Surgical reconstruction of late pelvic post-traumatic nonunion and malalignment

We have retrospectively reviewed the clinical and radiological results in 204 consecutive adult patients who had surgical correction of 70 late post-traumatic pelvic nonunions and 134 malalignments. The deformed pelvises were subdivided into united (true), unstable, ununited, and partially stable malalignments with heterotopic bone. The principal complaints were of pain, pelvic instability, sitting imbalance, and apparent limb-length discrepancy. After surgery, 195 patients (96%) achieved a primary union and 144 (71%) had slight, intermittent or no pelvic pain, while pelvic instability was entirely eliminated. Overall, 131 patients (64.2%) were extremely satisfied, 58 (28.4%) were satisfied and 15 (7.4%) were unsatisfied. After reconstruction of the malaligned pelvises, 67 results (50%) were anatomical, 47 (35%) were satisfactory and 20 (15%) were unsatisfactory. For a pelvic nonunion with local osteopenia and malalignment, stabilisation of all three pelvic columns is recommended. True pelvic (united) malunions were the most satisfactorily realigned and had the fewest complications. Ununited and unstable malalignments, especially those with heterotopic bone, had the poorest corrections and the most neurological complications. A therapeutic alternative, by the local resection of a symptomatic bony prominence, and fixation in situ of a posterior pelvic nonunion, gives highly effective symptomatic relief with fewer complications. Despite this, many patients had persistent low back pain.     

Long-term results of cementless femoral reconstruction following intertrochanteric osteotomy

Purpose

The objective of this retrospective cohort study was to assess the long-term outcome of cementless femoral reconstruction in patients with previous intertrochanteric osteotomy (ITO).

Methods

We evaluated the clinical and radiographic results of a consecutive series of 45 patients (48 hips, mean age 50 years) who had undergone conversion hip replacement following ITO with a cementless, grit-blasted, double-tapered femoral component. Clinical outcome was determined using the Harris hip score. Stem survival for different end points was assessed using Kaplan-Meier survivorship analysis.

Results

At a mean follow-up of 20 (range, 16–24) years, 11 patients (12 hips) had died, and no patient was lost to follow-up. Six patients (six hips) underwent femoral revision, two for infection, three for aseptic loosening and one for periprosthetic fracture. Mean Harris hip score at final follow-up was 78 points (range, 23–100 points). Stem survival for all revisions was 89% (95%CI, 75–95) at 20 years, and survival for aseptic loosening was 93% (95%CI, 80–98).

Conclusions

The long-term results with this type of cementless femoral component in patients with previous intertrochanteric osteotomy are encouraging and compare well to those achieved in patients with normal femoral anatomy.     

Mid-term results of concomitant epiphyseal fixation and trochanteric osteotomy for severe chronic slipped capital femoral epiphysis

The management of severe forms of slipped capital femoral epiphysis (SCFE) has been the subject of intense debate in the literature, and controversy remains as to whether the proximal femoral epiphysis should be realigned by intracapsular or extracapsular osteotomies or just fixated in situ. The aim of this study is to evaluate the late results of treatment of severe unreduced slipped capital femoral epiphyses by combined epiphyseal stabilisation in situ using a single cancellous screw and biplane corrective trochanteric osteotomy. Eighteen hips with severe chronic slipped capital femoral epiphysis before physeal closure were treated by combined epiphyseal fixation in situ using a single cancellous screw, and biplane corrective osteotomy fixed by an angled blade plate. The average follow-up period was 8 years. All patients achieved near-normal hip flexion, internal rotation and abduction, and most were able to bear weight in the early postoperative period. A satisfactory correction of the head-shaft angle was obtained post-operatively on both antero-posterior and frog leg lateral radiographs. There was no instance of chondrolysis, avascular necrosis or early osteoarthrosis. This procedure appears to offer a workable solution to the problem posed by the severely slipped capital femoral epiphysis.     

大转子延长截骨在股骨柄翻修术中的应用

目的 报道大转子延长截骨在股骨柄翻修术中的应用及其疗效。方法 从 1998年 1月～ 2000年 1月,采用大转子延长截骨术取出股骨柄、骨水泥,行翻修术 11例。男 7例,女 4例。年龄 53～ 69岁,平均 65.4岁。翻修原因 :股骨柄断裂 2例,人工股骨头置换术后髋臼骨关节炎 8例,假体位置异常 1例。结果 11例患者术后第 2 d均在助行器辅助下下床行走,术后 3个月大转子延长截骨处临床愈合后,改扶单拐行走, 6个月后弃拐行走。术后随访 6～ 30个月,大转子延长截骨处骨性愈合, Harris评分平均为 89.6分。结论 大转子延长截骨术多用于翻修术中取出固定牢固的骨水泥或非骨水泥假体柄。其适应证包括 :(1)股骨柄近端断裂,远端仍牢固固定者; (2)人工股骨头置换术后发生髋臼骨关节炎伴髋关节强直,股骨柄固定牢固,需行全髋翻修者; (3)股骨柄安放位置错误,但骨水泥固定良好者; (4)不伴有假体松动的早期严重感染需行翻修者。该方法显露充分,术后恢复快,是一种较好的股骨柄固定牢固的翻修方法。主要并发症有截骨处不愈合、移位及截骨片骨折。     

Follow-up and late results following treatment of childhood femoral shaft fractures

On reexamining 82 femoral shaft fractures in children (50 conservatively and 32 operatively treated) 75% of the patients did not have any complaints. 25% showed a mild limping which in the majority was caused by a longitudinal overgrowth of more than 5 mm. This overgrowth was mostly to be found in patients with unstable osteosynthesis. Muscular atrophy was seen mainly in the operative group. Cutaneous necrosis after plaster extension was the most common complication. Only one rotational deformity was observed. In conclusion we think that the conservative treatment of the uncomplicated femoral shaft fracture in children is the proceeding of choice. Open fractures, especially in polytraumatic cases, should be treated by osteosynthesis, which has to be motion stable. The worst therapy of femoral shaft fractures is, as our results show, an unstable osteosynthesis.     

股骨大转子延长截骨在假体稳定股骨柄翻修中的应用

目的 评估大转子延长截骨在股骨假体固定稳定型全髋关节翻修术中应用的中期临床效果.方法 1998年1月至2005年6月对27例患者(27髋)采用大转子延长截骨对股骨柄和(或)骨水泥壳固定稳定的全髋关节翻修.临床随访评估包括Harris评分和WOMAC评分,术前Harris评分平均42.7分,WOMAC评分平均55.6分;影像学评估包括术后拍摄X线片,对比观察截骨块愈合时间、是否存在截骨延迟愈合或不愈合,截骨块是否发生移位以及假体是否下沉等.结果 共19例患者(19髋)获得随访,平均随访时间5.3年.无一例发生术中或术后骨折.术后Harris评分平均87.3分,WOMAC评分平均46.3分.所有患者大转子截骨块均于术后6个月内愈合.无股骨大转子截骨块向近端移位,3例发生股骨柄下沉,平均下沉3.4 mm,无钢丝断裂.结论 对于假体固定稳定型股骨柄翻修,采用股骨大转子延长截骨有利于手术操作和翻修假体的植入和固定,有利于截骨块的愈合,降低术中、术后并发症发生率,中期疗效显著.     

Complications of trochanteric osteotomy.

Trochanteric osteotomy continues to have an important role in total hip replacement, but more so as a useful adjunct in selected instances rather than as a necessary and integral part of every arthroplasty. Improved exposure is the most important benefit of and indication for trochanteric osteotomy. Trochanteric nonunion per se has little adverse effect on the final result, but most clinically significant complications of trochanteric osteotomy are a consequence of nonunion. Migration or total separation of the greater trochanter is usually preceded by nonunion. Either can result in impaired abductor function manifested as impaired gait and, occasionally, as subluxation or dislocation. Limp and decreased walking endurance are often mild and generally do not warrant specific treatment. However, when they are severe and accompanied by either pain or instability, trochanteric reattachment is indicated. Trochanteric bursitis may or may not be directly related to the presence of prominent fixation devices and, therefore, may not resolve with their removal. Likewise, pain localized to the trochanteric region may in fact be due to other causes, such as component loosening or the presence of infection. Pain unresponsive to a local anesthetic agent warrants a thorough search for alternative causes. Careful patient selection optimizes the benefits and minimizes the risks of trochanteric osteotomy. The procedure is technically demanding, and meticulous attention to detail is essential to avoid complications. We prefer a sliding trochanteric osteotomy for its versatility and for the resistance to trochanteric migration it provides.     

Avoiding your next extended trochanteric osteotomy: An alternative for femoral component removal

The removal of well-fixed implants can be challenging for every orthopedic surgeon. The most commonly used methods for the removal of solid implants are the transfemoral osteotomy and the extended trochanteric osteotomy (ETO). However, those techniques are often associated with various complications such as non-unions or migration of the osteotomy fragment and persistent abductor weakness. Therefore, the authors present the endofemoral technique for the removal of well-fixed cemented and uncemented femoral stems. For a successful and efficient implant removal, it is of enormous importance to have proper instruments available.     

扩展型转子截骨技术在骨水泥型股骨柄翻修中的临床应用

目的探讨扩展型转子截骨技术在较困难的骨水泥型股骨柄翻修手术中的作用和临床效果。方法2002年2月至2006年5月采用扩展型转子截骨翻修股骨侧假体12例，应用扩展型转子截骨技术取出所有骨水泥和假体柄，重新植入翻修用假体柄，以多道金属线缆环扎固定。其中1例选择的是骨水泥股骨假体，11例是非骨水泥股骨假体。结果所有患者均获得随访，时间16～24个月，术后6个月所有截骨处均愈合，无大转子移位。Harris评分由术前平均（48．4±7．5）分上升至术后平均（89．3±8．1）分（为术后1年的评分），假体无松动、下沉、假体周围未见骨吸收、骨溶解。结论扩展型转子截骨对骨水泥取出困难的股骨侧翻修术具有骨水泥取除彻底，安全可靠，手术时间短，并发症少的优点。     

Surgical treatment of post-traumatic malalignment of the ankle

Post-traumatic malalignment is evident in cases of malunion of ankle fractures. This condition predisposes to the development of chronic pain, functional impairment, and finally post-traumatic arthritis. The aim of this paper is to present a joint-saving surgical treatment of post-traumatic ankle malalignment. It is based on the review of a series of patients who developed fracture malunion and were treated with articular reconstruction.Twenty-two ankle fractures, which malunited and resulted into valgus deformity and fibular shortening are presented. Pre-reconstruction and mid-term follow-up evaluation included the AOFAS score and standard weight-bearing radiographs. Surgical treatment consisted in articular reconstruction with malleolar osteotomies. Post-operatively, the non-weight-bearing period extended to 6 weeks post-surgery, while full weight-bearing was allowed at 12 weeks on average.All osteotomies healed, while no intra-operative or early post-operative complications were reported. The average pre-operative AOFAS score was 45, while post-operatively climbed to 87. At the last follow-up, on average at 5-years post-surgery, 10 patients reported “excellent” function, 7 “good”, 3 “fair” and 2 “poor” function. The correction of the malalignment was maintained in 20 cases. The two patients with poor function and loss of reduction underwent ankle fusion.Articular reconstruction with malleolar osteotomies is indicated for the treatment of ankle post-traumatic malalignment, offering reduction of pain, improvement of the ankle function, delaying the development of post-traumatic arthritis, and minimising the need of radical surgery such as ankle fusion or prosthetic replacement. Moreover, once a correct alignment of the joint is achieved, secondary surgery, if necessary, can be performed more easily, and with better results.     

大转子延长截骨在全髋关节翻修术中应用的临床评价

目的 回顾性研究采用大转子延长截骨(extended troehanteric osteotomy,ETO)行全髋关节翻修术后股骨柄的位置变化,评价ETO在股骨假体稳定件髋关节翻修术中的作用.方法 1998年1月至2007年6月,采用ETO对股骨柄或骨水泥壳固定稳定性全髋关节33例33髋进行翻修.翻修术后采用Harris评分和MOMAC评分评估髋关节功能,摄动态X线片观察截骨块愈合、假体位置改变及股骨柄与股骨髓腔匹配等情况.结果 25例随访12～103个月,平均63个月.Harris评分由术前平均38.4分,提高到末次随访时88.7分;WOMAC评分由术前平均56.2分,降至末次随访时42.8分.大转子截骨块均在术后4～10个月骨性愈合.3例发生股骨柄下沉.平均3.4mm.股骨柄假体出现外翻、内翻各1例.无术中或术后骨折、钢丝断裂、感染、假体周围骨溶解以及异位骨化发生.术后关节脱位1例.结论 对假体固定稳定性股骨柄进行翻修,采用ETO有利于假体的安全取出,术后截骨块愈合率高,延长截骨不影响假体稳定性.股骨柄下沉、位置改变、截骨块骨折等并发症发生率低.     

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.     

How to avoid unintended valgus alignment in distal femoral derotational osteotomy for treatment of femoral torsional malalignment - a concept study

Background

Defining the optimal cutting plane for derotational osteotomy at the distal femur for correction of torsion in cases of patellofemoral instability is still challenging. This preliminary study investigates changes of frontal alignment by a simplified trigonometrical model and demonstrates a surgical guidance technique with the use of femur cadavers. The hypothesis was that regardless of midshaft bowing, a cutting plane perpendicular to the virtual anatomic shaft axis avoids unintended valgus malalignment due to derotation.

Methods

A novel mathematical model, called the Pillar-Crane-Model, was developed to forecast changes on frontal alignment of the femur when a perpendicular cutting plane to the virtual anatomical shaft was chosen. As proof of concept, eight different torsion angles were assessed on two human cadaver femora (left and right). A single cut distal femoral osteotomy perpendicular to the virtual anatomical shaft was performed. Frontal plane alignment (mLDFA, aLDFA, AMA) was radiographically analyzed before and after rotation by 0°, 10°, 20°, and 30°. Measurements were compared to the model.

Results

The trigonometrical equation from the Pillar-Crane-Model provides mathematical proof that slight changes into varus occur, seen by an increase in AMA and mLDFA, when the cutting plane is perpendicular to the virtual anatomical shaft axis. A table with standardized values is provided. Exemplarily, the specimens showed a mean increase of AMA from 4.8° to 6.3° and mLDFA from 85.2° to 86.7 after derotation by 30°. Throughout the derotation procedure, aLDFA remained at 80.4°?±?0.4°SD.

Conclusions

With the use of this model for surgical guidance and anatomic reference, unintended valgus changes on frontal malalignment can be avoided. When the cutting plane is considered to be perpendicular to the virtual anatomical shaft from a frontal and lateral view, a slight increase of mLDFA results when a derotational osteotomy of the distal femur is performed.

     

The transtrochanteric anterior rotational osteotomy of Sugioka. Early and late results in idiopathic aseptic femoral head necrosis

The early and late results of 39 transtrochanteric anterior rotational osteotomies of Sugioka, performed since 1975 in idiopathic aseptic necroses of the femoral head, are presented; 23 results are excellent and good. The rates of postoperative complications and reoperations are high, more than 40% each. Reoperations in smaller necrotic areas are far less frequent. There is no deterioration of the result when the hip joint is replaced by an endoprosthesis after Sugioka osteotomy. Insufficiency of the gluteus muscles is more frequent, but, on the other hand, range of motion of the hip joint increases after total hip replacement. Based on the results, we feel that there are fewer indications for this operation. The procedure is indicated for young patients with good function of the hip joint and sectors of necrosis up to 90 degrees, especially when there is not other way to remove the area of necrosis from the weight-bearing zone of the femoral head.     

Morbidity and mortality following fractures of the femoral neck and trochanteric region: analysis of risk factors

A retrospective review of casenotes with patient review at 3 years was carried out of 405 patients who had surgery for fracture of the femoral neck (including the trochanteric region). The operative management consisted of either internal fixation (61%), hemiarthroplasty (38%), or total arthroplasty (1%). Medical complications developed in 30% of patients; surgical complications developed in 14%. The mortality rate was greater for the first 9 months after operation, but thereafter approached the rate found in the general population (matched for age and sex). Followup 3 years postoperatively recorded 50% of patients still alive. Factors associated with death within the first postoperative year included increasing age, male sex, and the presence of dementia or congestive cardiac failure. Of the survivors, 55% described unlimited range of mobility but 32% reported only poor mobility (progressive dementia being the most common cause). Factors associated with poor mobility were increasing age, female sex, placement in an institution, and the presence of dementia or cerebrovascular insufficiency. Transfer to the specialist rehabilitation ward postoperatively was associated with significantly improved survival and mobility.     

Nonunion of femoral neck fracture and trochanteric osteotomy after a pinned, slipped capital femoral epiphysis: a case report

Femoral neck fracture as a complication of slipped capital femoral epiphysis (SCFE) is rare. Even rarer is a femoral neck nonunion as an additional complication. This is the first case reported in the literature of a failed valgus osteotomy for a femoral neck nonunion. A salvage operation involving a step-cut valgus/flexion/internal rotation osteotomy, open reduction and internal fixation, with a blade plate and cannulated screw, placement of an allograft femoral strut, and allograft bone grafting was successfully performed. Femoral neck fractures following SCFE fixation are more difficult to treat because of abnormal femoral neck configuration. Therefore a valgus, flexion, and internal rotation producing osteotomy may need to be initially performed to prevent a femoral neck nonunion.