Lateral Femoral Cortex Research Articles

Callus formation after total hip arthroplasty using a short tapered-wedge stem.

The incidence of periprosthetic fractures after total hip arthroplasty using a short tapered-wedge stem is high. Callus formation preceding this fracture, which indicates postoperative stress fracture around the stem, has been reported. However, previous studies on postoperative callus are limited. Hence, the current study aimed to evaluate the prevalence and risk factors of postoperative callus after total hip arthroplasty with a short tapered-wedge stem. This retrospective study included 127 patients who underwent total hip arthroplasty using a cementless short tapered-wedge stem. The depth of stem insertion was measured as the distance from the lateral corner of the stem to the most medial point of the lesser trochanter along the body axis. Postoperative callus was defined as a bridging callus on the lateral femoral cortex at the distal end of the porous coating of the stem. Plain radiography was performed before surgery and immediately and at 1, 3, and 6months after surgery to assess postoperative callus. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for PC. In total, 60 (47.2%) of 127 patients presented with postoperative callus. Multivariate logistic regression analysis with postoperative callus as the dependent variable revealed that the stem depth at 1month after total hip arthroplasty (odds ratio, 1.14; 95% confidence interval, 1.04-1.24, p = 0.002) was a significant and independent risk factor of postoperative callus. Deep insertion of a short tapered-wedge stem is a risk factor for postoperative callus.

A finite element analysis of a low-profile femoral neck system of screws in sleeves in a vertical femoral neck fracture model

BackgroundFemoral neck system (FNS) has exhibited some drawbacks, such as non-fit of the plate with the lateral femoral cortex, postoperative pain, and the potential risk of subtrochanteric fractures. We have developed a low-profile FNS system that addresses some compatibility issues in FNS. In this study, we conducted finite element analysis on the 1-hole FNS (1 H-FNS), 2-holes FNS (2 H-FNS), and low-profile FNS (LP-FNS) and compared their biomechanical performance.MethodsAfter the mesh convergence analysis, we established three groups of 1 H-FNS, 2 H-FNS, and LP-FNS. The interfragmentary gap, sliding distance, shear stress, and compressive stress and the bone-implant interface compression stress, stiffness, and displacement were determined under the neutral, flexion, or extension conditions of the hip joint, respectively. The stress and displacement of the femur after the implant removal were also investigated.Results(1) There were no obvious differences among the three FNS groups in terms of the IFM distance. However, the LP-FNS group showed less rotational angle compared with conventional FNS (neutral: 1 H-FNS, -61.64%; 2 H-FNS, -45.40%). Also, the maximum bone-implant interface compression stress was obviously decreased under the neutral, flexion, or extension conditions of the hip joint (1 H-FNS: -6.47%, -20.59%, or -4.49%; 2 H-FNS: -3.11%, 16.70%, or -7.03%; respectively). (2) After the implant removal, there was no notable difference in the maximum displacement between the three groups, but the maximum von Mises stress displayed a notable difference between LP-FNS and 1 H-FNS groups (-15.27%) except for the difference between LP-FNS and 2 H-FNS groups (-4.57%).ConclusionsThe LP-FNS may not only provide the same biomechanical stabilities as the 1 H-FNS and 2 H-FNS, but also have more advantages in rotational resistance especially under the neutral condition of the hip joint, in the bone-implant interface compression stress, and after the implant removal. In addition, the 1 H-FNS and 2 H-FNS have similar biomechanical stabilities except for the maximum von Mises stress after the implant removal. The femur after the LP-FNS removal not only is subjected to relatively little stress but also minimizes stress concentration areas.

Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture.

To assess the correlation between the amount of proximal screw lateralization and clinical symptoms in patients treated with a cephalomedullary nail (CMN) after a pertrochanteric fracture. Retrospective study. Level 1 trauma center. Patients operated for a pertrochanteric fracture (OTA/AO A1, A2, A3) between 2019 and 2022 and treated with a CMN were included. Three measurements were evaluated: D1 distance between the most laterally prominent point of the lag screw and the line tangent to the greater trochanter, D2 distance between the lateral femoral cortex and the most laterally prominent point of the lag screw, and D3 distance between the point where the lag screw emerges at the lateral edge of the femur shaft and the skin's surface. Clinical scores and information regarding lateral thigh pain were obtained, and a correlation analysis was performed. Mean age of the study cohort (n = 134) was 77.9 ± 12.3 years. Patients with categorical protrusion (considered present in cases where the distance between the lateral tip of the lag screw and the lateral border of the greater trochanter was ≥0.2 mm) had significantly higher rates of lateral thigh pain ( P = 0.007) and discomfort while lying on the side ( P = 0.032) compared with those without protrusion. Correlation analyses showed a positive correlation between measurements D1 and D2 and lateral thigh pain (r = 0.324 and r = 0.334, respectively, P < 0.001) and a negative correlation between D3 and lateral thigh pain (r = -0.286, P = 0.001). Regression analysis showed that higher D1 and D2 distances and shorter D3 distances are risk factors for lateral thigh pain ( P = 0.001, 0.001, and 0.002, respectively). Increasing lateral protrusion of the lag screw leads to significantly greater clinical complaints and lateral hip pain in patients treated with a CMN. Patients with lower distance between the lateral femoral wall and the skin are at higher risk of lateral pain. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

Osteochondral femoral anterior cruciate ligament avulsion in a 13 years old patient: a case report

Anterior cruciate ligament (ACL) injury, is one of the most common injuries occurring in young active patients. Regarding pediatric group, ACL avulsion is the most common form of injury in contrast to adults, whose injury pattern is described as mid-substance injury. Tibial avulsion of ACL is the most common form of avulsion in pediatrics, while osteochondral femoral avulsion is considered rare entity. Our case report is about a 13-year-old pediatric male patient, sustained injury over his right knee during soccer game in March 2023. Immediately after injury, patient described having giving way, associated with severe pain. 2 days after initial injury, patient and his family noticed that his giving way continued to occur. Upon presentation to clinic, physical examination raised suspicion to have ACL injury, magnetic resonance imaging (MRI) and computed tomography (CT) confirmed osteochondral femoral origin avulsion of ACL. After reviewing literature, decision was to go for ACL repair through femoral origin avulsion fracture fixation using suture pullout technique secured with two anchors fixed through lateral femoral cortex to avoid physis injury while reaming femoral and tibial tunnels used for graft reconstruction. On follow up, excellent functional outcome regarding knee stability and range of motion. We conclude that although femoral-sided repair using suture pullout technique carried higher risk of failure than ACL reconstruction, this method shows excellent functional outcome, and can be used in cases of osteochondral femoral avulsion in pediatric group to avoid risk of physis injury in such age group.

Can ultrasound-guided radiofrequency ablation of genicular nerves of the knee, be performed without locating corresponding arterial pulsations—a cadaveric study

IntroductionGiven the rising prevalence of knee osteoarthritis, radiofrequency ablation of genicular nerves (RFA) has emerged as a promising treatment option for knee pain. The knee has an extremely complex and variable innervation with nearly 13 genicular nerves described. The frequently ablated genicular nerves are the superomedial (SMGN), the superolateral (SLGN), and the inferomedial (IMGN) genicular nerves. Conventionally, under ultrasound guidance, these nerves are ablated near the corresponding arterial pulsations, but due to the rich vascular anastomosis around the knee joint, identifying the arteries corresponding to these constant genicular nerves can be tedious unless guided by some bony landmarks. In this study, we have evaluated whether it is possible to accurately target these three genicular nerves by just locating bony landmarks under ultrasound in human cadaveric knee specimens.MethodsFifteen formalin-fixed cadaveric knee specimens were studied. SMGN was targeted 1 cm anterior to the adductor tubercle in the axial view. For SLGN, in the coronal view, the junction of the lateral femoral condyle and shaft was identified, and at the same level in the axial view, the crest between the lateral and posterior femoral cortex was targeted. For IMGN in the coronal view, the midpoint between the most prominent part of the medial tibial condyle and the insertion of the deep fibers of the medial collateral ligament was marked. The medial end of the medial tibial cortex was then targeted at the same level in the axial view. The needle was inserted from anterior to posterior, with an in-plane approach for all nerves. Eosin, 2% W/V, in 0.1 ml was injected. Microdissection was done while keeping the needle in situ. Staining of the nerve was considered a positive outcome, and the percentage was calculated. The nerve-to-needle distance was measured, and the mean with an interquartile range was calculated.ResultThe accuracies of ultrasound-guided bony landmarks of SMGN, SLGN, and IMGN were 100% in terms of staining, with average nerve-to-needle distances of 1.67, 3.2, and 1.8 mm respectively.ConclusionIt is with 100% accuracy, that we can perform RFA of SMGN, SLGN, and IMGN under ultrasound guidance, by locating the aforementioned bony landmarks.

Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia: A Case Report.

In the setting of a total hip arthroplasty performed in a patient with a proximal femoral deformity, atraumatic periprosthetic femoral stress fracture may arise as a complication. We report a rare case of a late periprosthetic femoral stress fracture around a cemented stem in a patient with a history of fibrous dysplasia of the proximal femur. After a 10-year uneventful period, the patient complained about a subtle, subacute pain in his left thigh induced by exercise but not with daily axial load. Diagnosis of a nondisplaced, incomplete (i.e., only compromising the lateral femoral cortex) periprosthetic femoral stress fracture was made with plain radiographs, blood work, and bone scintigraphy. Surgical treatment consisted of a minimally invasive plate osteosynthesis bridging the femoral deformity plus percutaneous osteoperiosteal decortication. At 5-year follow-up, the patient was asymptomatic with full return to physical activity, with radiographs evidencing callus formation. Stress fractures around well-fixed femoral stems, while infrequent, should be addressed in patients with a history of severe proximal femur deformity experiencing atraumatic thigh pain.

Anatomical Landmark Technique for Femoral Tunnel Placement of Lateral Extra-Articular Tenodesis

The anterolateral ligament is a crucial part of the anterolateral complex of the knee, providing rotator stability to the knee and being a primary restraint to tibial internal rotation. Lateral extra-articular tenodesis added to anterior cruciate ligament reconstruction can reduce pivot shift without sacrificing the range of motion or increasing the risk of osteoarthritis. A 7- to 8-cm longitudinal skin incision is made and a 9.5- to 10-cm × 1- cm wide iliotibial band graft is dissected, leaving the distal attachment intact. The free end is whip stitched. One of the most important steps during the procedure is the identification of the site of attachment of the iliotibial band graft. The leash of vessels, fat pad, lateral supracondylar ridge, and fibular collateral ligament serve as important landmarks. The tunnel is drilled from the lateral femoral cortex with a guide pin and reamer pointing 20 to 30° anteriorly and proximally while the arthroscope visualizes the femoral anterior cruciate ligament tunnel. The graft is routed under the fibular collateral ligament. The graft is fixed with a bioscrew while the knee is kept in 30° flexion and the tibia is kept in neutral rotation. We believe that lateral extra-articular tenodesis gives the anterior cruciate ligament graft a good chance for faster healing along with addressing anterolateral rotatory instability. Choosing a correct fixation point is very important to restore normal knee biomechanics.

A NEW LESS INVASIVE HIP APPROACH

This technique is a novel superior based muscle sparing approach. Acetabular reaming in all hip approaches requires femoral retraction. This technique is performed through a hole in the lateral femoral cortex without the need to retract the femur.A 5 mm hole is drilled in the lateral femur using a jig attached to the broach handle, similar to a femoral nail. Specialised instruments have been developed, including a broach with a hole going through it at the angle of the neck of the prosthesis, to allow the rotation of the reaming rod whilst protecting the femur. A special C-arm is used to push on the reaming basket. The angle of the acetabulum is directly related to the position of the broach inside the femoral canal and the position of the leg. A specialised instrument allows changing of offset and length without dislocating the hip during trialling.Some instrumentation has been used in surgery but ongoing cadaver work is being performed for proof of concept. The ability to ream through the femur has been proven during surgery. The potential risk to the bone has been assessed using finite analysis as minimal. The stress levels for any diameter maintained within a safety factor &gt;4 compared to the ultimate tensile strength of cortical bone.The described technique allows for transfemoral acetabular reaming without retraction of the femur. It is minimally invasive and simple, requiring minimal assistance. We are incorporating use with a universal robot system as well as developing an electromagnetic navigation system. Assessment of the accuracy of these significantly cheaper systems is ongoing but promising.This approach is as minimally invasive as is possible, safe, requires minimal assistance and has a number of other potential advantages with addition of other new navigation and simple robotic attachments.

Arthroscopic Visualization of Femoral Cortical Button Deployment During Anterior Cruciate Ligament Reconstruction

Background: Up to 25% of femoral cortical suspensory fixation devices are reported to be deployed inappropriately during anterior cruciate ligament (ACL) reconstruction. Most techniques for visualizing suspensory button deployment reported in the literature are for adjustable loop buttons and outside-in femoral tunnel technique. Intraoperative radiographs are inconvenient and involve exposure to radiation. No “gold standard” technique for visualization of femoral cortical button deployment has been described yet. Indications: This technique can be employed for all patients requiring ACL reconstruction surgery. Technique Description: The femoral tunnel is prepared from the anteromedial portal. With the knee in flexion, a beath pin loaded with a suture loop is passed via the anteromedial portal through the femoral tunnel; the eyelet of the pin with the suture loop is retained in the femoral tunnel. The knee is extended without fear of bending the beath pin. The arthroscope is shifted into the lateral gutter. An outside-in lateral parapatellar portal is made at the level of the center of the patella, 1 cm lateral to its lateral edge. The joint capsule and soft tissues in the lateral gutter are resected using a shaver. The beath pin is identified without fear of lacerating the suture loop. The exit point of the pin depends on the knee flexion at the time of femoral tunnel preparation, and more flexion results in more anterior pin exit and vice versa. The rest of the surgery is performed as planned. The definitive sutures of the desired femoral cortical suspensory device are passed from the tibial tunnel into the femoral tunnel. The arthroscope is then positioned in the lateral gutter and the cortical button is deployed appropriately under vision, onto the lateral femoral cortex. If required, the cortical button can be manipulated to seat it appropriately, using an instrument from the lateral parapatellar portal. The remainder of the surgery is performed as per the surgeon’s preference. Results: We routinely perform this step during ACL reconstruction. It adds 2 to 4 minutes to the surgical time. We have not encountered any complications of this procedure. Discussion/Conclusion: This maneuver is effective in facilitating appropriate deployment of femoral cortical suspensory devices under vision.

The effect of onlay cortical fibula strut grafts on biomechanical features of Vancouver type B1 periprosthetic femoral fractures.

This study aimed to investigate biomechanically the effects of onlay fibula grafts on Vancouver Type B1 Periprosthetic Femoral Fractures (PPFs). Vancouver Type B1 PFF models were created in 25 fourth-generation synthetic femurs and fixed with locking plates using bicortical, unicortical screws, and cables. While no graft was used in group 1, onlay fibula grafts were placed anteriorly in group 2 and medially in group 3. In group 4, the cortical strut allograft was placed on the medial femoral cortex, and a locking compression plate (LCP) was applied to the lateral femoral cortex. In group 5, the strut allograft was placed over the anterior cortex of the femur and fixed with the same technique as in group 4. All models were then subjected to rotational and axial cyclical stiffness tests and load to failure to measure and compare the mechanical strengths of the constructs. The mean stiffness values of group 4 with medial allograft, before and after cyclical loading, were higher than all other groups, under both rotational and axial forces. The mean stiffness values of fibula autografts (groups 2 and 3) were similar to that of anterior allografts (group 5) in each test except that the mean initial axial stiffness of group 5 was higher than group 2. Failure loads were also not different between the groups. Although the rigidity of Vancouver type B1 periprosthetic femur fractures is highest if allografts are placed medially, fibula autografts can also provide similar fixation strengths to allografts if locking plates with unicortical and bicortical screws and cables are used.

Comparison of anterior knee laxity immediately after anatomic double-bundle anterior cruciate ligament reconstruction: Manual tensioning vs tensioning boot techniques

PurposeTensioning technique at graft fixation is one of key factors for successful outcomes in ACL reconstruction. The tensioning boot, which had two tensioners and was fixed to the tibia with a bandage, was developed for precise graft tensioning. The purpose was to compare the anterior knee laxity between the manual tensioning and the tensioning boot techniques immediately after ACL reconstruction under anesthesia in order to elucidate the effectiveness of using the tensioning boot. Methods33 patients had anatomic double-bundle ACL reconstruction with semitendinosus tendon graft. After grafts were fixed with EndoButton-CL on lateral femoral cortex, grafts were tied to Double Spike Plate (DSP). Each graft was pre-tensioning with 20 N (totally 40 N) at 20 degree of flexion for 3 minutes using manually-held tensioner in 11 patients and using tensioner installed to tensioning boot in the remaining 22 patients before graft fixation, and were then fixed in the same manner. Tibial displacement under 67 and 89 N of tibial anterior load was measured by KT-2000 Knee Arthrometer under anesthesia before and immediately after operation. ResultsThe anterior knee laxity in the operated knee was 4.5 ± 1.0 mm in the manual tensioning group and 2.9 ± 0.9 mm in the tensioning boot group at 89 N of anterior load, showing a significant difference. (P < .0001) The side-to-side difference in the manual tensioning group was significantly less than that in the tensioning boot group. (P = .002) ConclusionsAnterior laxity of the operated knees as well as KT side-to-side difference immediately after ACL reconstruction was larger in the tensioning boot technique than the manual tensioning technique, when the graft was fixed in the same manner. Thus, the initial tension at graft fixation with the tensioning boot can be smaller than 40 N.

Safe femoral condyle range for the reverse Rigidfix femoral fixation device in anterior cruciate ligament reconstruction

BackgroundTo determine the characteristics of cross-pin protrusion in patients treated with the reverse Rigidfix femoral fixation device for femoral tunnel preparation through the anteromedial portal in Arthroscopic anterior cruciate ligament reconstruction (ACLR), analyse the reasons for this outcome, and identify safety hazards of this surgical technique for improvement.MethodsA retrospective analysis of patients who underwent ACLR using this technology at our hospital in 2018 was conducted. Patients with and without cross-pin protrusion were included in the protrusion positive and negative groups, respectively. The sex, age and imaging characteristics of the patients with cross-pin protrusion were identified, and the reasons for cross-pin protrusion were analysed.ResultsThere were 64 and 212 patients in the protrusion positive and negative groups, respectively. The proportion of cross-pin protrusion cases was 23.19% (64/276). There was a significant difference in the ratio of males to females (P < 0.001, χ2 = 185.184), the mediolateral femoral condyle diameter (protrusion positive group, 70.59 ± 2.51 mm; protrusion negative group, 82.65 ± 4.16 mm; P < 0.001, t = 28.424), and the anteroposterior diameter of the lateral femoral condyle (protrusion positive group, 58.34 ± 2.89 mm; protrusion negative group, 66.38 ± 3.53 mm; P < 0.001, t = 16.615). The cross-pins did not penetrate the lateral femoral condyle cortex in patients with a mediolateral femoral condyle diameter ≥ 76 mm, but the cross-pins definitely penetrated the cortex when the diameter was ≤ 70 mm. The cross-pins did not penetrate when the anteroposterior lateral femoral condyle diameter was ≥ 66 mm, but the cross-pins definitely penetrated it when the diameter was ≤ 59 mm.ConclusionThe patients with cross-pin protrusion after reverse Rigidfix femoral fixation treatment to prepare the femoral tunnel through the anteromedial portal in ACLR were mainly females with small femoral condyles. For patients with a mediolateral femoral condyle diameter ≥ 76 mm and an anteroposterior lateral femoral condyle diameter ≥ 66 mm, there is no risk of cross-pin protrusion, so this technique can be used with confidence.Levels of evidenceIII.

Greater trochanter morphology and association with patient demographics, surgical factors, and post-operative stem position: a retrospective assessment of 150 cementless THRs in 135 dogs

BackgroundTotal hip replacement (THR) in the gold standard surgical treatment for the canine hip. While it has been shown that greater trochanter morphology affects post-operative cementless stem position in humans, trochanter morphology and the effect on cementless stem position has not been extensively evaluated in dogs. The objective of this study was to classify greater trochanter morphology and identify potential associations between trochanter morphology and patient demographics, femoral canal geometry, surgical time, technique modifications, and post-operative stem position in client-owned dogs undergoing cementless THR.ResultsIn this retrospective study, medical records and radiographs of 135 dogs undergoing 150 cementless total hip replacements from 2013 to 2020 were included. Trochanters were classified in the frontal plane using an ordinal grading system adapted from human THR. A Grade I trochanter denoted a trochanter positioned lateral to the periosteal surface of the lateral femoral cortex, whereas a Grade IV trochanter denoted a trochanter positioned medial to the anatomic axis of the femur. Associations between trochanter grade and other variables were examined using ANOVA, Kruskall-Wallis, or chi-squared tests. Significance was assumed at P ≤ .05.Trochanters were classified as follows: Grade I (44/150, 29.3%), Grade II (56/150, 37.4%), Grade III (44/150, 29.3%), Grade IV (6/150, 4.0%). Grade IV trochanters had lower anatomic lateral distal femoral angle (aLDFA; 91.0 ± 6.2°), angle of inclination (117.7 ± 10.5°), and canal flare index (1.53 ± 0.27). When compared to all groups, Grade IV trochanters were associated with longer surgical times (Grade IV: 227.0 ± 34.2 min; all grades: 183.2 ± 32.9 min) and technique modifications (Grade IV: 83.3%; all grades: 18%). Grade I trochanters had stems placed in valgus (− 1.8 ± 2.33°), whereas Grade II (0.52 ± 2.36°), III (0.77 ± 2.58°), and IV (0.67 ± 2.73°) trochanters exhibited varus stems. Depth of stem insertion was greater (11.2 ± 4.2 mm) for Grade IV trochanters.ConclusionsTrochanter grade was associated with post-operative stem alignment and translation in the frontal plane. Grade IV trochanters were associated with altered femoral geometry, increased surgical time, technique modifications, and stem insertion depth. Pre-operative greater trochanter classification may prove useful in identifying cases requiring prolonged surgical times or technique modifications.

Mechanical effects of surgical variations in the femoral neck system on Pauwels type III femoral neck fracture : a finite element analysis.

AimsIn this study, we aimed to explore surgical variations in the Femoral Neck System (FNS) used for stable fixation of Pauwels type III femoral neck fractures.MethodsFinite element models were established with surgical variations in the distance between the implant tip and subchondral bone, the gap between the plate and lateral femoral cortex, and inferior implant positioning. The models were subjected to physiological load.ResultsUnder a load of single-leg stance, Pauwels type III femoral neck fractures fixed with 10 mm shorter bolts revealed a 7% increase of the interfragmentary gap. The interfragmentary sliding, compressive, and shear stress remained similar to models with bolt tips positioned close to the subchondral bone. Inferior positioning of FNS provided a similar interfragmentary distance, but with 6% increase of the interfragmentary sliding distance compared to central positioning of bolts. Inferior positioning resulted in a one-third increase in interfragmentary compressive and shear stress. A 5 mm gap placed between the diaphysis and plate provided stability comparable to standard fixation, with a 7% decrease of interfragmentary gap and sliding distance, but similar compressive and shear stress.ConclusionFinite element analysis with FNS on Pauwels type III femoral neck fractures revealed that placement of the bolt tip close to subchondral bone provides increased stability. Inferior positioning of FNS bolt increased interfragmentary sliding distance, compressive, and shear stress. The comparable stability of the fixation model with the standard model suggests that a 5 mm gap placed between the plate and diaphysis could viably adjust the depth of the bolt.Cite this article: Bone Joint Res 2022;11(2):102–111.

Clinical and radiographic outcomes of primary total hip arthroplasty with the revelation hip system using density mapping.

The Revelation Hip System is a cementless stem with a lateral flare concept. Stable fixation is achieved by fitting the stem to the medullary cavity of the proximal lateral femoral cortex. Patients who have undergone total hip arthroplasty using the Revelation Hip System show good postoperative clinical and radiographic outcomes. However, to the best of our knowledge, no study has reported the relationship between stem fitting and clinical or radiological outcomes after the surgery. In the present study, we investigated the relationship between stem fitting and clinical or radiological outcomes after total hip arthroplasty (THA) using the Revelation Hip System. In this study, 28 hips of 26 patients who were treated with the Revelation Hip System for osteoarthritis, osteonecrosis of the femoral head, rheumatoid arthritis, and rapidly destructive coxarthropathy and were followed up for > 5 y were enrolled. These patients were divided into two groups, including the rest fit group (11 hips, group R) and the control group (17 hips, group C), according to the results of the density mapping analysis. In group R, the lateral side of the stem fits on the medullary cavity of the proximal lateral femoral cortex, while in group C, the lateral side of the stem did not fit. Radiographic results showed no significant differences between the groups in terms of stem alignment, subsidence, and stress shielding around the cup. The incidence of stress shielding around the stem in zone 7 was not significant but tended to be higher in group R than in group C (p = 0.052). Clinical outcomes showed no significant differences between group R and group C in terms of the Harris hip score, the Japanese Orthopaedic Association (JOA) score, and the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) total score. However, pain complaints that were assessed by patient-reported outcomes using the 36-Item Short Form Health Survey (SF-36) bodily pain and vitality subscales and the JHEQ pain subscale were significantly higher in group R than in group C at the final follow-up. These results suggest that some patients had pain complaint even if the stems were inserted as per the concept after THA with the Revelation Hip System.Trial Registration911.

Occult fracture propagation in patients with isolated greater trochanteric fractures: patterns and management.

To demonstrate the degrees of occult intertrochanteric extension on MRI in patients with a greater trochanteric fracture on radiography or computer tomography (CT) and whether these patients undergo conservative or surgical management with hardware. Retrospective review was performed of 146 patients (104 females, 42 males, ages 33-102) who had follow-up MRI after identification of a greater trochanteric fracture without intertrochanteric extension on radiography or CT. Extent of intertrochanteric extension was recorded. Subsequently, EMR review was performed to see if patients underwent surgery. Specific note was made of hardware type. Analysis was performed to determine if there is a correlation with fracture type and surgical management as well as fracture type and age and gender. Nineteen patients had horizontal greater trochanter fractures without intertrochanteric extension; none underwent surgery. Seventeen patients had a vertical fracture along the lateral femoral cortex; one underwent surgery. Thirty-three patients had a fracture with intertrochanteric extension less than 50% in the mid coronal plane; 21 underwent surgery. Forty patients had intertrochanteric extension greater than 50% in the midcoronal plane not contacting the medial cortex; 28 underwent surgery. Thirty-seven patients had fractures contacting the medial cortex; 28 underwent surgery. There was significant difference with fractures extending 50% or greater of the midline of the intertrochanteric region undergoing surgical management compared with fractures less than 50% (p < 0.0001). MRI identifies the presence and extent of occult intertrochanteric fractures in patients with greater trochanteric fractures. Description of intertrochanteric fractures on MRI helps determine the patient's treatment course and influence surgical decisions.

Hip Hemiarthroplasty: The Misnomer of a Narrow Femoral Canal and the Cost Implications.

ObjectiveHemiarthroplasty has been identified as the treatment of choice for displaced intracapsular femoral neck fractures. A modular prosthesis is sometimes preferred for its sizing options in narrow femoral canals, despite its higher cost and no advantage in clinical outcomes. Thus, in this study, we investigated the factors affecting surgeons’ choice of prosthesis, hypothesizing that modular hemiarthroplasty is overused for narrow femoral canals compared to monoblock hip hemiarthroplasty.MethodsA retrospective study of a regional level 1 trauma center was conducted. Patients who had sustained femoral neck fractures from March 2013 to December 2016 were included in this study. Inclusion criterion was modular hemiarthroplasty for a narrow femoral canal. A matched group of patients who underwent monobloc hemiarthroplasty (MH) was created through randomization. The main outcome measurements were sex, age, Dorr classification, and femoral head size. We measured the protrusion of the greater trochanter beyond the level of the lateral femoral cortex postoperatively. Modular hemiarthroplasty patients were templated on radiographs using TraumaCad for Stryker Exeter Trauma Stem (ETS®).ResultsIn total, 533 hemiarthroplasty procedures were performed, of which 27 were modular for a narrow femoral canal. The ratio of modular to monobloc was 1:18. Average head size was 46.7 mm ± 3.6 mm for monobloc and 44.07 ± 1.5 for modular (P= 0.001). There were four malaligned stems in the monobloc group versus 14 in the modular group (P= 0.008). Unsatisfactory lateralization was noted in 18 patients (7 mm ± 2.9 mm) in the modular group compared with 8 (4.7 mm ± 3.9 mm) in the monobloc group (P= 0.029). Dorr classification was A or B in 24 patients in the modular group and 18 in the monobloc group (P = 0.006). Templating revealed that modular was not required in 25 patients.ConclusionsAs per our findings, it was determined that patients with a narrow femoral canal intraoperatively should not receive modular hemiarthroplasty. This is especially true for female patients with small femoral head and narrow femoral canal dimensions (Dorr A and B). They would require extensive careful planning. Surgical techniques should be explored through education intraoperatively to achieve lateralization during femoral stem preparation. This may avoid prolonged anesthetic time and achieve potential cost savings.

Anterior Cruciate Ligament Femoral Socket Preparation Using a Cannulated, Calibrated Drill With Adjustable Stop and Slotted Cannula

Anteromedial portal–guided femoral tunnel preparation during anterior cruciate ligament reconstruction can be difficult owing to poor visualization. This may cause iatrogenic damage to the medial femoral condyle cartilage and the posterior cruciate ligament fibers or overdrilling through the lateral femoral cortex, creating difficulties in the use of femoral suspensory devices during anterior cruciate ligament reconstruction. We describe an accurate and safe technique for femoral graft socket preparation using a cannulated, calibrated drill with an adjustable stop and slotted cannula. This easy and reproducible technique uses simple additional instruments and effectively addresses concerns related to femoral graft socket preparation, without requiring additional surgical time.

The effect of soft tissue interposition of the Endobutton on clinical results and on its postoperative migration after single-bundle anterior cruciate ligament reconstruction

BackgroundThis study aimed to investigate the possible consequences of soft tissue interposition of Endobutton on clinical outcomes and reoperation rates after anterior cruciate ligament reconstruction. MethodsWe measured the distance between the centre of the Endobutton and the lateral femoral cortex on the postoperative first day anteroposterior X-rays of the 156 knees that underwent anterior cruciate ligament reconstruction. Those with a distance less than 1 mm were regarded as Group 1 (118 patients), the ones between 1 mm and 2 mm were regarded as Group 2 (30 patients) and the ones more than 2 mm were regarded as Group 3 (8 patients). The movement of the Endobutton of more than 1 mm along the femoral tunnel axis on anteroposterior X-rays or its rotation by more than 5° on lateral X-rays during follow-up were considered migration. Clinical assessment scores (Lysholm, Tegner Activity Scale), clinical examination tests, and rates of Endobutton migration in the groups were analysed. ResultsEleven Endobuttons (9.3%) in Group 1, 26 Endobuttons (86.7%) in Group 2 and all of the 8 Endobuttons (100%) in Group 3 were observed to have migrated. Clinical results and examination tests showed no significant difference between Groups 1 and 2, whereas a significant difference was detected in Group 3 compared to Groups 1 and 2 (p < 0.05). ConclusionSoft tissue interposition is a major cause of Endobutton migration, and an interposition over 2 mm between the Endobutton and the lateral femoral cortex can negatively affect the outcomes after an anterior cruciate ligament surgery.