Greater Trochanter Region Research Articles

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.

脊髄損傷患者の遷延する褥瘡・瘻孔部位より生じた有棘細胞癌の1例

脊髄損傷患者の遷延する褥瘡・瘻孔部位より生じた有棘細胞癌の1例

Sentinel Presentation of Disseminated Blastomyces dermatitidis Infection as Hip Pain in a Young Adult

In young, active patients, the common causes of hip pain are multiple and can include muscle strain, contusion, acetabular labral tear, osteochondral injury, sports hernia, snapping hip, proximal femoral stress fracture, and spinal abnormalities1-3. In most patients, an initial trial of nonoperative management is instituted. If pain persists or is of an unusual presentation, a more extensive diagnostic workup may be used. A thorough clinical evaluation can expedite the diagnosis of uncommon conditions of the musculoskeletal system, and the diagnostic evaluation may include magnetic resonance imaging of the pelvis and hip to evaluate the integrity of the periarticular structures. The case of the patient in the present report illustrates an unusual presentation of disseminated Blastomyces dermatitidis infection causing hip pain that was diagnosed with magnetic resonance imaging and was successfully treated through a multidisciplinary approach. The parents of the patient were informed that data concerning the case would be submitted for publication, and they consented. A seventeen-year-old boy presented to our clinic with a chief complaint of an insidious onset of hip pain of approximately two weeks’ duration that was minimally responsive to nonsteroidal anti-inflammatory drugs. He had previously worked at a job in construction requiring heavy labor and lived in the Missouri River valley region. The hip pain was limiting his ability to work at his normal level. The pain was primarily localized to the lateral aspect of the hip at the greater trochanteric region and the lateral iliac wing without radiation. He denied any fevers, chills, or other constitutional symptoms …

Early periprosthetic femoral bone remodelling using different bearing material combinations in total hip arthroplasties: a prospective randomised study

The present study was performed to test the hypothesis that different bearing materials have an impact on femoral bone remodelling within the first year after a total hip arthroplasty. A total of 225 patients with osteoarthrosis of the hip or avascular necrosis of the femoral head were included in this randomised prospective study. All patients had an identical hybrid total hip arthroplasty (cemented BiMetric stem and cementless RingLoc acetabular cup) except for the bearing materials: polyethylene-on-zirconia (n = 78), CoCr-on-CoCr (n = 71), or alumina-on-alumina (n = 76). Bone mineral density (BMD) was measured with Dual-energy X-ray absorptiometry (DEXA) in seven Gruen zones adjacent to the femoral implant. The DEXA scan was performed within one week after surgery and was repeated one year postoperatively. There was no significant difference in periprosthetic BMD change between the three groups. After twelve months the relative BMD decrease was highest in the proximal part of the femur, - 6.2% in the greater trochanter region and - 12.7% in the lesser trochanter region. In the distal zones the relative BMD decrease was -5.3, -4.2, -2.1, -2.3, and -5.6%, respectively. The use of different bearing materials had no significant impact on femoral bone remodelling adjacent to the cemented hip stem within one year after surgery.

Cementless titanium tapered-wedge femoral stem: 10- to 15-year follow-up

This investigation is an ongoing clinical and radiographic analysis of a titanium tapered-wedge femoral component with a proximal plasma-spray porous coating. Integral femoral stems (Biomet, Warsaw, IN) were implanted in 200 hips in 186 patients. Nineteen patients died before 10-year follow-up, and 50 patients were lost to follow-up. The mean follow-up of the remaining 129 hips was 11.6 years. Harris Hip Scores improved from 58 to 93. Thigh pain was 2.3%. Radiographic analysis revealed adaptive distal remodeling in zones 2, 3, 5, 6, and 13, with no evidence of osteolysis below the level of the calcar and the greater trochanteric region. Only 2 femoral stems were revised: 1 with suspected fibrous fixation at 7 years postoperatively and another with a broken trunion at 10 years postoperatively. A tapered titanium femoral stem with circumferential plasma-spray porous coating provides excellent long-term fixation, durable clinical outcome, and protects against osteolysis below the level of the calcar and greater trochanter.

Effect on the femur of a new hip fracture preventive system using dropped-weight impact testing.

To reduce hip fractures during falls, we devised a new hip fracture preventive system to attenuate impact on the greater trochanteric region and studied the effects of the system on the femur. Twelve coupled, embalmed, cadaveric femora were used. Right femora were fractured without protection as a control and compared with left femora covered by the protection system, which consisted of a silicone gel pad or the silicone gel pad combined with a resin cover. The impact of a fall was simulated by mounting a femur in the horizontal plane and dropping an 8.4 kg mass on its greater trochanteric region. The impact load and time were measured using a load cell within the mass. The maximum strain during impact at the inferior side of the femoral neck was determined from an attached strain gauge. Trochanteric fractures were produced in 18 of the 24 femora (75%). The mean impact load for a drop height of 25 cm was reduced from 3117 N to 2176 N by silicone gel (p < 0.01) and to 1681 N by the addition of the resin cover (p < 0.01). The mean maximum strain was similarly reduced from 2276 microvarepsilon to 1872 microvarepsilon (p = 0.15) and to a mean 1559 microvarepsilon (p < 0. 05). The mean impact time was prolonged from 13 ms to 20 ms (p < 0. 01) and 22 ms (p < 0.01), respectively. The effect of the cover became more conspicuous as height increased. We concluded that the silicone gel pad provided effective impact attenuation, and the addition of the rigid cover was even more effective for impact reduction. This system was thought to be clinically useful in preventing hip fractures.

Presence of silicon in massive osteolysis after cementless total hip arthroplasty: Case report

Osteolysis associated with artificial joint arthroplasty seems to be the result of particles of wear debris (from ultra-high molecular weight polyethylene (UHMWPE), polymethylmethacrylate (PMMA), and metals), causing a macrophage response. Silicon particles, as residual contaminants embedded in the surface of both textured metal implants and polyethylene sockets, may be a factor in osteolysis. We present the case of a 57-year-old woman who had massive and aggressive osteolysis. The osteolytic lesion was isolated in the greater trochanter region 5 years after she had had primary cementless total hip arthroplasty (Cobalt-chromium alloy). There were no signs of mechanical loosening, but she experienced moderate pain. Under a polarized microscope and scanning electron micrography, a biopsied specimen from the osteolytic lesion revealed conglomerates of UHMWPE particles of various sizes between proliferated synovium-like cells. Quantitative energy-dispersive X-ray analysis focused on the conglomerates of UHMWPE particles demonstrated a marked presence of silicon. Although the definitive causative factor for a 1he osteolysis was regarded as a foreign-body reaction induced by UHMWPE particles, the presence of silicon was interesting in terms of the pathogenesis of osteolysis associated with artificial joint surgery.

Quantitative Analysis of Cancellous Bone Graft Available from the Greater Trochanter

To quantify the amount of cancellous bone graft available from the greater trochanteric region, 20 paired iliac crest-proximal femur specimens were harvested and compared in 10 adult pelvises. A 1.3 x 1.3-cm cortical window was made in the lateral aspect of the proximal femur 2 cm distal from the tip of the greater trochanter. Cancellous bone evacuation was performed by curettage. The extent of harvest was mechanically limited by the medial wall of the trochanter and by curette impingement on the margins of the cortical window. The graft was quantitated after maximal digital compression in a 10-ml syringe and compared with cancellous graft obtained from the paired anterior iliac crest. The average compressed volume of cancellous bone harvested from the greater trochanter was 6.5 ml (range, 4.2-9.6 ml). The average iliac crest cancellous bone volume was 6.0 ml (range, 2.7-8.8 ml). Differences in graft volume between the anterior iliac crest and the trochanter were not statistically significant. The resulting defect in the proximal femur remained isolated to the trochanteric region. In this study, we demonstrate that cancellous bone is available from the greater trochanteric region in an amount similar to that available from the anterior iliac crest. We also show that it is obtainable in a reproducible manner. Our clinical experience of over 100 cases has demonstrated acceptable morbidity associated with this technique. The greater trochanteric region may be used as a secondary source of autogenous cancellous bone graft when specific procedures demand more bone graft than available from the iliac crest alone, or in patients who have had previous iliac crest graft harvest.

Bone mineral density around femoral stems. DXA measurements in 22 porous-coated implants after 5 years.

In this cross-sectional study the bone mineral density (BMD) close to proximal porous-coated femur stems was measured by DXA 4.5-6 years after the stem implantation and compared to the contralateral non-operated femur in 22 cases. Measuring areas were defined by Gruen's method. The average precision error varied according to the zone assessed and ranged from 2.2 to 4.9 percent. The median BMD values of the operated femur were in 5 of 7 areas lower than those of the contralateral side. The largest differences were noted in the calcar region and the greater trochanteric region (21 and 20 percent, respectively). No correlation was found between the femoral BMD differences and the stem diameter.

Reversal of severe osteoporosis with vitamin B 12 and etidronate therapy in a patient with pernicious anemia

Pernicious anemia has recently been recognized as a risk factor for osteoporosis and fructures. Although vitamin B 12 is important for osteoblast function, the effect of vitamin B 12 replacement in states of vitamin B 12 deficiency on bone density and fracture incidence is not known. We report 2-year follow-up data from a patient with severe osteoporosis, multiple vertebral compression fractures, and pernicious anemia who exhibited a dramatic response to treatment with vitamin B 12 and cyclic etidronate. Serial bone density measurements demonstrated a 15% and 17% increase in the lumbar and greater trochanter regions, respectively, and a 79% increase in the femoral neck region over the 2-year follow-up period. In addition to normalization of bone density compared with age-matched controls, no subsequent vertebral fractures were noted in the 2-year period following initiation of vitamin B 12 and etidronate therapy. This case demonstrates that osteoporosis associated with pernicious anemia may be markedly improved by vitamin B 12 replacement and cyclic etidronate therapy.

Relationship Between Trunk Muscle Torque and Bone Mineral Content of the Lumbar Spine and Hip in Healthy Postmenopausal Women

The purpose of the study was to determine the relationship between trunk muscle strength and bone mineral density (BMD). Fifty-six postmenopausal women, aged 38 to 73 years, were examined. The BMD of lumbar vertebrae L2-4, the femoral neck, the Ward's triangle, and the greater trochanter was measured with dual-photon absorptiometry. Isometric and isokinetic torque and work measurements obtained on a trunk testing unit were used to assess trunk flexor and extensor strength. Correlation analysis demonstrated a statistically significant relationship between most trunk torque and work measurements and BMD. The trunk extensors generally provided higher correlations with BMD than did the trunk flexors, and the isokinetic extension torque values demonstrated higher correlations than the isometric extension values in every case. Linear backward-regression models, based on the subjects' weight and trunk flexor and extensor torque and work measurements, demonstrated multiple-correlation coefficients of .67, .58, .43, and .65 in predicting the BMD of the L2-4 region, femoral neck, Ward's triangle, and greater trochanter region, respectively. Estrogen therapy status did not affect the linear regression models. These data suggest a positive relationship in postmenopausal women between flexor and extensor torque values and BMD at the lower lumbar spine and proximal femur.

Pseudobursae: a useful finding in patients with painful hip arthroplasty.

A retrospective review of 178 consecutive subtraction hip arthrograms (175 patients) was performed to evaluate the significance of cavities or bursal communications (or both) with the pseudocapsule in patients with painful hip arthroplasty. Bursae and/or communicating cavities were shown in 75 (43%) of the 175 patients. Communicating irregular cavities were noted in 12 patients (nine infected), and smooth bursae or bursalike structures were noted in 63 patients. The most frequent bursal locations were the greater trochanteric region (32/63), supraacetabular region (18/63), and iliopsoas (12/63). Three patients had multiple bursae. Six of the 18 acetabular bursae were associated with previous dislocations. Twenty-seven patients with bursae had no radiographic findings of loosening or infection. Of these 27, 12 (44%) responded to local injection of anesthetic into the bursa and were judged clinically to have bursitis. Arthrography, with aspiration from the bursae or cavities and injection of anesthetic, provides additional information regarding painful hip arthroplasty and may prevent unnecessary surgery.

Measurement of bone blood flow with a 133Xe washout method

A method based on the intravenous 133Xe injection technique has been used for measurement of bone blood flow in man. The measurements were made from the greater trochanteric region of the femur of eight healthy subjects and three patients with bone marrow or a bone disease in which bone blood flow is known to be increased. The half-times of the fast and the slow compartments of the externally recorded two-exponential bone washout curves were 4.05 +/- 0.88 min and 45.4 +/- 7.4 min (mean +/- 1 sd) in the healthy subjects, 1.46 min and 20.1 min in the patient with chronic myeloid leukemia, 2.50 min and 22.9 min in metastic bone disease and 1.93 min and 18.1 min in the patient with osteosarcoma, respectively. The corresponding flow values were 11.5 +/- 1.4 ml/100 g/min (mean +/- 1 sd) in healthy subjects and 59.8, 28.3 and 34.0 ml/100 g/min in patients with bone disorders. The precision of the method estimated from the duplicate measurements in eight healthy persons is; for the fast compartment, 6.8%; and for the slow one, 3.2%. Because of the rapid washout of xenon and the very low radiation dose the measurements are easily repeatable.