External validation of the clinical indications of computed tomography (CT) of the head in patients with low-energy geriatric hip fractures

IntroductionOn evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS) < 15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution.Patients and methodsPatients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables.ResultsIn total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative.ConclusionWith the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS < 15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.     

The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs)

BackgroundNew direct oral anticoagulants (DOACs) are commonly used in the management of atrial fibrillation and VTE. Currently, there is no strong evidence to support the current practice of routinely repeating computed tomography (CT) head in anticoagulated patients within 24 hours after their first negative CT scan to assess for new and delayed intracranial hemorrhage (ICH). Our hypothesis is that the vast majority will not have new CT scan findings of ICH and those who do would not require any further intervention.MethodsThis is retrospective cohort study. IRB approval was obtained. Subjects included adults age ≥ 18 taking DOACs who presented to our level III trauma center with confirmed or suspected blunt head trauma between August 2013 and October 2019 and received at least one head CT scans.Results498 Patient encounters met inclusion criteria. Only 19 patients (3.8%) had positive traumatic ICH on the initial CT head. Those had a higher ISS. 420 out of 479 initial negative CT encounters received a second CT head. Only 2 (0.5%) had delayed positive second CT scan for ICH. 95%CI [0.06%, 1.7%] Patients who developed a new ICH on the second CT head after an initial negative CT scan had a lower Glasgow Coma Scale (GCS) on presentation and a higher ISS. None of those patients required neurosurgical interventionConclusionOur data suggests that the risk of developing a new or delayed traumatic ICH for patients on DOAC on a second CT head within 24 hours following an initial negative CT is very low and when present did not require neurosurgical intervention and thus does not support routinely obtaining a repeat CT head within 24 hours after a negative initial CT scan. Patients presenting with lower GCS and higher ISS had a higher chance of having a delayed ICH.     

A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed

BACKGROUND: Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination. METHODS: A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge. RESULTS: In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%. CONCLUSIONS: Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.     

Management and radiographic outcomes of femoral head fractures

Background

Femoral head fractures are uncommon injuries. Small series constitute the majority of the available literature. Surgical approach and fracture management is variable. The purpose of this study was to evaluate the incidence, method of treatment, and outcomes of consecutive femoral head fractures at a regional academic Level I trauma center.

Materials and methods

A retrospective review of a prospective database was performed over a 13-year period. All AO/OTA 31C femoral head fractures were identified. A surgical approach and fixation method was recorded. Clinical and radiographic evaluation was performed for patients with 6 months or greater follow-up. Radiographs were evaluated for fixation failure, heterotopic ossification (HO), avascular necrosis (AVN) and post-traumatic arthritis.

Results

We identified 164 fractures in 163 patients; 147 fractures were available for review. Treatment was operative reduction and internal fixation (ORIF) in 78 (53.1%), fragment excision in 37 (25.1%) and non-operative in 28 (19%). An anterior approach and mini-fragment screws were used in the majority of patients treated with fixation. Sixty-nine fractures had follow-up greater than 6 months. Sixty-two fractures (89.9%) proceeded to uneventful union. All Pipkin III fractures failed operative fixation. Six patients developed AVN, seven patients had a known conversion to hip arthroplasty; HO developed in 28 (40.6%) patients and rarely required excision.

Conclusions

Fractures of the femoral head are rare. An anterior approach can be used for fragment excision or fixation using mini-fragment screws. Pipkin III fractures represent catastrophic injuries. Non-bridging, asymptomatic HO is common. AVN and posttraumatic degenerative disease of the hip occur but are uncommon.

Level of evidence

IV—prognostic.

     

Warfarinized Patients with Proximal Femoral Fractures: Survey of UK Clinical Practice

Abstract Introduction:   In an aging population, anticoagulation in patients with musculoskeletal injuries is increasingly prevalent. The North American literature indicates an absence of consensus concerning the most appropriate management for this group. We aim to test the hypothesis that there is a lack of consensus in the UK regarding the perioperative management of patients with hip fractures on long-term warfarin therapy. Materials and Methods:   A representative group of 400 consultant orthopedic surgeons was surveyed by postal questionnaire regarding their policy on the reversal of anticoagulation in warfarinized patients with hip fractures. The consultants contacted were selected to represent a geographical spread throughout the UK. Results:   There were 159 respondents (40% response rate), of which 79% (126) had a trauma commitment. 95 (75%) of these had a protocol for the reversal of anticoagulation prior to surgery. The commonest method used was to simply withhold warfarin and wait (70%). Other methods included FFP (16%), and low-dose (23%) and high-dose (14%) vitamin K. Some respondents used more than onemethod. Although nearly all respondents preferred an INR < 2.0 prior to surgery, 55% preferred an INR < 1.5. Discussion:   Hip fracture in the presence of long-term warfarin use is associated with significantly increased morbidity. This problem is likely to increase. Our results demonstrate variation in approach throughout the UK with regard to warfarin reversal and the acceptable INR at which to operate in this group of patients. We propose that low-dose vitamin K is considered more widely as a safe and effective method of warfarin reversal in this group.     

Imaging of occult hip fractures: CT or MRI?

ObjectivesPatients presenting with hip pain but normal plain radiographs may ultimately be shown on further investigation to have suffered an occult hip fracture (OHF). This diagnosis can be made with CT or MRI. Traditionally MRI has been considered a superior modality. We performed a retrospective review of all patients presenting to our service with a suspected OHF over a four-year period, investigated with either CT or MRI.DesignRetrospective review.SettingUrban trauma centre.PatientsPatients with suspected hip fractures and negative radiographs.InterventionCT or MRI.Main outcome measuresDetection rate; delay in request for further imaging; delay to theatre; re-presentations with missed fractures.ResultsA total of 179 patients were investigated, with a mean age of 82 ± 13 years. The ultimate diagnosis was of an OHF in 71 cases and pelvic or acetabular fracture in 34. The average time from presentation plain radiograph to further imaging was 2.0 ± 2.7 days, but was significantly shorter for CT. No patient re-presented with unidentified fractures or other localised hip pathology within a 12-month period.ConclusionsModern imaging technology does not appear to miss clinically significant fractures. As CT is usually more accessible than MRI, the results of our study should encourage surgeons to consider CT as a first line investigation for occult hip fractures. We advocate a high index of suspicion and early imaging referral for elderly patients presenting with non-specific hip pain following a fall.Level 3 Evidence.     

Risk of delayed intracranial hemorrhage in patients on anticoagulation with negative initial imaging

BackgroundMany institutions obtain a delayed head CT in patients presenting after a ground level fall while on anticoagulation. This study evaluates their risk of delayed ICH.MethodsRetrospective chart review of 635 patients on anticoagulation who sustained a ground level fall with a negative initial head CT and a GCS above eight. Patients underwent a repeat head CT within 48 h. The ISS was calculated for all patients.ResultsFive patients had a delayed ICH. All survived and none required neurosurgical intervention. Patient variables did not have any correlation with development of ICH. Patients with a delayed ICH had a significantly higher ISS.ConclusionPatients on anticoagulation presenting to the hospital after a ground level fall, with a GCS above eight and an initial negative head CT, do not need to undergo repeat imaging. ISS could be used to stratify patients who are at higher risk of delayed ICH.     

CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes?

PurposeSustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center.MethodsWe reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review.ResultsOf 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1–5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations.ConclusionUse of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource.Level of EvidenceLevel III     

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.     

Analysis of vertical and horizontal offsets in displaced femoral neck fracture in elderly treated with indigenous bicentric bipolar hip device

ObjectivesTo analyze the effect of indigenous bicentric bipolar prosthesis on horizontal and vertical offsets in fracture neck of femur when compared to contralateral normal hip and to evaluate functional outcomes. We hypothesized that our non-modular bipolar device restores satisfactory offsets in such patients.MethodsAll active elderly patients with displaced fracture NOF having contralateral normal hip were included. We used an indigenous bicentric bipolar hip-prosthesis, which is a non-modular single-piece device in all cases by lateral Hardinge approach. Postoperative radiograph AP view was taken in 15° internal rotation to decrease the effect of limb rotation on offset. CT scan was also used to evaluate offsets using ADW4.6 ADVANCED GE optima 128 slice software system. Subjects were followed for a minimum of 12 months postoperatively and functional outcome of effect of offsets change were evaluated by modified Harris Hip Score.ResultsThere is minimal difference in horizontal and vertical offset after bicentric bipolar hemi-replacement which is statistically insignificant supporting our hypothesis. The clinical outcomes were good to fair according to modified Harris Hip Score. The mean value of horizontal offset after our bipolar hemireplacement was 42.4 ± 2.04 mm and of normal hip was 41.8 ± 1.81 mm and P-value=0.08 in plain radiographs and value of horizontal offset in CT scan was 40.73 ± 0.27on bipolar side and 41.19 ± 0.77 on normal side. Vertical offset after bicentric bipolar was 32.67 ± 2.85 mm and vertical offset of normal hip was 32.53 ± 2.73 mm. Mean 9.77 ± 1.09 mm of calcar was preserved. Modified Harris Hip Score at 6 and 12 months postoperatively was 75.78 ± 4.16 and 79.53 ± 3.95 respectively. There was no incidence of hip dislocation.ConclusionOur study data clearly demonstrates that vertical and horizontal offsets are effectively maintained by the indigenous bicentric hip device. There was insignificant change in offsets as compared to contralateral normal side due to its design modifications. Indigenous bicentric non-modular bipolar device offers an excellent option for femur neck fractures in elderly patients in resource constrained situations. It allows rapid rehabilitation due to reduced surgical time, minimal blood loss and early return to function and activities of daily living.     

Evaluation of a 30-day-mortality risk calculator for patients undergoing surgical fixation of fragility hip fractures

IntroductionHip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system.Materials & Methods625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk calculator were also evaluated.ResultsThe observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated troponin were significantly associated with 30-day mortality.DiscussionThe HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia.Level of EvidenceIV     

Internal fixation of acetabular fractures in an older population using the TIMI approach – Midterm results of a prospective study

IntroductionThe incidence of geriatric acetabular fractures continues to increase due to demographic changes. In the elderly, anterior column fractures are common, and standard approaches are associated with a considerable risk for surgery-associated complications. Therefore, a minimally invasive approach was developed in our department. The aim of this study was to examine early and mid-term results regarding the use of this novel two-incision minimally invasive (TIMI) approach in patients aged over 55 years with acetabular fractures.MethodsFrom July 2007 to April 2014, 47 patients aged over 55 years were treated via the TIMI approach; these patients were included in the present prospective study. The patients' characteristics, data, and early phase of care were assessed during acute care. A radiological evaluation comprised pre- and postoperative CT scans and x-rays, including Judet views at follow-up. Follow-up examinations were performed after 6 and 24 months and comprised a clinical and radiological examination and an evaluation of hip function (Harris Hip Score) and health-related quality of life (EQ-5D).ResultsThe mean age of the patients was 74 ± 11 years, with a gender ratio of 35/12 (m/f). The average operation time was 93 ± 30 min, and perioperative blood loss amounted to 858 ± 463 ml. In total, five (11%) complications associated with the operative procedure occurred, and revision surgery was necessary in three patients. We observed no wound infections, abdominal wall hernias or cases of heterotopic ossification in our sample. The Harris Hip Score at six months after surgery was 81, and it slightly improved to 84 after 24 months. The mean EQ5D index was 0.91 at six months after surgery and 0.92 at 24 months after surgery.ConclusionThe TIMI approach represents a valuable alternative to the ilioinguinal and modified Stoppa approach for the treatment of acetabular fractures located in the anterior column, which are often observed in geriatric patients.Level of evidenceTherapeutic Level II (Prospective cohort study).     

Influence of coincident distal radius fracture in patients with hip fracture: single-centre series and meta-analysis

BackgroundHip and wrist fractures are the most common orthopaedic injuries. Combined hip and distal radius fractures are an important clinical and public health problem, since mobilisation and rehabilitation is challenging and likely to be prolonged in this setting. Few studies have explored the influence of an associated wrist fracture in patients with hip fracture. We present the largest series of patients with concomitant hip and wrist fractures. We perform the first meta-analysis of the literature on patients with concurrent hip and wrist fractures.ResultsPatients with the combined fracture were of a similar age compared to those with isolated hip fracture. There were a significantly higher proportion of women in the cohort with both hip and wrist fractures (female:male ratio of 9:1 versus 4:1 p < 0.0001). The combination fracture group had a greater length of hospitalisation (18 vs 13 days p < 0.0001). The survivorship of both groups was not significantly different even after adjustment for age and gender. Meta-analysis of the literature showed female preponderance, increased length of stay but no significant difference in survival in patients with concomitant hip and wrist fractures.ConclusionThe combination fracture occurs much more commonly in women and patients require a greater length of hospitalisation. The patients who sustained simultaneous hip and wrist fractures experienced no statistically significant difference in survivorship when compared to those who suffer isolated hip fractures. This is not withstanding the presence of two fractures. This difference in mortality did not reach statistical significance.

Level of evidence

Level III (retrospective comparative study).     

Mid-term functional and radiological outcomes after total hip replacement performed for complications of acetabular fractures

ObjectiveAcetabular fractures can lead to serious complications such as avascular necrosis of the femoral head (AVN), osteoarthritis, non-union. Total hip replacement (THR) is a treatment option for these complications. The purpose of this study was to assess the functional and radiological outcomes of THR at least 5 years after the primary implantation.MethodsThis retrospective study analysed clinical data from 77 patients (59 males, 18 females) who were treated from 2001 to 2022. Data was collected on the incidence of AVN of the femoral head, complications, interval from fracture to THR, reimplantation. The modified Harris Hip Score (MHHS) was used to evaluate outcome.ResultsThe mean age at the time of fracture was 48 years. Avascular necrosis developed in 56 patients (73%), with 3 cases of non-union. Osteoarthritis without AVN developed in 20 patients (26%), non-union without AVN in one patient (1%). The mean time from fracture to THR was 24 months for AVN with non-union, 23 months for AVN alone, 22 months for AVN with arthritis, 49 months for hip osteoarthritis without AVN. The time interval was significantly shorter for cases of AVN than for cases of osteoarthritis without AVN (p = 0.0074). Type C1 acetabular fracture was found to be a risk factor for femoral head AVN (p = 0.0053). Common complications of acetabular fractures included post-traumatic sciatic nerve paresis (17%), deep venous thrombosis (4%), infections (4%). Hip dislocation was the most common complication of THR (17%). There were no cases of thrombosis following THR. According to Kaplan-Meier analysis, the proportion of patients without revision surgery within 10-year period was 87.4% (95% CI 86.7–88.1). The results of the MHHS after THR: 59.3% of patients had excellent results, 7.4% good, 9.3% satisfactory results, and 24.0% had poor results. The mean MHHS was 84 points (95% CI 78.5–89.5). Paraarticular ossifications were observed in 69.4% of patients in the radiological evaluation.ConclusionTotal hip replacement is an effective treatment for serious complications of acetabular fracture treatment. Its results are comparable to THR peformed for other indications, although it is associated with a higher number of paraarticular ossifications. Type C1 acetabular fracture was found to be a significant risk factor for early femoral head AVN.     

The older they are the harder they fall: Injury patterns and outcomes by age after ground level falls

BackgroundTrauma centers are seeing an increasing number of geriatric patients that are more susceptible to injuries even from relatively minor insults such as a ground level fall (GLF). As life expectancy increases, people are living in the geriatric age bracket for decades and often use anticoagulation agents for various comorbidities. We hypothesize that this patient population is not homogenous and we investigated the injury patterns and outcomes after GLF as a function of age and anticoagulation use. We also sought to identify injury patterns and patient characteristics of GLF patients.MethodsA retrospective review of a Level I trauma center’s database identified all adult (age > 18) trauma patients admitted after GLFs between 1/2003 and 12/2013. Demographics, injury patterns, antiplatelet use, anticoagulation use (including warfarin, enoxaparin, and rivaroxaban) and outcomes were abstracted.ResultsThe cohort included 5088 patients. 3990 patients were >60 years and 38.2% were male. With each decade, although the mean ISS did not considerably change (range 7.0–8.6), mortality increased (0.9% at <60 years vs. 5.5% at >90 years), and the likelihood of home discharge decreased dramatically (73.7% at <60 years vs. 18.2% at >90 years). Abdominal solid organ injuries were rare (0.8%). Age was associated with an increased incidence of cervical spine (p = 0.002), rib (p = 0.009) and pelvic fractures (p < 0.001). Only aspirin use was significantly associated with intracranial bleed (p = 0.001). Aspirin (p = 0.049) or warfarin (p < 0.001) use was associated with increased overall mortality.ConclusionGLF patients are not homogenous as certain injury patterns change with increasing age. Aspirin use was associated with an increased incidence of intracranial bleeds, whereas other antiplatelet or anticoagulation agents were not. GLF is also associated with significant morbidity and mortality that increases dramatically with age. Both aspirin and warfarin are independently associated with increased mortality. These patient differences have implications for their evaluation and management.Level of evidenceEpidemiological/prognostic study level IV.     

手术治疗髋关节后脱位合并股骨头与髋臼骨折的体会

目的：探讨髋关节后脱位合并股骨头与髋臼骨折的手术治疗效果与预后。方法：回顾性总结17例髋关节后脱位合并股骨头骨折与髋臼骨折患者的手术治疗经验。所有患者于伤后12h内行髋关节手法复位,并于术前通过CT定位,股骨头骨折采用切开复位可吸收螺钉内固定,髋臼骨折根据情况或予切除,或予钢板内固定。结果：17例患者术后6个月内所有骨折均骨性愈合,无股骨头坏死,按Modifie Daobigne and Postal临床分级标准评定关节功能恢复情况,优8例,良7例,可2例。优良率为88.2%。结论：髋关节后脱位伴股骨头骨折与髋臼骨折,采取手术治疗可获得较好的预后。     

Mid-Term Clinical and Radiographic Outcomes of a Long Cementless Monobloc Stem for Revision Total Hip Arthroplasty

BackgroundFor the past 2 decades, the authors have been using a long tapered cementless stem made of titanium and fully coated with hydroxyapatite for revision total hip arthroplasty. The purpose of this multicentric study is to assess clinical outcomes, radiographic outcomes, re-revision rates, and survival rates of this revision stem at a minimum 5-year follow-up.MethodsThe records of a multicentric continuous series of 335 adults undergoing revision total hip arthroplasty using the Corail revision stem (DePuy, Leeds, UK) between 2000 and 2012 were retrospectively reviewed. The Harris Hip Score, Oxford Hip Score, and Engh score were recorded. Survival was assessed using the Kaplan-Meier method and cumulative incidence function.ResultsSeventy-seven patients died with their revision stem in place, 47 could not be contacted, and 22 had stem re-revisions. This left a final cohort of 201 patients, aged 70 ± 12 years at revision surgery, with a body mass index of 26 ± 4. The Kaplan-Meier survival was 93.9% for re-revision of any component for any reason, 96.7% for re-revision of the stem for any reason, and 99.3% for re-revision of the stem for aseptic reasons. At last follow-up, the Harris Hip Score was 84.8 ± 13.1, the Oxford Hip Score was 21.0 ± 7.8, and the Engh score was 16.4 ± 6.7.ConclusionThe long tapered cementless revision stem had excellent clinical and radiographic outcomes at a minimum follow-up of 5 years. The revision stem enabled restoration of bone stock in femurs with pre-revision bone defects, confirming that the hydroxyapatite coating promotes osseointegration, even in femurs with extensive bone loss.Level of EvidenceLevel IV, retrospective cohort study.     

Limited range of motion of hip resurfacing arthroplasty due to unfavorable ratio of prosthetic head size and femoral neck diameter

Background and purpose?Hip resurfacing arthroplasty is being used more and more frequently. The small ratio in size between the resurfaced femoral head and the relatively thick femoral neck raises the question of whether the range of motion is sufficient, particularly with regard to the high mobility required by younger patients. We analyzed motion in a CAD model.

Methods?Three-dimensional CAD models of the natural hip were created from CT scans and 8 designs of hip resurfacing prostheses (head diameter between 42 mm and 54 mm combined with a hemispherical cup) were implanted in a virtual sense. We simulated 3 different leg positions and the range of motion was evaluated, considering five different implant positions.

Results?The range of motion of the hip resurfacing designs analyzed was far below the range of motion of stemmed total hip prostheses. None of the resurfacing prostheses provided flexion movements of 90° without impingement. The average range of motion of hip resurfacing arthroplasty was 31–48° below the range of motion of a stemmed total hip replacement with 32-mm head diameter.

Interpretation?The range of motion of the hip resurfacing designs examined was substantially less than that of a conventional total hip prosthesis. Since impingement of the femoral neck on the acetabular component increases the risk of neck fractures, of dislocation and of subsequent implant loosening, the design and position of the implant should be considered before using hip resurfacing arthroplasty as a standard treatment for younger patients.     

Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral stem

BackgroundMalposition of the femoral stem is a risk factor for dislocation after total hip arthroplasty (THA). Currently, two radiological methods are available for the measurement of stem anteversion. However, one method is not applicable in patients with a stiff hip, and the other one cannot differentiate the anteversion and retroversion of the stem. Therefore, we developed a method to measure the stem anteversion and assessed its reliability as well as validity.MethodsTrans-lateral decubitus view of the proximal femur was taken with the patient in lateral decubitus position, the hip in extension and the knee in 90° flexion. Hip anteroposterior (AP) view, trans-lateral decubitus view and CT scan of the hip were taken in 36 patients, who underwent THA. Their mean age was 59.8 (27–84) years and the mean body mass index was 25.2 (18.8–30.9) kg/m². The stem neck-femoral shaft angle was measured on hip AP view and the trans-lateral decubitus view. Then, the stem anteversion was calculated using the Ogata-Goldsand formula. We assessed the intra- and inter-observer reliabilities and evaluated the validity by comparing with the measurements on CT scan.ResultsThe intra- and inter-observer reliabilities were 0.934 and 0.935, respectively. The calculated stem anteversion (23.72°±8.17°) correlated well with the stem anteversion on CT scan (23.91°±10.25°), especially when the radiological anteversion was <30° (correlation coefficient = 0.729, p = 0.001).ConclusionWe developed a reliable and valid method to measure stem anteversion using hip AP view and trans-lateral decubitus view of the femur. This method can replace conventional radiological methods.