An algorithm for the management of femoral neck fractures

The choice of total hip arthroplasty should probably be reserved for those rare patients with preexisting osteoarthritis of the hip in the setting of a subcapital hip fracture. Additionally, relative indications for total hip arthroplasty may include the presence of contralateral hip disease; the presence of metabolic bone disease, which may controvert internal fixation or reasonable results with endoprosthetic replacement; and those patients with high activity expectations or life expectancy greater than 5 years. Given the diminished performance of hemiarthroplasty with time and activity, it may be argued that the most cost effective solution to the subcapital hip fracture in the majority of patients may be the reduction and internal fixation pathway, with elective conversion, when necessary, of the approximately 25% of patients who suffer avascular necrosis to total hip arthroplasty. It appears that hemiarthroplasty is best suited for the elderly household ambulator, whereas total hip arthroplasty is the better alternative either as the elective solution to failed internal fixation of femoral neck fractures or in the occasional community ambulator with high activity expectations and irreducible femoral neck fractures. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip joint.     

Cytokines--the compounds of the nineties: where is it leading?

A case of a patient with traumatic, simultaneous right posterior and left anterior hip dislocations without associated fractures is reported. Simultaneous asymmetric bilateral hip dislocation is very rare. The mechanism of this injury is discussed.     

Gas bubbles in the hip joint on CT: an indication of recent dislocation

OBJECTIVE: The purpose of this study was to determine if gas bubbles in the hip joint seen on CT scans after trauma are reliable indicators of recent (< 48 hr) hip dislocation. We believe that the gas seen in the hip joint represents intracapsular nitrogen bubbles that result from the vacuum created by forcible distraction associated with traumatic dislocation. MATERIALS AND METHODS: CT scans of 79 consecutive patients with pelvic injury were reviewed retrospectively. We noted the number and position of intracapsular gas bubbles, presence of joint effusion, soft-tissue injury, and associated fractures or dislocations. Intracapsular gas bubbles were defined as round areas of low attenuation, in an intracapsular position, that on visual inspection were equivalent to air. Seventy-three of 79 patients were imaged within 48 hr of injury. Most patients had been involved in a motor vehicle collision or were pedestrians struck by a motor vehicle. Fifteen patients had hip dislocation, including one patient with bilateral dislocation. Fifty-five patients had pelvic fractures without hip dislocation, and nine patients had soft-tissue injury without fracture or dislocation. Fourteen of 16 dislocations had been reduced at the time of scanning. RESULTS: Gas bubbles were seen in the hip joint on CT scans in 13 (81%) of the 16 dislocated hips, including 12 (92%) of 13 dislocations in patients scanned within 4 hr of admission. Bubbles were present in 11 (79%) of 14 hip joints that had dislocations reduced at the time of scanning and in both hip joints that remained dislocated. Most bubbles were located anterior to the femoral neck; however, bubbles were also seen posteriorly. Bubble size (1-3 mm) and number (1-7) varied. Only two (3%) of 64 patients without dislocation had intracapsular gas bubbles; one had been shot and the other had extensive soft-tissue emphysema. CONCLUSION: In the absence of penetrating trauma, intracapsular gas bubbles on CT are reliable indicators of recent hip dislocation and may be the only objective finding of this injury.     

Tripolar hip replacement for recurrent prosthetic dislocation

An innovative treatment is described for unstable total hip arthroplasty that uses a large inside diameter acetabular cup and a bipolar femoral head sized to approximate the diameter of the normal hip. Eight consecutive patients with recurrent prosthetic dislocations were treated with this tripolar hip. Joint stability was achieved in all patients, who have an average of 4.2-years' followup (range, 2.6-6.3 years).     

Effect of a patient management system on outcomes of total hip and knee arthroplasty

Five hundred fifty-three patients undergoing hip and knee reconstructive procedures in one institution that used a patient management system were compared with a retrospective group of 340 patients undergoing similar procedures in the same institution. All procedures were performed by one surgeon and the same patient management team. Measures of length of stay, discharge disposition, and hospital charges were recorded for all patients in each subgroup of total hip arthroplasty, revision total hip arthroplasty, total knee arthroplasty, revision total knee arthroplasty, unicompartmental knee arthroplasty, and bilateral procedures. The length of stay and hospital charges were reduced significantly in all groups, whereas the percentage of patients discharged to home was unchanged. There was no significant difference in complication rates between the two groups.     

Looking back

Fractures of the first rib are extremely rare and are more commonly associated with either multiple rib fractures or life-threatening injuries. First rib fractures are commonly caused by direct trauma, violent muscular contraction or by chronic stress. We present a case of isolated bilateral rib fracture in an elderly patient, in the absence of multiple trauma, where the mechanism of injury appears to be a whiplash injury.     

Fractures through cystic lesions of the greater trochanter. A cause of late pain after cementless total hip arthroplasty

Four patients who presented with sudden onset of hip pain 7 to 11 years after successful porous-coated cementless hip arthroplasty are described. These four patients were all diagnosed to have fractures through osteolytic cysts in the greater trochanter. One patient was seen initially with a displaced fracture of the greater trochanter. Two patients were treated operatively with curettage of the cystic area and with polyethylene exchange. One of these patients underwent revision of the femoral component in addition to the polyethylene exchange. Two patients were treated nonoperatively. The fractures treated nonoperatively have healed and the patients have resumed their normal activities. This report should stimulate an awareness of fractures through cystic lesions of the greater trochanter as a late cause of hip pain after porous-coated cementless hip arthroplasty.     

Dislocation and instability complicating low friction arthroplasty of the hip joint

Among the complications in a series of 1,400 consecutive Charnley low friction arthroplasty procedures, there were 8 dislocations, and 3 highly unstable hips. Three dislocations followed severe trauma, in 2 of the 3 there was only fibrous union of the greater trochanter. In all but 2 of the hips, more than one previous operation had been performed. More than one technical fault was evident in most dislocations. Six of the 8 dislocations required reoperation. Meticulous attention to the Charnley procedure, including soft tissue elements of the hip joint is necessary to avoid instability and dislocation following total hip arthroplasty.     

Role of the Y5 neuropeptide Y receptor in feeding and obesity

Removal of a plate from the distal femur creates a risk of fracture through the screw holes. This is a particular concern when a total knee arthroplasty is present because supracondylar fracture may occur with minimal trauma. A patient who presents after prior plating of a distal femur fracture with osteoporosis, retained hardware associated with pain, and gonarthrosis severe enough to warrant total knee arthroplasty is often difficult to manage. Prophylactic intramedullary rodding is a well-accepted method of treating pathologic stress risers in the femur. An intramedullary rod can be inserted into the femur at the time of total knee arthroplasty. This method permits simultaneous plate removal and total knee arthroplasty while protecting the femur from postoperative fracture.     

Salvage of a recurrently dislocating total hip prosthesis with use of a constrained acetabular component. A retrospective analysis of fifty-six cases

Fifty-six constrained acetabular components were placed, between April 1988 and February 1993, in fifty-five patients who had had recurrent dislocations (average, six dislocations; range, two to twenty dislocations) of the femoral component after a previous total hip arthroplasty. All patients had additional factors contributing to the instability of the implant, including absence or disruption of the abductor mechanism, poor health, mental retardation, confusion, and Alzheimer disease. One patient was lost to follow-up. The remaining patients were followed clinically for a minimum of three years (average, sixty-four months; range, thirty-seven to ninety-seven months) or until the time of death. During the follow-up interval, only two (4 per cent) of the fifty-five patients had a subsequent dislocation. The use of this type of component should be considered for patients who have recurrent dislocation if other treatment modalities are unlikely to be effective.     

Ibutilide: an antiarrhythmic agent for the treatment of atrial fibrillation or flutter

The results of nineteen semiconstrained modified Coonrad-Morrey total elbow arthroplasties performed in nineteen patients to treat instability were evaluated at an average of seventy-two months (range, twenty-five to 128 months) postoperatively. Preoperatively, all patients had either a flail elbow or gross instability of the elbow that prevented useful function of the extremity. The instability of sixteen elbows was the result of a traumatic injury or of the treatment of such an injury. The most recent result was satisfactory for sixteen elbows and unsatisfactory for three. The average overall Mayo elbow performance score increased from 44 points preoperatively to 86 points postoperatively. At the most recent follow-up examination, no elbow was unstable. The average arc of flexion was from 25 degrees (range, 0 to 60 degrees) to 128 degrees (range, 30 to 142 degrees), which represented a 58-degree increase from the preoperative average arc. Sixteen patients had little or no pain after the arthroplasty. There were four complications in four patients. Three complications (loosening of the humeral component in one patient and a fracture of the ulnar component in two) occurred postoperatively; all three were treated with a revision procedure. The other complication (a fracture of the olecranon) occurred intraoperatively and was treated with tension-band fixation; the most recent outcome was not affected. Radiographically, one patient had complete (type-V) radiolucency about the humeral component. None of the nine patients for whom true anteroposterior radiographs were available had evidence of wear of the bushings. The bone graft behind the anterior flange of the humeral prosthesis was mature in fourteen elbows, incomplete in two, and resorbed in two. One patient was excluded from this analysis because radiographs were not available. Instability of the elbow resulting in the inability to use the extremity is a challenging clinical situation. However, in patients who are more than sixty years old and in selected patients who are less than sixty years old but who have extensive loss of bone as a result of severe injury, have had multiple operations, or have rheumatoid arthritis, total elbow arthroplasty with a linked, semiconstrained prosthesis reestablishes a mobile, stable joint without premature loosening or failure of the components. In our experience, the use of customized implants, maintenance of the muscular attachments to the epicondyles, and reconstruction of the epicondyles to the implant were unnecessary.     

Causes of and treatment protocol for instability of total hip replacement

Dislocation of the total hip replacement is a devastating complication, physically and mentally. It was determined whether there are radiographic or operative findings predictive of repeat dislocation and whether there are causes of dislocation that require immediate reoperation. A previously published classification of dislocations was used which evaluates (1) positional (no radiographic abnormality); (2) component malposition (femur or acetabulum), which is inadequate version or position of the acetabular or femoral component; (3) soft tissue imbalance (change in the length or displacement of the hip), which is a change in the muscle functional length of the hip; and (4) component malposition and soft tissue imbalance. Categories of treatment of dislocations were established that could be correlated to the cause of the dislocation: (1) Category I is a successful closed reduction; (2) Category II is a successful reoperation; (3) Category III is a reoperation with subsequent repeat dislocations successfully treated with closed reduction; and (4) Category IV is comprised of hips that require multiple reoperations for treatment of dislocations. The results are that any dislocation of any origin may be treated successfully with closed reduction so that this should be the first choice of treatment. To avoid multiple treatments, immediate reoperation should be performed if the hip is unstable when the patient is examined under anesthesia after the closed reduction. Hips with soft tissue imbalance and weakness of the abductor musculature, with or without component malposition, are most at risk for multiple operations. These hips may be considered for mechanical stability (constraint in the acetabular replacement) at reoperation.     

Immediate weightbearing after uncemented total hip arthroplasty

Radiographic subsidence of the femoral prosthesis and clinical results after unilateral and simultaneous bilateral uncemented total hip arthroplasty were compared. Patients who had bilateral total hip arthroplasty began weight-bearing as tolerated on both lower extremities the day after surgery. Patients who had undergone unilateral total hip arthroplasty were maintained at 10% weightbearing on the operative limb for 6 weeks after surgery. Patients in both groups were matched for age, gender, and weight. Minimal followup was 2 years. There was no difference between the two groups in terms of clinical results. Radiographic assessments were performed immediately after surgery, 6 weeks after surgery, and again at 2 years after surgery. Radiographs were reviewed by a single observer and analyzed with a digitized data recorder. Increased subsidence of the femoral prosthesis within the bilateral group was found at 6 weeks. The mean subsidence of the femoral prosthesis at 6 weeks for the bilateral total hip arthroplasty group was 0.86 mm (range, 0.18-2.60 mm) and for the unilateral group was 0.39 mm (range, 0.07-1.46 mm). However, subsidence occurring between 6 weeks and 2 years averaged 0.50 mm (range, 0.09-1.10 mm) for the bilateral group and 0.54 mm (range, 0.03-0.99 mm) for the unilateral group. This difference was not significant. At the 2-year followup, all femoral prostheses in both groups appeared radiographically stable with evidence of bone ingrowth and no indications of loosening. Thus, immediate weightbearing after bilateral total hip arthroplasty in this study resulted in more initial subsidence (during the first 6 weeks after surgery) of the femoral prosthesis but did not preclude the prosthesis from becoming stable and achieving bone ingrowth. Patients in both groups obtained satisfactory clinical results. Because initial stability and bone ingrowth are factors influenced by prosthesis design, the results of this study may not be applicable to all implants.     

Long-term use of hearing aids in patients with presbyacusis

By means of a prospective study, concerning the postoperative rate of ossification after cementless total hip replacement, it was due to prove the efficacy of radiotherapy in preventing periarticular ossification. In 1992 arthroplasty was followed by radiotherapy of 50 hip joints as regular therapy. The radiation was performed with a focal dose of 8 Gy. Patients with bilateral cementless total hip replacement and radiotherapy only at one side were of special interest in this study. Within the 24th postoperative week in 28 (56%) of the radiated hip joins no periarticular ossifications were found. In 20 (40%) we found ossifications grade 1, in 1 case ossification grade II and in 1 further case ossification grade III following the classification of Arcq. By 8 patients with former cementless total hip replacement without postoperative radiotherapy, a significant reduction of the ossification rate was found in the contralateral hip joint treated by postoperative radiotherapy. The rate of ossification was reduced by 28%. In correlation to reduction of periarticular ossification the increase on the overall range of motion in the radiated hip joins was 10.9%. By none of the patients treated by radiotherapy we found a disturbed healing process, a deep infection or an early loosening of the endoprosthesis. Postoperative radiotherapy as regular therapy for prophylaxis of periarticular ossification after Cementless total hip replacement can subsequently be recommended.     

Neuroimaging in the high-risk infant: relationship to outcome

PURPOSE OF THE STUDY: Dislocation following total hip arthroplasty (THA) continues to be a problem. An innovative treatment is described with the intermediate Bousquet's prosthesis. This study reported 13 cases and demonstrates its high reliability despite the origins of the dislocation. Recurrent dislocation following initial dislocation, occurs in between 25 to 60 per cent of the cases reported in the literature. The main cause is a malpositioned prosthetic component and especially a retroverted acetabulum. The other reasons for dislocation were: trochanteric non-union, bone or cement impingement, previous surgery, age and neurologic disorder. In every case the instability of the hip may be caused or increased by muscular insufficiency. Various methods are described to control recurrent dislocation: repositioning the component, posterior acetabular wall component, trochanteric advancement, retentive acetabular component, bracing. When the cause is clear and isolated, the rate of success may be 70-80 per cent. This study examines the results of a revision procedure with the intermediate Bousquet's prosthesis. MATERIAL AND METHODS: 13 recurrent dislocations were treated with the intermediate Bousquet's prosthesis. There were 10 women and 3 men with an average age at operation of 73 years. The main cause in 7 cases was an abductor insufficiency including 4 trochanteric non unions. The other causes were 6 component malpositions, 7 previous surgery, 1 impingement. The average delay between the first dislocation and revision was one year. The Bousquet's acetabular component is an steel cup covered with alumina, impacted without cement. The polyethylene component is free in the cup and retentive on the femoral head. The femoral positioning was not modified. RESULTS: The revision did not correct all of the causes of luxation, however we noted only one case of dislocation and no recurrent dislocations. DISCUSSION: At last follow-up, all recurrent dislocations were controlled. Nevertheless, there remained 7 abductor insufficiencies and 4 femoral malpositionings. In the literature the rate of success depends on the cause. The main difficulty is the treatment of joint laxity. Some authors propose trochanteric advancement, a larger head, a posterior wall acetabular component, retentive acetabular component. Success is not uniform. The Bousquet's acetabular component supports joint laxity and femoral malpositioning. This allows to keep the same original femoral component when the risk is too high for a cemented prosthesis or impossible for a non cemented prosthesis. CONCLUSION: This treatment of the recurrent dislocation is reliable with a short and simple operation.     

Total hip arthroplasty with porous-coated prostheses fixed without cement in patients who are sixty-five years of age or older

We reviewed the results of 212 total hip arthroplasties performed without cement in 203 unselected, consecutive patients who were sixty-five years of age or older. The outcome was known for 196 hips, thirty-seven of which had been followed until the death of the patient and 159 of which had been followed for a minimum of five years. A reoperation was done in 4 percent (seven) of the 196 hips. These reoperations included one revision because of loosening of the stem and five revisions of the cup. Three of the acetabular revisions were done because of fracture due to polyethylene wear; one, because of recurrent dislocation; and one, because of polyethylene wear and a fracture due to lysis. In the seventh reoperation, a cup and stem were exchanged because of infection. The probability that a hip prosthesis would survive twelve years without a reoperation was 0.92 (95 percent confidence interval, 0.85 to 0.99). We evaluated the clinical results for 152 patients who had not had a reoperation and had been followed for at least five years (mean, 8.5 years; range, five to fourteen years). Of these patients, thirteen (9 percent) had pain that limited activity: five (3 percent) had pain in the thigh (four patients) or groin (one patient), and eight (5 percent) had trochanteric pain and tenderness. One hundred and forty-four (95 percent) of the patients noted an improvement in overall function, and 149 (98 percent) reported satisfaction with the outcome. One hundred and thirty-five hips that were not revised were followed radiographically for at least five years (mean, 8.2 years; range, five to fourteen years). In this group, osteolysis was observed in three hips (2 percent); loosening of the cup, in three (2 percent); and loosening of the stem, in one (1 percent). Stress-shielding was seen on the two-year postoperative radiographs of forty-five (26 percent) of the 174 hips that were followed for at least that duration. The prevalence of osteolysis, loosening of a component, and reoperations was no greater in this subgroup than in the overall group. These results indicate that total hip arthroplasty without cement can be successful in older patients. This study also provides a reference for comparison with the results of total hip arthroplasty performed with cement and those of so-called hybrid total hip arthroplasty (an acetabular component fixed without cement and a femoral component fixed with cement) in patients who are sixty-five years of age or older.     

Postprostatectomy dysuria: restored voiding function by perineal hot water spray in an old male with a contractile bladder]

This study reports the first case of a subtrochanteric stress fracture of the femur after total knee arthroplasty. A 61-year-old obese woman was treated by right total knee arthroplasty for osteoarthrosis. Four months after the surgery and 1 month after full weight bearing, she complained of tenderness in the right groin and proximal thigh. There was no history of trauma. Radiographs of the right hip and of the right proximal femur were interpreted as unremarkable, and nonsteroid anti-inflammatory drugs were administered. Three months later, she had a sudden onset of increased pain with instability and giving way of the right leg. Radiographs revealed a subtrochanteric transverse fracture of the right femur. Histologic workup of the bone and tissue specimen taken at open reduction, as well as the laboratory data were consistent with the radiologic and clinical diagnosis of a stress fracture. It is most likely that a decrease in the tension band effect of the iliotibial tract in combination with coxa vara and changes in static and dynamic forces of the femur and an increased level of activity after a period of relative inactivity secondary to the knee arthroplasty are responsible for this very uncommon fracture type.     

Medical consultation for the elderly patient with hip fracture

BACKGROUND: This article describes a family physician geriatrician's perspective on the comprehensive management of hip fracture in frail elderly patients. Primary care physicians might be called upon to provide medical consultation for these patients. METHODS: Guidelines were developed by a combination of personal experience in consulting for several hundred elderly patients with hip fracture at a large community hospital, literature review using the key words "hip fractures," "aged," and "aged, 80 and over," and educational presentations for family practice residents. RESULTS AND CONCLUSIONS: Elderly patients with hip fracture offer a prime opportunity for comprehensive geriatric assessment. Intertrochanteric fractures are almost always treated with internal fixation, whereas femoral neck fractures can be treated by either fixation or by hemiarthroplasty. Hip fracture should be regarded as a surgical urgency, and generally operation should not be delayed, even if patients have serious comorbidity. The family physician can be instrumental in preparing the patient for surgery, preventing and treating complications, and assisting in the placement and rehabilitation of patients after hospital discharge.     

Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients

We retrospectively reviewed the results of primary total elbow arthroplasty for the treatment of an acute fracture of the distal aspect of the humerus in twenty consecutive patients (twenty-one elbows) who had a mean age of seventy-two years (range, forty-eight to ninety-two years) at the time of the injury. The patients were managed between November 1982 and October 1992. The presence of rheumatoid arthritis in nine patients (ten elbows) influenced the choice of treatment. The mean interval between the injury and the total elbow arthroplasty was seven days (range, one to twenty-five days). The mean duration of postoperative hospitalization was seven days (range, four to thirteen days). The mean duration of follow-up was 3.3 years (range, three months to 10.5 years). All patients were followed for a minimum of two years or until the time of death; the duration of follow-up was less than two years for three patients who died. None of the patients were lost to follow-up. Twenty implants were intact at the latest follow-up examination. One patient had a revision total elbow arthroplasty twenty months after the index procedure because of a fracture of the ulnar component sustained in a fall on the outstretched arm. On the basis of the Mayo elbow performance score, fifteen elbows had an excellent result and five had a good result; there were inadequate data for one elbow. There were no fair or poor results. The mean arc of flexion was 25 to 130 degrees. There was no evidence of loosening on the radiographs. Postoperative complications included fracture of the ulnar component in one patient, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one. The results suggest that total elbow arthroplasty can be an alternative form of treatment of a severely comminuted fracture of the distal aspect of the humerus in older patients even in the presence of rheumatoid arthritis. This procedure is not an alternative to osteosynthesis in younger patients.     

Dislocation following total hip endoprosthesis. Association with surgical approach and other factors

During a period of eight years (1984 to 1992) we found 45 dislocations in 1734 patients treated by total hip arthroplasty. We compared this retrospectively evaluated group with a randomized control group of 61 patients. As a cause for an increasing number of dislocations in 1989 we found: age over 70 years, high CCD-stem-angle (142 degrees), dorsal approach, abduction of the acetabular component under certain circumstances (left side). Revision operations always are a high risk procedure. Acetabular anteversion, anaesthesia, way of component fixation did not induce an increased rate of dislocation. We now left the dorsal approach and use only stems with an CCD-angle of 135 degrees or less by now. Careful positioning of the acetabular components and a better patient-instruction helped to decrease the number of dislocations. Because of these measures we reduced the THA-dislocations rate from 5.6 to 0.17 per cent (first operations) and from 12.1 to 6.5 per cent (revision operations).