocation (SHD) in a consecutive series of patients with an acetabular "fleck" sign associated with a traumatic hip dislocation/subluxation. A retrospective review of patients between 2008 and 2022 who presented to a single, level 1 pediatric trauma center with a traumatic posterior hip dislocation/subluxation was performed. Patients were included if they had an acetabular "fleck" sign on advanced imaging and underwent open labral repair through SHD. Medical records were reviewed for sex, age, laterality, mechanism of injury (MOI), and associated orthopaedic injuries. The modified Harris hip score (mHHS) was utilized as the primary clinical outcomes measure. Patients were assessed for the presence of heterotopic ossification (HO) and complications, including implant issues, infection, avascular necrosis (AVN), and post-traumatic dysplasia. Twenty-nine patients (23 male, average age: 13.0±2.7 y; range: 5.2 to 17.3) were identified. Eighteen injuries were sports related, 9 caused by motor vehicle accidents, and 1 pedestrian struck. All patients were found to have an acetabular "fleck" sign on CT (26 patients) or MRI (5 patients). Associated injuries included: femoral head fracture (n=6), pelvic ring injury (n=3), ipsilateral femur fracture (n=2), and ipsilateral PCL avulsion (n=1). At the latest follow-up (2.2±1.4y), all patients had returned to preinjury activity/sport. Three patients developed asymptomatic, grade 1 HO in the greater trochanter region. There was no incidence of AVN. One patient developed post-traumatic acetabular dysplasia due to early triradiate closure. mHHS scores showed excellent outcomes (n=21, 94.9±7.4, range: 81 to 100.1). The acetabular "fleck" sign indicates a consistent pattern of osteochondral avulsion of the posterior/superior labrum. Restoring native hip anatomy and stability is likely to improve outcomes. SHD with open labral repair in these patients produces excellent clinical outcomes, with no reported cases of AVN. Level IV-therapeutic.

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain. Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis. Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis. Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p< 0.001). Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region. Keywords: Trochanteric Bursitis, evaluation, clinical tests, ultrasound

Clinical and Ultrasonographic evaluation of patients with Trochanteric Bursitis

Background: Trochanteric bursitis is an inflammation of the greater trochanteric bursa which is a recurrent source of lateral hip pain.
 Objective: To assess the diagnostic value of 6 clinical tests that can be used to diagnose trochanteric bursitis and utilize ultrasound as an imaging modality to confirm the diagnosis.
 Patients and Methods: This Cross-sectional study included 85 consecutive patients who had been experienced lateral hip pain in the greater trochanteric area for at least 6 weeks with at least one of the following features: pain on lying on the affected side, pain while climbing stairs or when sitting. Six clinical tests on examination that elicit pressure on the greater trochanteric region were performed to evaluate their value to diagnose trochanteric bursitis and then ultrasound was utilized to confirm the diagnosis.
 Results: A total of 85 participants were enrolled in the study. Tenderness to deep palpation was the most accurate sign in predicting the diagnosis, with a sensitivity of 100% and specificity of 81.8%. There were no significant differences between its results and the ultra-sonographic findings (p=0.500). Regarding the other tests, there were significant differences between their results and the results of ultrasound (p< 0.001).
 Conclusion: Tenderness to deep palpation of the greater trochanter, combined with ultrasound imaging modality, is likely to have the best diagnostic value for evaluation of trochanteric bursitis in patients complaining of lateral hip pain around the greater trochanter region.

The Impact of Coronal Configuration of the Proximal Femur on its Mechanical Properties and the Validation of a New Theoretical Model: Finite Element Analysis and Biomechanical Examination.

This study aims to establish the coronal configuration of the proximal femur as an independent factor for its mechanical properties and provide validation for the theoretical model "fulcrum-balance-reconstruction." The digital 3D femur model constructed with the lower extremity high-resolution computed tomography of a senior subject was applied with the axial compression of 2100N under 5 different α angles of 10°, 5°, 0°, -5°, -10°. The equivalent stress distribution of the femoral geometric model under each angle were calculated. Under the same five α angles, fatigue test was performed on 15 composite artificial left femurs (three specimens in each angle group) to obtain the failure cycle and fracture site. The statistical analysis was accomplished using One-Way ANOVA. The maximum stress of the entire femur in physiological angle (α=10°) occurred below femoral neck with a value of 63.91 MPa. When the proximal femur is in extreme abducted angle (α=-10°), the maximum stress shift to the lower medial cortex of femoral shaft with a value of 105.2 MPa. As the α angle changed from 10° to -10°, the greater trochanteric region had the largest increment in maximum stress (2.78 times for cortex and 1.67 times for cancellous bone) locally at the proximal femur. The failure cycles of the artificial femurs with a variety of abduction angle were averagely 9126 ± 2453.87 (α=-10°), 58,112.33 ± 1293.84 (α=-5°), 92,879.67 ± 2398.54 (α=0°), 172,045.3 ± 11011.11 (α=5°), and 264,949.3 ± 35,067.26 (α=10°), and the statistical analysis revealed that the α angle of the group of concern is proportional to the P value of the corresponding group compared to the 10° group(α=5° & α=10°, P=0.01; α=0 & α=10°, P=0.001; α=-5°, -10° & α=10°, P < 0.001). In fatigue test, the fracture appeared on femoral neck for the α angles of 10° (three subcapital), 5° (two basal; one transcervical), and 0° (one transcervical). Fracture sites located at trochanteric region were observed with the more abducted angles including 0° (two subtrochanteric) and -5° (two intertrochanteric; one subtrochanteric). The fracture line was only found on femoral shaft in the -10° group. With increasing hip abduction, the proximal femur shows declining mechanical properties, which suggests higher risk of hip fracture and increasement in the fraction of trochanteric fracture subtype. Furthermore, the hypothesis of "fulcrum-balance-reconstruction" was validated by our study to a certain extent.

Motor control exercises versus general exercises for greater trochanteric pain syndrome: A protocol of a randomized controlled trial

Greater trochanteric pain syndrome is an overarching term used to define pain and tenderness in the greater trochanteric region of the femur, which is more common in women. Abnormal control of lower limb movements and deficient neuromuscular parameters may lead to greater trochanteric pain syndrome; however, no studies have used neuromuscular training as a treatment strategy. Thus, this study aims to compare the effect of a protocol of general exercises versus a program of motor control training on pain at baseline and after treatment in women with greater trochanteric pain syndrome. The study was approved by the Research Ethics Committee (CAAE: 87372318.1.0000.5406) and has been prospectively registered on the Brazilian Registry of Clinical Trials (RBR-37gw2x). Sixty participants will be randomized to receive motor control exercises or general exercises. The application will be performed twice a week for 8 weeks. The participants will be evaluated before the treatment (T0), after 8 weeks of intervention (T8) and after 60 weeks of intervention (T60). The primary outcome measures will be the hip pain intensity, and secondary outcomes will be muscle strength, kinesiophobia, global perceived effect, pain catastrophization, central sensitization and quality of life. Studies have suggested that greater trochanteric pain syndrome may be related to poor hip and pelvic control, however, no study has investigated an exercise protocol focused on increasing the strength of the abductor and extensor muscles of the hip associated with pelvic control training, especially in positions of unilateral support, such as gait. This study will help determine whether greater trochanteric pain syndrome is related to abnormal control of lower limb movements.

Rehabilitation After Gluteus Medius and Minimus Treatment

We reviewed the current literature regarding rehabilitation after gluteus medius and minimus tears as part of a conservative management or postoperative protocol. The greater trochanteric pain syndrome includes a constellation of pathologies that generate pain in the greater trochanteric region and may be accompanied by varying degrees of hip abductor disfunction. It may be related to tendinitis of the gluteus medius and minimus, greater trochanteric bursitis, or even formal tears of the hip abductor tendons. The initial management strategy of the hip abductor tears is conservative, including different anti-inflammatory therapies such as physical therapy and cortisone and platelet-rich plasma injections. The clearest indication for surgical management is failure of conservative management and loss of abductor muscle power. Surgical management has been performed both open and endoscopic with good reported clinical results. More severe tears typically require a more rigid and complex type of fixation. Exorcise intervention seem to improve symptoms after 4 months to a year of therapy therefore a very close supervision of the rehabilitation protocol is mandatory. Gluteus medius and minimus tears are frequent and may be not diagnosed timely. Treatment of these of lesions is based on the knowledge of pathomechanics involved and the extent of injury to the tendon and muscle tissue. Conservative management is based on protecting the hip abductor tendons from excessive tensile and compression stresses while applying progressive load in conjunction with physical and medical anti-inflammatory measures. Surgical treatment is indicated when conservative management fails or an abductor power deficit is associated with pain. Similar physical therapy protocols to those used in conservative management are used postoperatively. Level of EvidenceLevel V, expert opinion.

Bone Loss Following Cementless Hemiarthroplasty for the Treatment of Femoral Neck Fracture.

With the advances in medicine, an increasing number of the ageing population are a public health concern in terms of age-related complications. Among them, displaced neck fractures often require surgical intervention or arthroplasty to achieve the mobilization of the elderly and good life quality. The aim of the study is to monitor the changes in bone mineral density (BMD) around the femoral stem and the effects on functional outcomes in patients treated with cementless hemiarthroplasty following femoral neck fracture. Seventy-one patients aged 70years or older who were treated with cementless hemiarthroplasty for a displaced femoral neck fracture were prospectively followed for 2years. The percent change in the periprosthetic BMD in each Gruen zone was compared to the baseline using dual-energy X-ray absorptiometry (DEXA). Demographic factors [age, body mass index (BMI), and sex] that could possibly influence BMD and the clinical outcome were evaluated. Fifty-one patients were available for the final follow-up. The mean age was 76.5 (range 70-89) years. The mean BMI was 28.9 (range 22.7-37.2). The mean Harris hip score at the final follow-up was 84.3 (range 72-93). There was a significant decrease in BMD in all Gruen zones (p < 0.001), except in zone 3 (R3, p = 0.547). The reduction in BMD was highest in the calcar and the greater trochanter region. The femur diaphysis was relatively spared, with zone 3 showing no significant bone mineral loss. The age and BMI of the patients were not correlated with the postoperative change in BMD in any of the Gruen zones. The degree of reduction in bone density was not correlated with the clinical outcome. Cementless hemiarthroplasty for the treatment of femoral neck fracture in elderly patients achieves a good clinical outcome despite significant bone loss around the femoral stem. The reduction in BMD is more pronounced in the metaphyseal region.

Dry needling: A promising treatment modality for greater trochanteric pain syndrome

Greater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain, seen more commonly in females between the ages of 40 and 60 years. GTPS is presently attributed to tendinopathy of the gluteus medius and/or minimus with or without coexisting trochanteric bursitis. Conventionally, cortisone injection into the lateral hip, with the intention of injecting the bursa, was accepted treatment for this condition in cases not responding to conservative treatment. But since the etiology of GTPS is not necessarily the bursa, injecting it with steroid is not as logical. As trigger points and myofascial pain of the affected hip and thigh musculature are being implicated as sources of pain, dry needling (DN), that has shown potential in treating a variety of soft-tissue injury and neuromyofascial pain, and which requires the insertion of thin monofilament needles into sensitive loci (trigger points) in the muscles and soft tissue could be an effective option. Hereby, we present a case of a 52-year-old woman, who came to us with chronic lateral lower limb pain since 1 year. The pain was dull aching in quality, extended from the right buttock region to the lateral aspect of thigh and was specially felt on abduction of thigh while sitting in cross-legged position on the ground. The patient had tenderness along proximal lateral thigh around the greater trochanteric region. One-week course of nonsteroidal anti-inflammatory drugs had minimal effect. We decided to treat her with DN in her pain area. The patient reported more than 75% pain relief after the session.

Effect of Denosumab on Femoral Periprosthetic BMD and Early Femoral Stem Subsidence in Postmenopausal Women Undergoing Cementless Total Hip Arthroplasty.

ABSTRACTAntiresorptive denosumab is known to improve the quality and strength of cortical bone in the proximal femurs of osteoporotic women, but its efficacy in preventing periprosthetic bone loss and reducing femoral stem migration has not been studied in women undergoing cementless total hip arthroplasty. We conducted a single‐center, randomized, double‐blinded, placebo‐controlled trial of 65 postmenopausal women with primary hip osteoarthritis and Dorr type A or B proximal femur anatomy. The patients randomly received subcutaneous injections of denosumab 60 mg or placebo once every 6 months for 12 months, starting 1 month before surgery. The primary endpoint was the change in bone mineral density (BMD) of the proximal femur (Gruen zone 7) at week 48, and the secondary endpoint was stem subsidence measured by radiostereometric analysis (RSA) at week 48. Exploratory endpoints included changes in BMDs of the contralateral hip, lumbar spine and distal radius, serum levels of bone turnover markers, walking speed, walking activity, patient‐reported outcome measures, and radiographic assessment of stem osseointegration. The participants underwent vertebral‐fracture assessment in an extension safety study at 3 years. Denosumab significantly decreased bone loss in the medial femoral neck (zone 7) and increased periprosthetic BMD in the greater trochanteric region (zone 1) and lesser trochanteric region (zone 6). Denosumab did not reduce temporary femoral stem migration. The migration occurred mainly during the settling period (0 to 12 weeks) after implantation of the prosthesis. All of the stems osseointegrated, as evaluated by RSA and radiographs. There were no intergroup differences in functional recovery. Discontinuation of denosumab did not lead to any adverse events. In conclusion, denosumab increased periprosthetic BMD in the clinically relevant regions of the proximal femur, but the treatment response was not associated with any reduction of initial stem migration. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Nerve Blocks in the Geriatric Patient With Hip Fracture: A Review of the Current Literature and Relevant Neuroanatomy

Introduction:Hip fracture is a common occurrence in the elderly population with high morbidity and mortality due to postoperative pain and opioid use. The goal of this article is to review the current literature on the neuroanatomy of the hip and the use of localized nerve block in controlling hip fracture pain.Methods:A thorough search of MEDLINE/PubMed, Embase, and the Cochrane Database of Systematic Reviews was conducted using the search terms “hip fracture” and “fascia iliaca block (FICB).” An additional search was conducted utilizing multiple search terms including “hip fracture,” “greater trochanter,” “femur,” “hip,” “anatomy,” “neuroanatomical,” and “anatomic.” Each search result was investigated for cadaveric studies on the innervation of the trochanteric region.Results:Twenty-five clinical studies examining the use of FICBs in hip fracture patients were identified. These studies show that FICB is safe and effective in controlling perioperative pain. Additionally, FICB has been shown to decrease opioid requirement and opioid-related side effects. Neuroanatomical studies show that the hip capsule is innervated by contributions from the femoral, obturator, sciatic, and superior gluteal nerves. Imaging studies suggest that FICB anesthetizes these branches through localized spread along the fascia iliaca plane. Cadaveric evidence suggests that the greater trochanter region is directly innervated by a single branch from the femoral nerve.Discussion:The proven efficacy of nerve blocks and their anatomic basis is encouraging to both the anesthesiologist and orthopedic surgeon. Their routine use in the hip fracture setting may improve patient outcomes, given the unacceptably high morbidity and mortality associated with opioid use.Conclusions:Localized nerve blocks, specifically FICB, have been shown to be safe and effective in managing acute hip fracture pain in geriatric patients, leading to decreased opioid use. Knowledge of the hip neuroanatomy may help guide future development of hip fracture pain blockade.

First experiences with the Fitmore® hip stem: Early results of the 16-month monitoring.

Fitmore® hip stem belongs to the group of short stem prostheses with the metaphysar stabilization, with its shape and form that protects the bone mass in the greater trochanter region and the distal part of the femur. The aim of this paper was to present the early postoperative results in patients with implanted Fitmore® hip stem and point out some of the advantages. A series of 10 patients with implanted Fitmore® hip stem, was included in this study. The average age of the patients was 54.5 (48–65) years. There were 5 women and 5 men. The total monitoring time was 16 months. To rate the condition of the hip joint we used The Western Ontario and Mc Master Universities Arthritis Index (WOMAC) score. We also monitored the degree of hip pain, hip flexion, heterotopic ossification and indentation in the stem of the prosthesis. After 12 months of monitoring 9 (90%) of the patients had no pain in the thigh region, and only 1 (10%) experienced mild pain. The hip flexion rose from the average 89° to postoperative 114°. WOMAC score rose as well, from 49 to 94 average points. Indentation in the stem was registered 3 months after the operation in 2 (20%) of the patients – in one of the patients the indentation was 3 mm and in the other patient 5 mm. After the 16-month monitoring, the results were excellent. The monitoring period was short though it should be continued and the results should be presented after 5 and then after 10 years. Early results of the implantation Fitmore stem showed good bone ingrowth with excellent functional result.

The effect of local injection of methylprednisolone acetate on the hypothalamic-pituitary-adrenal axis among patients with greater trochanteric pain syndrome.

Greater trochanteric pain syndrome (GTPS) is a common clinical entity for which the most effective treatment is local corticosteroid injection (LCI). There are no studies on the effect of LCI among patients with GTPS on the hypothalamic-pituitary-adrenal axis. The present study recruited nonselected patients diagnosed with GTPS. After consenting, participants received low dose (1μg) of adrenocorticotropin hormone (ACTH) stimulation test at 09:00. Immediately following the test, participants received a LCI of 80mg of methylprednisolone acetate at the greater trochanteric region. The ACTH stimulation test was repeated 1, 2, 4, and 6weeks following the LCI. Cortisol samples were obtained at just prior to (basal) and 30min (post-stimulation) following every ACTH stimulation test. Serum cortisol levels of <500μmol/l obtained 30min following the ACTH stimulation test were considered evidence of secondary adrenal insufficiency. The study enrolled 22 patients, 21 of whom completed participation. There were 19 female participants (~90%), and mean age of all the participants was 55.2±8.6years. Four participants showed evidence of secondary adrenal insufficiency, which was observed only at weeks 1 and 2 following the LCI. Mean serum cortisol level among these four participants 30min following the ACTH stimulation test was 354μmol/l, with a range of 268-430μmol/l. LCI of 80mg of methylprednisolone acetate in the greater trochanteric area among patients with GTPS was associated with transient secondary adrenal insufficiency in ~20% of the patients, mainly 1week following the injection.

Change of Biomechanical Parameters in the Lower Jaws of Rabbits with Experimental Osteoporosis after Implantation of Calcium-Phosphate Bioceramic Material in the Greater Trochanter Region

Investigation of biomechanical properties of the rabbit bone tissue from a corner of the lower jaw was done. Experimental osteoporosis was induced by ovariectomy and following injections of methylprednisolone. The defects in the greater trochanter region was created and filled with granules of a hydroxyapatite and tricalcium phosphate (HAP/TCP 30/70) or HAP/TCP 30/70 together with 5% strontium ranelate. After 3 month animals were euthanased, squared samples have been cut out from a corner of the lower jaw and tested on a bend. Results of research show, that the corner of a lower jaw in rabbit becomes more rigid after filling of defects in the greater trochanter region with granules of a hydroxyapatite and tricalcium phosphate (HAP/TCP 30/70) or granules together with strontium ranelate. The ultimate strain for the bone tissue in the 2nd and 3rd group is less, than for control group. Thus, local uses calcium – phosphatic bioceramic material around the greater trochanter region improves biomechanical parameters of a bone tissue in the lower jaw of animals.

Study of the bone behavior around a neck preserving short stem implant: bone densitometric analysis over a span of two years.

Purpose: Study the bone mineral density (BMD) changes and the remodelling process after implantation of a neck preserving short stem implant over a period of two years. Methods: Using specific patients’ selection criterion, a prospective study was done including 26 patients. All were operated upon by a single surgeon using the MiniHipTM, (Corin, Cirencester, UK). Mean age was 42.5 years. Clinical and radiological evaluation was done. Periprosthetic bone density was measured by DEXA. First scan was obtained within 10 days after surgery and served as a baseline for comparison. Results: The mean pre-operative Harris Hip score of 37.8 increased to 95.1 points two years post-operatively. BMD in the overall periprosthetic area showed a significant reduction during the first three months. Restoration to the original levels was reached in all zones except the most proximal zones at one year. A net increase was detected (+3%) after two years. Conclusion: The neck preserving MiniHip short stem implant has proven to be a bone-friendly design. Significant bone remodeling process continues after the first year. Although bone resorption in the greater trochanteric region is still a problem, however, it has proven that the BMD in all the other periprosthetic regions including the calcar and the lesser trochanteric regions, are subjected to bone formation process over a period of two years.

Cortical hypertrophy with a short, curved uncemented hip stem does not have any clinical impact during early follow-up.

BackgroundShort stems have become more and more popular for cementless total hip arthroplasty in the past few years. While conventional, uncemented straight stems for primary total hip arthroplasty (THA) have shown high survival rates in the long term, it is not known whether uncemented short stems represent a reasonable alternative. As cortical hypertrophy has been reported for short stems, the aim of this study was to determine the radiographic prevalence of cortical hypertrophy and to assess the clinical outcome of a frequently used short, curved hip stem.MethodsWe retrospectively studied the clinical and radiographic results of our first 100 consecutive THAs (97 patients) using the Fitmore® hip stem. Mean age at the time of index arthroplasty was 59 years (range, 19 – 79 years). Clinical outcome and radiographic results were assessed with a minimum follow-up of 2 years, and Kaplan-Meier survivorship analysis was used to estimate survival for different endpoints.ResultsAfter a mean follow-up of 3.3 years (range, 2.0 – 4.4 years), two patients (two hips) had died, and three patients (four hips) were lost to follow-up. Kaplan-Meier analysis estimated a survival rate of 100 % at 3.8 years, with revision for any reason as the endpoint. No femoral component showed radiographic signs of loosening. No osteolysis was detected. Cortical hypertrophy was found in 50 hips (63 %), predominantly in Gruen zone 3 and 5. In the cortical hypertrophy group, two patients (two hips; 4 %) reported some thigh pain in combination with pain over the greater trochanter region during physical exercise (UCLA Score 6 and 7). There was no significant difference concerning the clinical outcome between the cortical hypertrophy and no cortical hypertrophy group.ConclusionsThe survival rate and both clinical and the radiographic outcome confirm the encouraging results for short, curved uncemented stems. Postoperative radiographs frequently displayed cortical hypertrophy but it had no significant effect on the clinical outcome in the early follow-up. Further clinical and radiographic follow-up is necessary to detect possible adverse, long-term, clinical effects of cortical hypertrophy.

Clinical, radiological features, and surgical management of 6 patients with rupture of the gluteus medius tendon

The rupture of the anterior part of the gluteus medius tendon has remained an ill-defined entity. The objectives are to develop some specific clinical signs, to emphasize the importance of MRI and to discuss the place of surgery. Six patients were treated in the physical medicine department (Besançon) from 2009 to 2014 for trochanteric pain, with tears of the gluteus medius tendon confirmed by MRI. They all received suture surgery. It was 4 women and 2 men (mean age 71 years). The interrogation at diagnosis: pain lasting for 5.4 months [3.5–9], no injuries reported, visual analog scale(VAS) 7.6 [5–9], sudden onset (83%), night pain (100%), Blazina score ≥ 3 (100%). Clinical examination: normal and symmetric range of motion except a limitation of 10 degrees of lateral rotation on the symptomatic side for 5/6 patients (83%), symptomatic triad (stretching, resisted contraction, palpation) in 100% of cases, positive Trendelenburg sign for 5 patients (83%) and 4/6 patients with decrease of the gluteus medius strength (cotation 4/5). All patients had an MRI: partial rupture (1 case), complete rupture (5 cases) of the anterior fibers of the gluteus medius. After failure of medical treatment, conducted on average 4.7 months [3–11 months], a surgical treatment was chosen for all patients. Clinical reassessment 6 months after surgery: significant improvement on pain: VAS = 2.4 (0 to 5.5) ( P < 0.01), disappearance of night pain in 5/6 cases (83%), disappearance of lameness (4/5 cases) except for one patient with persistent loss of gluteus medius muscle strength (cotation 4/5). Tears of the gluteus medius tendons are likely to be a more common cause of pain in the greater trochanteric region than previously thought, especially if there are sudden onset, night pain, loss of muscle strength or Trendelenburg sign. The most useful examination technique for diagnosis is MRI. The surgical suture is recently proposed. That produce good to excellent functional results and reduce pain in this series.

A Plethora of Complications from Paget Disease.

In and of itself, Paget disease can be a challenging condition for patients to live with and for orthopaedists to treat. Moreover, as this edition of “Case Connections” illustrates, this mysterious bone-remodeling anomaly can trigger additional orthopaedic complications, including fractures and advanced arthritis. This month’s cases also illustrate that orthopaedic surgery in a zone of pagetic bone can be especially tricky, due in part to the apparent potential of Paget disease to “spread.” Total hip arthroplasty (THA) is one viable approach to treating Paget disease of the hip, but in the March 11, 2015, JBJS Case Connector, Amundsen et al. reported on a case in which the onset of Paget disease soon after THA led to stem loosening that necessitated revision. The seventy-seven-year-old man in this case had two years previously undergone a left THA for posttraumatic arthritis that included a cementless stem, cobalt-chromium head, and polyethylene liner. Radiographs made six months after the arthroplasty showed normal bone morphology, and the patient was symptom-free for the subsequent twelve months. Eighteen months after the procedure, however, he began experiencing hip pain and noticed a mass on the proximal aspect of the right tibia. Left hip radiographs showed femoral component subsidence with cortical thickening and expansion of the greater trochanteric region. Radiographs of the right tibia showed a mixed lytic and sclerotic lesion of the anterior cortex, characteristic of mixed-phase Paget disease. Upon physical exam, surgeons noted a 10-cm × 3-cm firm, nontender mass over the proximal tibial crest, and a bone scan showed areas of increased activity in the proximal half of the left femur …

Bone Remodelling around A Cementless Straight Tha Stem: A Prospective Dual-Energy X-Ray Absorptiometry Study

The design of the Bicontact® stem (BBraun, Aesculap, Tuttlingen, Germany) and the implantation technique have undergone no major alterations in the last 20 years leading, and good clinical results have been reported. The aim of our study was to investigate whether the implant encourages beneficial bone remodelling. Twenty-four patients were included in a prospective dual-energy X-ray absorptiometry (DEXA) study of this stem, after appropriate statistical power analysis. Preoperative and postoperative (1 week, 6 months, and 12 months) clinical and DEXA examinations were performed. The Harris Hip Score increased significantly by 39 points. The strongest decreases in BMD were observed in the greater trochanter region (-11%) and the calcar (-12%). In the second half of the study period the bone mineral density recovered slightly and even returned to baseline values in the lesser trochanter region. Therefore, proximal load transfer and physiological bone remodelling around the Bicontact® stem appeared to be achieved.