Efficacy of Modified Lightbulb Technique by Percutaneous Femoral Neck-Head Fenestration Combined With Compacted Artificial Bone Graft for Treating Precollapse Osteonecrosis of the Femoral Head

BackgroundWhether artificial bone provides comparable outcomes to autogenous bone has not been determined for osteonecrosis of the femoral head (ONFH). This study was conducted to compare the clinical outcomes of autogenous and artificial bone grafting (demineralized bone matrix/calcium sulfate [DBM/CaS]) through a modified lightbulb technique by percutaneous femoral neck-head fenestration for treating precollapse ONFH.MethodsA total of 73 Association Research Circulation Osseous Stage Ⅱ ONFH patients (81 hips) who had a mean follow-up of 61 months (range, 52 to 74) were included in this retrospective study. Among them were 40 hips treated with autogenous bone and 41 hips treated with DBM/CaS grafting through the percutaneous femoral neck-head fenestration. The Harris scores, radiographic progressions, clinical success rates, and survival analyses were analyzed.ResultsAt final follow-up, the mean Harris score was 80 points (range, 63 to 92) in the DBM/CaS group and 76 points (range, 69 to 91) in the autogenous bone group (P = .751). The radiographic progression rate was 29.9% in the DBM/CaS group, without significant difference from the autogenous bone group, which was 37.5% (P = .43). About 73.2% of patients in the DBM/CaS group and 75% in the autologous bone group avoided a total hip arthroplasty (P = .85). Survival analysis for femoral head protection revealed similar outcomes between the 2 groups (P > .05).ConclusionPercutaneous femoral neck-head fenestration combined with artificial bone (DBM/CaS) grafting had comparable clinical outcomes to autologous bone grafting on preventing femoral head collapse and rescuing THA at a mean of 61-month follow-up for treating early ONFH.     

Hip Resurfacing: A Single Surgeon U.S. Series With Minimum Ten-Year Follow-up

BackgroundMetal-on-metal hip resurfacing is an alternative to total hip arthroplasty (THA). The aim of this study was to determine implant survivorship, analyze patient-reported outcomes measures and to determine patient satisfaction for patients who underwent metal-on-metal hip resurfacing at a large US academic institution by a single surgeon with a minimum of 10-year follow-up.MethodsPatients who underwent hip resurfacing from September 2006 through November 2009 were included. Patient demographics and variables were collected from a prospectively maintained institutional database and patients completed an additional questionnaire with patient-reported outcomes measures.ResultsA total of 350 patients (389 hips) out of 371 (433 hips) with a minimum 10-year follow-up were successfully contacted (94.3% follow-up). Mean age was 53 years, 258 were male (73%). 377 out of 389 hips (96.9%) did not require additional surgery. Gender was significantly related to implant survivorship (males 99.0%, females 90.9%; P < .001). 330 patients (369 hips, 94.8%) were satisfied with their surgery. Males had higher proportion of satisfaction scores (P = .02) and higher modified Harris Hip Score (odds ratio = 2.63 (1.39, 4.98), P = .003). Median modified Harris Hip Score score for non-revised hips was 84.0 [80.0; 86.0] versus those requiring revision, 81.5 [74.0; 83.0], (P = .009).ConclusionAt a minimum 10-year follow-up, hip resurfacing, using an implant with a good track record, demonstrates 99.0% survivorship in male patients with an average age of 52 years. We believe that the continued use of metal-on-metal hip resurfacing arthroplasty in this population is justified by both positive patient reported outcomes and survivorship.     

Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy

BackgroundCore decompression is the most common procedure for early-stage osteonecrosis of the femoral head (ONFH). This study investigated outcomes of core decompression with/without bone marrow aspirate concentrate (BMAC), based on the Kerboul combined necrotic angles using magnetic resonance imaging.MethodsWe reviewed 66 patients (83 hips) with early ONFH, Association Research Circulation Osseous stages I-IIIa, who underwent core decompression alone (26 patients, 33 hips) or in combination with BMAC (40 patients, 50 hips). Survival rate and progressive collapse were analyzed using the Kaplan-Meier method, and conversion to total hip arthroplasty (THA) was evaluated. Subgroup analyses based on the modified Kerboul angle were performed: grade I (<200°), grade II (200°-249°), grade III (250°-299°), and grade IV (≥300°).ResultsMean follow-up was 36 ± 23 months. Femoral head collapse with BMAC (16 hips, 32%) was significantly lower than without BMAC (19 hips, 58%, P = .019). Conversion THA was significantly lower with BMAC (28%) than without (58%, P = .007). Survival rates among groups showed significant differences (P = .017). In grade I, 0/12 hips with BMAC collapsed while 3/9 (33%) without BMAC collapsed (P = .063); in grade II, 2/16 hips (12%) with BMAC collapsed while 7/13 (54%) without BMAC collapsed (P = .023). There was no significant difference in collapse with (64%) or without (82%) BMAC in grade III-IV hips (P = .256).ConclusionCore decompression with/without BMAC had a high failure rate, by increasing disease progression and the necessity for THA, for combined necrotic angles >250°. In our study, addition of BMAC had more reliable outcomes than isolated core decompression for precollapse ONFH if the combined necrotic angles were <250°.     

Femoral head resurfacing in the treatment of osteonecrosis: 3 to 5-year follow-up

We reviewed the clinical and radiological results of 32-cemented femoral head resurfacing arthroplasty, performed by a single surgeon in 25 patients with femoral head osteonecrosis at a mean age of 36.2 years. All patients received a cemented conserve (Wright Medical Technology Inc., Arlington, TN, USA) femoral hemiresurfacing arthroplasty. Data were complete on 16 patients with 21 hips at a mean follow-up period of 50.8 months. Five patients had bilateral procedures. The Harris hip score, and the Merle d’Aubigné score improved significantly from 54.7 to 72.3 (P = 0.0001), and from 12.1 to 13.9 (P = 0.01), respectively. Seven hips had undergone revision to total hip arthroplasty at the time of follow-up while one hip is scheduled for revision surgery, representing a 38% failure rate. When clinical failure is defined as a Harris Hip Score of less than 70 at follow-up, clinical failure was 81% at 4.25 years.     

Mild Coronal Stem Malalignment Does Not Negatively Impact Survivorship or Clinical Results in Uncemented Primary Total Hip Arthroplasties With Dual-Tapered Implants

BackgroundProper component positioning in total hip arthroplasty (THA) is crucial for implant fixation and hip stability. The purpose of this study is to assess if neutral coronal stem alignment (0° ± 3°) improved long-term survivorship in uncemented femoral components.MethodsBetween 2005 and 2010, 1028 primary THAs were performed with 2 contemporary dual-tapered, proximally coated uncemented stem types. Alignment was measured immediately postoperatively and at most recent follow-up. In total, 978 femoral stems (95%) were within 0° ± 3° of the neutral anatomic coronal axis, and the 50 stems (5%) outside that range were considered outliers (3.1° of valgus to 4.8° of varus). Outcomes analyzed included implant survivorship, Harris Hip Scores, and incidence of dislocation. Mean follow-up was 5 years.ResultsSurvivorship free of aseptic femoral component loosening was 99.3% and 98.2% at 5 and 8 years in the neutral group vs 100% at 5 and 8 years in the outlier group (P = .98). Survivorship free of femoral component revision for any reason was 99.1% and 97.3% at 5 and 8 years vs 100% at 5 and 8 years, respectively (P = .80). Harris Hip Scores were similar (89 in both groups; P = .84) at most recent follow-up. The incidence of mild to moderate thigh pain was also similar in both groups (6.1% vs 6%, P = .85). The incidence of dislocation was 1.5% at 8 years, and similar between both groups (P = .77).ConclusionSlight malalignment of contemporary dual-tapered uncemented THA femoral components does not appear to negatively impact survivorship or clinical outcomes, which is in contrast to cemented femoral components.Level of evidence IIICase-control study.     

Combination of Anterior Acetabular Coverage and Femoral Head Shape Predicts Femoroacetabular Impingement After Periacetabular Osteotomy

BackgroundFemoroacetabular impingement (FAI) after periacetabular osteotomy (PAO) may be affected by both anterior acetabular coverage and femoral head shape. This study aimed to radiographically evaluate the relationship of the combination of acetabular coverage and femoral head shape with the occurrence of FAI after curved PAO.MethodsIn this study, 76 hip joints from patients with symptomatic developmental dysplasia of the hip underwent curved PAO. The relationship between the combined postoperative anterior center-edge and alpha angles (ie, the combination angle) and the occurrence of postoperative FAI was evaluated. Clinical factors and the preoperative and postoperative 3-dimensional center-edge angles, acetabular versions, femoral versions, radiographic alpha angles of the femoral head, and the combination angle were measured and compared to clinical outcomes.ResultsThe modified Harris Hip Scores, University of California, Los Angeles activity scores, and acetabular coverage angles were significantly improved following curved PAO. Receiver operator characteristic curve analysis demonstrated that the combination angle over 108° may be a predictive factor for the occurrence of FAI after curved PAO. Multivariate analysis demonstrated that an age <40 years (odds ratio 6.6, 95% confidence interval 1.2-36.4, P = .037) and a combination angle <108° (odds ratio 9.2, 95% confidence interval 1.7-50.0, P = .010) were significantly associated with modified Harris Hip Scores ≧90 points.ConclusionA combination angle >108° may be a predictive factor for the occurrence of FAI after curved PAO and impaired clinical outcomes. To avoid postoperative FAI, we propose that osteochondroplasty of the femoral head should be performed for patients with preoperative combination angles >90°.     

Long-Term Results of Periacetabular Rotational Osteotomy Concomitantly With Arthroscopy in Adult Acetabular Dysplasia

BackgroundAlthough the long-term results of periacetabular osteotomy in acetabular dysplasia have been well documented, there is paucity in reports on the long-term outcomes of periacetabular osteotomy with simultaneous hip arthroscopy. This study aimed to assess the cumulative 10-year outcomes of periacetabular rotational osteotomy with concomitant hip arthroscopy.MethodsThrough an arthroscopic procedure, the status of the labrum was assessed, and torn labrum was debrided. Evaluations on survival from conversion to total hip arthroplasty and success in radiographic and clinical long-term results were completed in 39 hips (36 patients). Acetabular parameters (center-edge angle, Sharp angle, acetabular-head index, and head lateralization index), Tönnis grades on radiograph, Harris Hip Score, and range of motion of the hip were evaluated. Survivorship analyses were evaluated with the Kaplan-Meier method.ResultsThirty-eight hips (97.4%, 95% confidence interval 0.832-0.996) were preserved for 12.8 ± 1.7 years on average, and only 1 hip was converted to total hip arthroplasty at 7.8 years. All the acetabular parameters were improved (P < .001). Twenty-eight hips (71.8%) showed unchanged or improved Tönnis grades at the latest follow-up. The average Harris Hip Score was significantly better than the preoperative value (P < .001), and range of motion was not significantly different until the latest follow-up.ConclusionSufficient acetabular reorientation, such as periacetabular rotational osteotomy, with concomitant arthroscopic debridement showed successful long-term outcomes for acetabular dysplasia in adults.     

Total Hip Arthroplasty With the Wagner Cone Femoral Stem in Patients With Crowe IV Developmental Dysplasia of the Hip: A Retrospective Study

BackgroundThe aim of this study is to assess treatment of Crowe type IV hip dysplasia with the Wagner cone femoral stem combined with transverse subtrochanteric shortening osteotomy and augmenting the osteotomy site using the intercalary segment as a strut autograft.MethodsOne hundred twenty-seven hips of 91 patients diagnosed with Crowe type IV hip dysplasia and treated with total hip arthroplasty using the Wagner cone stem combined with transverse subtrochanteric shortening osteotomy were retrospectively evaluated by clinical and radiographic outcomes as well as complications.ResultsThe mean follow-up was 8.4 years. The Harris Hip Score and the Western Ontario and McMaster University Osteoarthritis Index scores were significantly improved postoperatively (P = .000). Intraoperative femoral cracks were observed in 70 hips (55.1%) and all femurs healed smoothly. Femoral cracks did not have a significant effect on clinical outcomes, except for heterotopic ossifications (P = .032). The probability of 10-year survivorship of the components free of revision for any reasons as end point was 94.5%; when only the femoral components were considered the survivorship was of 96.9%.ConclusionTransverse subtrochanteric shortening and augmenting the osteotomy site using the intercalary segment of bone resected from the shortened femur with the Wagner cone stem is an effective and reliable technique in the management of total hip arthroplasty in Crowe type IV hip dysplasia. Stable and firm placing of the femoral component which leads to an increased frequency of intraoperative femoral cracks does not have an unfavorable effect on clinical and radiological outcomes.     

Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy in Patients With High Hip Dislocation Secondary to Childhood Septic Arthritis: A Matched Comparative Study With Crowe IV Developmental Dysplasia

BackgroundTotal hip arthroplasty (THA) with subtrochanteric shortening osteotomy (SSO) is performed to manage hips with high dislocations. We compared outcomes of THA with SSO in patients with high hip dislocation resulting from childhood septic arthritis and Crowe IV developmental dysplasia of the hip (DDH).MethodsWe reviewed 60 THAs with SSO performed between May 1996 and December 2013. Thirty-one cases were classified as sequelae of childhood infection and 29 as DDH. Twenty-five hips were selected for each group after the propensity score was matched with preoperative demographics and leg length discrepancy (LLD). Clinical scores, complication and reoperation rates, radiographic results, and survivorships were compared. The mean duration of follow-up was 12.3 (range 5-22) years.ResultsThe average correction in LLD was 2.5 cm for childhood infection and 3.6 cm for DDH (P = .002). The infection group received more transfusions (mean 3.3 vs 2.0 units, P = .002), required more time for union of osteotomy site (mean 6.8 vs 5.2 months, P = .042), and reported lower Harris Hip Score (mean 85.1 vs 91.3, P = .017). Reoperations were performed in 11 (44%) previously infected hips and 3 (12%) DDHs (P = .012). Kaplan-Meier survivorship with an endpoint of revision for any reason was lower in the infection group (83.6%) than in the DDH group (100%) at 10 years (log rank, P = .040).ConclusionTHA with SSO in high hip dislocation secondary to childhood septic arthritis demonstrated less favorable clinical outcomes with increased risks of complication, compared with those performed in Crowe IV DDH with similar degree of chronic dislocation.     

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis

BackgroundAvascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same.Research questionIs CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip?MethodologyA systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles.ResultsThe present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC.Primary outcomes39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55–3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41–2.06)ConclusionCD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.     

Minimum 10-Year Results of Cementless Ceramic-On-Ceramic Total Hip Arthroplasty Performed With Transverse Subtrochanteric Osteotomy in Crowe Type IV Hips

BackgroundTotal hip arthroplasty (THA) performed for developmental dysplasia of the hip is a technically difficult procedure with a high complication rate, especially in the presence of completely dislocated hips. This study aimed to evaluate at least 10 years of follow-up results of cementless, ceramic-on-ceramic (CoC) THA performed with transverse subtrochanteric osteotomy in Crowe type IV hips.MethodsWe retrospectively reviewed 50 patients’ 67 hips that underwent CoC, cementless THA with transverse subtrochanteric osteotomy between 2008 and 2011. Clinical and radiological data of the hips were examined. Clinical results were evaluated using the Harris Hip Score and the Western Ontario and McMaster Universities Osteoarthritis Index.ResultsThe mean Harris Hip Score improved from 22.9 ± 9.9 preoperatively to 94.1 ± 8.1 at the final follow-up (P < 0.001). The median Western Ontario and McMaster Universities Osteoarthritis Index score improved from 72 (interquartile range: 17) preoperatively to 2 (interquartile range: 17) postoperatively (P < 0.001). The preoperative mean leg length discrepancy was improved from 4.9 ± 1 cm to 1.5 ± 1 cm in unilateral cases at the last follow-up (P < 0.001). Revision surgery was required because of nonunion in two patients, prosthetic infection in one patient, and aseptic femoral loosening in the other patient. The overall ten-year survival rate was 94% for femoral stems and 98.5% for acetabular components as per Kaplan-Meier survival analysis.ConclusionTransverse subtrochanteric shortening osteotomy combined with using cementless acetabular and femoral components with a CoC bearing surface promises successful clinical results and high prosthesis survival in the treatment of Crowe IV hips at long-term follow-up.     

Comparison of Dislocation and Outcome Between Piriformis-Sparing and Conventional Posterior Approach After Bipolar Hemiarthroplasty for Femoral Neck Fracture in Patients Over 60 Years

BackgroundHemiarthroplasty is a treatment option for femoral neck fractures in patients aged more than 60 years and postoperative dislocation after a posterior approach is not uncommon. The piriformis tendon is one of the structures providing posterior hip stability. However, evidence of piriformis-sparing approach in hemiarthroplasty is unclear regarding a reduced dislocation rate.MethodsBetween January 2017 and December 2019, 321 patients underwent a posterior approach in consecutive cohorts for a hemiarthroplasty for femoral neck fractures with the minimum 24 months follow-up time (24-60 months). There were two cohorts: (1) 129 underwent the conventional posterior (CP) approach and (2) 192 underwent the piriformis-sparing (PS) approach. The differences in dislocation rate, postoperative Harris Hip Society at 1 and 2 years and other surgical complications were compared in both groups.ResultsThere were 6 dislocations of 129 (4.7%) underwent the CP approach and 0 dislocation from 192 underwent the PS approach that had posterior hip dislocations (P = .004). In addition, the CP group had a significantly higher mortality rate (14.7% versus 7.3%, P = .031) and lower functional outcomes as assessed by mean Harris Hip Scores at 1 year (73 versus 78, P = .005) and 2 years postoperatively (73 versus 80, P < .001) relative to the PS group.ConclusionPS hemiarthroplasty was associated with a lower dislocation and mortality rate. Moreover, this approach gained a superior early to the mid-term functional outcome than the conventional posterior approach in elderly femoral neck fractures.Level of EvidenceII, prospective cohort study.     

Core Decompression Prevents Progression of Asymptomatic Type C Osteonecrosis of Femoral Head According to the Japanese Investigation Committee Classification: A Retrospective Study

ObjectiveTo evaluate whether core decompression could prevent progression of asymptomatic type C osteonecrosis of the femoral head (ONFH) according to the Japanese Investigation Committee (JIC) classification.MethodsThis retrospective cohort study included 124 hips (117 patients) with asymptomatic type C ONFH. Seventy‐one hips (67 patients) received core decompression (core decompression group) and 53 hips (50 patients) received no surgical treatment (control group). Clinical and radiological follow‐up was conducted at 6 and 12 months, then annually until 5 years. Clinical outcomes were evaluated in terms of the Oxford hip score and UCLA Activity Level rating. Radiological outcomes were evaluated using X‐ray and magnetic resonance imaging. Survival analysis was performed based on collapse of the femoral head as the first endpoint and total hip arthroplasty (THA) as the second endpoint.ResultsThere were no significant differences in clinical outcomes between the core decompression group and the control group within 2 years after surgery. Patients in the core decompression group had significantly better Oxford hip score and UCLA Activity Level from year 3 to the end of follow‐up (P < 0.05). In year 5, the absolute difference in Oxford hip score (5.3 points) exceeded the reported minimal clinically important difference (MCID, 5.2 points). In years 3–5, the absolute difference in UCLA Activity Level rating (0.95 points, 0.95 points, and 0.99 points, respectively) exceeded the reported MCID (0.92 points). By 5‐year follow‐up, significantly fewer patients in the core decompression group had experienced femoral head collapse (40.8% vs 62.3%, P = 0.011) or received THA (26.8% vs 45.3%, p = 0.022).ConclusionsCore decompression can prevent progression of asymptomatic type C ONFH according to the JIC classification, leading to better medium‐term hip function and activity levels than no surgical treatment. Core decompression is recommended for early intervention against asymptomatic type C ONFH.     

Core Decompression with Local Administration of Zoledronate and Enriched Bone Marrow Mononuclear Cells for Treatment of Non‐Traumatic Osteonecrosis of Femoral Head

ObjectiveTo investigate the efficacy and safety of core decompression (CD) with local administration of zoledronate and enriched bone marrow mononuclear cells (BMMCS) for the treatment of non‐traumatic osteonecrosis of femoral head (ONFH).MethodsA total of 17 patients (30 hips) diagnosed with stage II and III ONFH according to the 2019 revised Association for Research on Osseous Circulation (ARCO) staging criteria from 2012 to 2014 were retrospectively reviewed. The patients received the following therapy: the BMMCs and zoledronate were injected into the necrotic zone, respectively, along with CD. The mean age of the patients was 36.8 years; 14 were men and three were women. All patients included had non‐traumatic ONFH and a minimum follow‐up of 5 years, which ended when total hip arthroplasty (THA) was performed. Imaging modalities, including plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI) were taken pre‐ and postoperatively. Harris hip score (HHS) was used to evaluate the functional outcomes of femoral head necrosis. Kaplan–Meier analysis was adopted to determine the probability of survivorship with THA as the end point in this series of patients. The correlation between radiological progression or THA and related risk factors were further analyzed. All complications were recorded.ResultsWith THA as the follow‐up endpoint, All patients were followed up for an average of 69.1 ± 20.5 months (range, 18–95 months). Preoperative imaging found six hips (20%) at ARCO stage II, 14 hips (46.7%) at stage IIIA, 10 hips (33.3%) at stage IIIB. Fourteen hips (46.7%) shown progression radiologically, while six hips (20%) underwent TKA among these patients with hip preservation. The cumulative survival was 80% (95% CI, 0.608–905) at 5 years with THA as the end point. HHS improved from 63.3 ± 8.7 preoperatively to 74.6 ± 20.6 postoperatively (P = 0.000). Radiological progression was found to be associated with ARCO stage, Japanese Investigation Committee (JIC) type, and corticosteroid exposure (P = 0.047; P = 0.012; P = 0.031). However, no correlation was found between conversion to THA and the known risk factors. No major complication was reported, with only four patients complaining about general weakness and muscle soreness, and all disappeared within 2–3 days.ConclusionsThe novel treatment modality could relieve pain, delay the progression of collapse, which might be an effective and safe method for hip preservation of early and mid‐term ONFH. However, the effect of this method may be related to ARCO stage, JIC type, and corticosteroid exposure.     

Management of osteonecrosis of the femoral head: A novel technique

Background:Osteonecrosis of the femoral head (ONFH) is a debilitating disease in orthopedics, frequently progressing to femoral head collapse and osteoarthritis. It is thought to be a multifactorial disease. ONFH ultimately results in femoral head collapse in 75–85% of untreated patients. Total hip arthroplasty (THA) yields satisfactory results in the treatment of the end stage of the disease. However, disease typically affects males between the ages of 20 and 40 years and joint replacement is not the ideal option for younger patients. Recently, mesenchymal stem cells and platelet rich plasma (PRP) have been used as an adjunct to core decompression to improve clinical success in the treatment of precollapse hips.Results:The mean HHS improved from 46.0 ± 7.8 preoperatively to 90.28 ± 19 at the end of followup (P < 0.0001). The mean values of VAS were 78 ± 21 and 35 ± 19 at preoperatively period and final followup, respectively, with an average reduction of 43 points.Conclusion:We found that the use of PRP with collagen sheet can increase the reparable capacity after drilling of necrotic segment in stage IIb and III ONFH.     

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head

IntroductionOsteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH.MethodsWe performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA.ResultsSeventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1–33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69–93), a mean improvement of 20.6 (p < 0.001).ConclusionsOur study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.     

股骨颈骨折内固定术后股骨头坏死的相关因素分析及生活质量评价

目的:探讨年轻患者股骨颈骨折内固定术后发生股骨头坏死的危险因素,描述股骨头存活患者的生活质量,量化其预测因素。方法:选取2013年1月至2016年12月采用闭合复位空心钉内固定手术治疗的股骨颈骨折患者172例(174髋)进行回顾性分析,总结患者的一般资料包括年龄、性别、体重指数、创伤机制、创伤-手术间隔时间、创伤发生季节和内固定物是否取出,影像学资料包括骨折Garden分型、Pauwel分型、股骨头后倾角度、术后骨折复位、螺钉分布情况。进行单因素分析及多因素Logistic回归分析,探讨股骨头坏死及内固定失败的危险因素。对上述内固定术后股骨头存活的患者进行随访,通过SF-36健康调查简表评估患者的生活质量,髋关节功能Harris评分评估患髋关节功能,并通过多重线性回归分析探讨股骨颈骨折术后患者生活质量的预测因素。结果:172例(174髋)患者纳入研究,共29例(16.67%)患者发生股骨头坏死。股骨头坏死多因素Logistic回归分析中有显著差异的变量是复位质量(OR=0.126,P=0.027)和后倾角(OR=4.380,P=0.010)。股骨头存活136例患者(137髋)纳入生活质量调查,Harris评分90.14±7.92,其中优96髋(70.07%),良28髋(20.44%),中13髋(9.49%),差0髋。SF-36评分中生理健康得分为46.12±9.12,心理健康得分为50.21±3.97,两者不呈线性相关(P0.05),多重线性回归分析中,与生理健康得分相关有显著差异的变量是复位质量与后倾角度,与心理健康得分相关有显著差异的变量是骨折是否移位与创伤机制。结论:复位质量位不佳和后倾角15°是并发股骨头坏死的危险因素。股骨颈骨折术后患者髋关节功能及心理健康得分恢复良好,但生理健康得分不能恢复到正常人群平均水平,复位质量与后倾角度可作为生理健康得分预测因素,骨折是否移位与创伤机制可作为心理健康得分的预测因素。     

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

BackgroundIntra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI).MethodsAt a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group.ResultsNo differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group.ConclusionOur findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.     

股骨头髓芯减压带旋髂深血管蒂髂骨骨瓣植骨治疗股骨头缺血性坏死

目的　探讨股骨头髓心减压带旋髂深血管蒂髂骨骨瓣植骨术治疗股骨头缺血坏死的疗效及手术适应证。　方法　 1995年 10月～ 2 0 0 0年 8月共进行 18例 (2 6髋 )股骨头髓心减压带旋髂深血管蒂髂骨骨瓣植骨术。根据Harris髋关节评分系统进行关节功能评价 ,根据ARCO分期分型系统进行影像学评价。　结果　随访 16例 2 3髋 ,平均 3 1 5个月。Harris评分由术前平均 61 7改善为随访时 76 0分。 13髋 (5 6% )随访时Harris评分 >80 0分 (内侧型 8髋 ,中央型 3髋 ,外侧型 2髋 ) ,根据ARCO分期分型系统进行分类随访时优良率 ,内侧型 80 % ,中央型 60 % ,外侧型 2 5 %。 8髋分期发生进展。塌陷及失败率内侧型 2 0 % ,中央型 40 % ,外侧型 75 %。　结论　股骨头髓芯减压带旋髂深血管蒂髂骨骨瓣植骨术适用于ARCO分期分型系统中ⅠA中央型、ⅠB内侧型、ⅡA中央型、ⅡB内侧型股骨头缺血性坏死 ,并具有良好的近、中期疗效。对坏死范围较大的股骨头不能防止病程的进展 ,但可缓解症状 ,延缓全髋关节置换的时间     

Eighteen-Year Follow-Up Study of 2 Alternative Bearing Surfaces Used in Total Hip Arthroplasty in the Same Young Patients

BackgroundThis study compares the long-term functional, radiographic, and computed tomography scan outcomes and implant survivorship of ceramic-on-ceramic total hip arthroplasty (C-O-C THA) and ceramic-on-highly cross-linked polyethylene total hip arthroplasty (C-O-HXLPE THA) in the same patients.MethodsIn this randomized, prospective trial conducted between January 1999 and April 2003, 133 patients (266 hips) younger than 55 years were enrolled. Each patient received C-O-C THA in 1 hip and a C-O-HXLPE THA in the other. The mean follow-up was 17.1 years (range, 15-18 years); there were 84 men and 49 women with a mean age of 53 ± 7 years (range, 25-55 years).ResultsAt the latest follow-up, mean Harris hip scores (94 vs 93 points; P = .861), pain scores (43 vs 42 points; P = .651), and patient satisfaction scores (7.8 vs 7.6 points; P = .379) were not different between the 2 groups. Eight hips (3%) in the C-O-C THA had an audible squeaking sound. The mean annual penetration rate of HXLPE was 0.0162 ± 0.032 mm per year. No osteolysis was recorded on radiographs or computed tomography scans in either group. At 17.1 years, the survival rate of the acetabular component was 97% in the C-O-C bearing group and 98% in the C-O-HXLPE bearing group (P = .923). The survival rate of the femoral component was 99% in both groups.ConclusionBoth C-O-C THA and C-O-HXLPE THA functioned well, with no osteolysis at mean of 17.1-year follow-up.