Closed reduction and internal fixation versus total hip arthroplasty for displaced femoral neck fracture

Objective： To compare the clinical effects between closed reduction and internal fixation （CRIF） and total hip arthroplasty （THA） for displaced femoral neck fracture. Methods： In this prospective randomized study, 285 patients aged above 65 years with hip fractures （Garden III or IV） were included from January 2001 to December 2005. The cases were randomly allocated to either the CRIF group or THA group. Patients with pathological fractures （bone tumors or metabolic bone disease）, preoperative avascular necrosis of the femoral head, osteoarthritis, rheumatoid arthritis, hemiplegia, long-term bed rest and complications affecting hip functions were excluded. Results： During the had significantly higher 5-year follow-up, CRIF group rates of complication in hipjoint, general complication and reoperation than THA group （38.3% vs. 12.7%, P〈0.01; 45.3% vs. 21.7%, P〈0.01; 33.6% vs. 10.2%, P〈0.05 respectively）. There was no difference in mortality between the two groups. Postoperative function of the hip joint in THA group recovered favorably with higher Harris scores. Conclusion： For displaced fractures of the femoral neck in elderly patients, THA can achieve a lower rate of complication and reoperation, as well as better postoperative recovery of hip joint function compared with CRIF.

Meta-analysis comparing total hip arthroplasty with hemiarthroplasty in the treatment of displaced femoral neck fractures in patients over 70 years old

Objective： Total hip arthroplasty （THA） and hemiarthroplasty （HA） are effective methods currently used to treat femoral neck fracture in elderly patients, but the two options remain controversial in patients over 70 years old. The main purpose of our study was to determine whether THA or HA is a superior treatment of femoral fractures involving a displaced neck in patients who are over 70 years of age. Methods： A computer-based online search of Medline （1970-2011）, PubMed （1977-2011）, and the Cochrane Cen- tral Register of Controlled Trials （2002-201 l） was conducted. Six relevant randomized controlled trials with a total of 739 patients were included for the final analysis. The analysis was performed with software RevMan 5.0. Results： We found that compared with THA, HA needed shorter average time and lost less blood. While over the long-term follow-up, THA patients exhibited significantly less pain and better function and were less likely to require a revision hip surgery. Postoperative infection was equally common among HA and THA patients. Conclusions： The significant differences in outcomes suggest that THA is a valuable treatment option for active elderly hip fracture individuals. However, patients who are older, impaired or institutionalized benefit from HA.

Comparative study of anterolateral approach versus posterior approach for total hip replacement in the treatment of femoral neck fractures in elderly patients

Objective： To compare the clinical outcome of anterolateral minimally invasive approach versus conventional posterior approach for total hip replacement against femoral neck fractures in elderly patients. Methods： The retrospective study was carried out on 42 patients who suffered from displaced femoral neck fractures （19 cases of Garden type Ⅲ, 23 cases of Garden type Ⅳ） treated by total hip replacement via anterolateral minimally invasive approach or conventional posterior approach by the same experienced surgeon. The average age of the patients was 78.1 years （range： 65-89 years）. They were divided into anterolateral mini-invasive group （22 cases） and posterior group （20 cases）. The mean time of follow-up was 13 months （range： 6-36 months）. The anterolateral approach described by Hardinge goes through between anterior 1/3 and posterior 2/3 of the gluteus medius muscle, reaching the femoral neck from anterior capsule. The traditional posterior approach described by Moore （Southern incision） goes through the insertions of short external rotation muscles, reaching the femoral neck from posterior capsule. The related variables under observation were length of incision, operation time, postoperative limp, length of hospital stay and bed stay and dislolcation rate. Results： The length of the skin incision varied between 7 cm and 12 cm with the anterolateral minimally invasive technique, compared to 15-22 cm in the conventional procedure. It took less time （average 15 minutes） to complete the anterolateral minimally invasive approach （72 15 min）, compared with the conventional approach （87 min ±10 min）. The average Harris hip score was 91.23±10.20 in anterolateral approach, 90.03±11.05 in the posterior approach. The average length of hospital stay for patients with the anterolateral approach was （6.4±2.2） days （range： 4-9 days）, while that in posterior approach was （9.2 ±3.1） days （range： 6-13 days）. The average length of bed stay was （3.4±1.1） days （range： 2-5 days） in anterolateral group and （6.2±2.8） days （range： 3-10 days） in posterior group. No patients in anterolateral group experienced dislocation. One （5%） hip in posterior approach had dislocation. Conclusions： Anterolateral mini-invasive approach can decrease trauma, operation time, length of hospital stay and bed stay and rehabilitation time. The stability and minimal muscular damage permit the acceleration of postoperative rehabilitation, which can subsequently reduce the perioperative risk in the treatment of femoral neck fractures in the elderly undergoing total hip replacement.

Multimodal prophylaxis for venous thromboembolic disease after total hip and knee arthroplasty： current perspectives

Life-threatening in the short term and leading to a high level of morbidity in the long term, venous thromboembolism （VTE） is the most fearful complication following lower limb arthroplasty. With advances in surgical procedure, anesthetic management and postoperative convalescence have altered the risks of venous thromboembolism after total joint arthroplasty in the lower extremity.The pathogenesis of VTE is multifactorial and includes the well-known Virchow＇s triad of hypercoagulability, venous stasis and endothelial damage. Therefore, it is appropriate to use a multimodal approach to thromboprophylaxis. Despite extensive research, the ideal multimodal prophylaxis against venous thrombolism has not been identified. So this article reviews the recent developments in multimodal prophylaxis for thromboembolism after total joint arthroplasty.

The strength and function of hip abductors following anterolateral minimally invasive total hip arthroplasty

Objective： To analyze the extent of postoperative hip abductor insufficiency in primary total hip arthroplasty （THA） patients undergoing anterolateral minimally invasive （ALM1） approach, and to investigate whether the clinical outcomes are more favorable in femoral neck fracture （FNF） patients than in non-femoral neck fracture （nFNF） patients. Methods： A total of 48 patients were enrolled in this study. Each patient underwent a clinical examination preoperatively and 6, 12, 24 and 48 weeks postoperatively. The abductor torque, Trendelenburg＇s sign, gait velocity, Harris hip score, Oxford hip score, Westren Ontario and McMaster Universities （WOMAC） score and visual analog scale pain score were recorded. Statistical evaluation was performed with SPSS software version 18.0. The significance level was set at P〈0.05. Results： The abductor torque of the operated hip and the recovery ratio showed a gradual improving tendency from 6 weeks postoperatively until the last follow-up. Gait velocity, Harris hip score, Oxford hip score and WOMAC score improved significantly after the operation until 24 weeks postoperatively. In the FNF group, the abductor torque of the operated side and the recovery ratio were significantly higher than in nFNF group at 6 weeks postoperatively, however, as time passed, this trend tended to disappear. Conclusion： This study demonstrates that patients can obtain good abductor strength and function in the early postoperative period and the hip abductor function of patients who suffer from hip osteoarthritis, rheumatoid arthritis, avascular necrosis of the femoral head could be significantly improved following ALMI THA.

Clinical Trial on the Role of Tuina in Rehabilitation Therapy Following Total Hip Replacement

Objective： To observe the clinical effect of tuina in rehabilitation following total hip replacement. Methods： 60 cases were randomly allocated into a treatment group and control group, 30 cases in each group. Cases in the treatment were treated with combined tuina and rehabilitation, while cases in the control group were treated with rehabilitation alone. All treatment retained for two weeks. The results were observed 7 d, 2 weeks and 6 weeks following the total hip replacement using Harris scale and Hamilton Anxiety Rating Scale （HAMA）. Results： For Harris scale, there were significant intra-group differences in different time frames （P〈0.05）; there were no statistical differences between the two groups 1 d, 7 d and 6 weeks following the total hip replacement （P〉0.05）; and there were statistical differences between the two groups 2 weeks following the total hip replacement. For HAMA scale, there were significant intra-group differences in different time frames （P〈0.05）; there were no significant differences between the two groups 1 d following the total hip replacement; and there were substantial differences between the two groups 7 d, 2 weeks and 6 weeks following the total hip replacement. Conclusion： In a given unit time, combined tuina and rehabilitation is superior to rehabilitation alone in improving the patients＇ post-operative pain, articular range of motion and anxiety.

Anterolateral muscle sparing approach total hip arthroplasty： an anatomic and clinical study

Background Many kinds of approaches have been used for minimally invasive surgery of total hip arthroplasty （MIS-THA）. However, until now when considering the balance of efficacy and associated surgical injury there is no approach widely accepted for MIS-THA. In this study, a modified anterolateral muscle sparing approach was developed to optimize MIS-THA. Methods Twenty adult cadaver specimens （40 hips） were used for anatomic research. The distance from anterior origin of the gluteus medius on the iliac crest to the anterior superior iliac spine was measured; the course of the superior gluteal nerve and the distances from the nerve to the regional anatomic landmarks were recorded. Simulated surgeries were performed in three fresh cadaver specimens to evaluate the soft tissues injury around incisions. From October 2004 to June 2006, 57 patients （57 hips） were treated with anterolateral muscle sparing minimally invasive total hip arthroplasty, of which 17 were femoral neck fractures, 9 osteoarthritis, 16 developmental dysplasia of hip （DDH） and 15 avascular necrosis （AVN）. All the operations were performed by the same senior surgeon. Operation time, blood loss and drainage volume were recorded and the correlation between the local complications and the native anatomical characteristics was especially noted. All cases were followed for at least 12 months. Results The distance from the anterior origin of the gluteus medius to anterior superior iliac spine along the iliac crest was （61±4） mm （range, 55-68 mm）, and the distance from inferior branch of the superior gluteal nerve to the anterior tubercle of the greater trochanter was （74±6）mm （range, 60-88 mm）. In simulated surgeries, excessive distraction of tissue was found to be the main cause of the anterior border injury of the gluteus medius muscle. Of the 57 patients treated with anterolateral muscle sparing MIS-THA, the average incision length was 9 cm （range 7.5-13 cm）. Blood transfusions were performed in 11 patients. During the operations, anterior border injury in deep layers of the gluteus medius was found in 9 patients. Posteromedial perforation of the prosthesis stem on the femoral side was found in 2 patients, which were revised immediately. No positive Trenderlenburg sign was found during the 12 months of follow-up. Conclusions The incision of the anterolateral muscle sparing approach should be directed from the anterior tubercle of the greater trochanter toward 6 cm posterior to the anterior superior iliac spine. The proximal part of the incision should be within 6 cm from the anterior tubercle of the greater trochanter, and it is safe to be extended distally. The anterolateral muscle sparing approach is a minimally invasive approach for total hip arthroplasty, through which the surgeon can operate on the acetabulum and femoral sides in a single incision without muscle detachment, and fluoroscopy assistance is not needed. The surgeon should pay more attention to protecting the gluteus medius from injury by distraction before femoral neck cutting and during the preparation of the femoral side.

Case report： A 10 years follow-up of periprosthetic femoral fracture after total hip arthroplasty in osteopetrosis

Osteopetrosis is an inherited disorder characterized by increased bone density and brittle bone quality. Degenerative changes often occur after the age of 40 in patients with osteopetrosis. Operative inter- vention is the primary treatment option if the clinical manifestation of secondary osteoarthritis is severe. A 44-year-old male suffering autosomal dominant osteopetrosis and progressive unilateral hip osteo- arthritis required a total hip arthroplasty. However, there were several technical challenges associated with this procedure including creating a femoral medullary canal and developing a Vancouver type B2 periprosthetic femoral fracture postoperatively. To afford some experience for the management of similar cases, we here present our technical solutions to these problems.

Local infiltration analgesia following total hip replacement： a review of current literature

Controlling postoperative pain after total hip replacement is important and controversy remains regarding different regimens.By reviewing 18 studies,we attempt to find whether local infiltration analgesia after total hip replacement has any effect on postoperative pain,length of hospital stay and opioid consumption.We conclude that local infiltration analgesia is an effective method for decreasing postoperative pain.

Clinical observation of particulate cancellous bone impaction grafting in combination with total hip arthroplasty for acetabular reconstruction

Objective： To investigate the effect of particulate cancellous bone impaction grafting in combination with total hip arthroplasty （THA） for acetabular reconstruction in patients with posttraumatic arthritis and bone loss after acetabular fractures. Methods： Totally 15 consecutive cases with unilateral acetabular fracture were treated with bone impaction grafting in combination with THA in our department. There were 10 males and 5 females with mean age of 48.2 years （ranging from 36 to 73 years）. Eight cases had the fracture at left hips, 7 at right hips. The average age at injury was 28 years （ranging from 18 to 68 years）. The mean follow-up period was 4.3 years （ranging from 2 to 7 years）. Results： Compared with mean 42 points （ranging from 10 to 62） of the preoperative Harris score, the survival cases at the final follow-up had mean 84 points （ranging from 58 to 98）. One patient had mild pain in the hip. No revision of the acetabular or femoral component was undertaken during the follow-up. Normal rotational centre of most hips was recovered except 2 cases in which it was 0.8 mm higher than that in opposite side. All of them had a stable radiographic appearance. Progressive radiolucent lines were observed in Ⅰ,Ⅲ zones in 2 cases. One patient had a nonprogressive radiolucent line in zone Ⅲ. The cup prosthesis was obviously displaced （6 mm） in one patient, but had not been revised. Conclusion： Particulate cancellous bone impaction grafting in combination with THA as a biological solution is an attractive procedure for acetabular reconstruction in patients with posttraumatic arthritis and bone loss after acetabular fracture, which can not only restore acetabular bone stock but also repair normal hip anatomy and its function.

Horizontal platform supported total hip replacement

Objective To investigate the effect of horizontal platform supported (HPS) prosthesis on cementless total hip replacement for surgical treatment of arthritis in a long-term follow-up study.Methods Clinical and radiographic follow-up of 65 consecutive primary cementless porous coated HPS total hip replacements, which were implanted in 60 patients between 1982 and 1989, was carried out.Results The 53 hips in 50 patients were evaluated both clinically and radiographically. The average follow-up was 6.8 years (range: 5 to 12 years). According to the Harris hip score, 52 (98%) of the hips had sustained an excellent or good result with an average score of 92. At the time of final assessment, no patient experienced anterior thigh pain. There were two revisions performed early in the series due to technical failures. Radiographically, osteolysis and bone re-modelling were assessed. Conclusion The findings suggest that the clinical and radiographic results after cementless total hip replacement for primary hip arthroplasty may be favourably influenced by the use of the proximal stress loaded HPS femoral component.

Radiographic and clinical analysis of cementless acetabular fixation in total hip arthroplasty

Objective： To investigate the factors affecting the fixation, loosening and therapeutic effect of cementless acetabular prosthesis through following up the patients with total hip arthroplasty clinically and radiographically. Methods： From February 1998 to May 1999, 139 patients （148 hips） underwent total hip arthroplasty with cementless acetabular prosthesis in our department. In this study, the clinical therapeutic effect and the anteroposterior radiographs of the pelvis and anteroposterior and lateral radiographs of the hips of 109 patients （116 hips） made before operation, at 1 week operation and annually 3, 6, and 12 months after thereafter were analyzed retrospectively. The clinical therapeutic effects were evaluated with Harris hip score. Radiographs were used to observe the position of prostheses and the bone changes around the implant, and to measure the wearing speed and direction of the acetabular cup. All evaluations were made by an independent examiner who did not participate in the operation. The patients were followed up for 5-6 years. Results- The mean Harris score was 44 points （ range, 10-70 points ） before operation, but it increased to 92.4 points （ range, 80-100 points） at the latest review after operation, which was significantly higher than that before operation （P 〈 0.05 ）. No acetabular component was revised because of infection or aseptic loosening. And no acetabular component migrated. There was no revision of fixed acetabular component because of pelvic osteolysis secondary to polyethylene wear. The mean linear wear rate was 0.15 mm per year. All the acetabular prostheses were classified as stable on the radiographs. Conclusions ： In terms of fixation, total hip arthroplasty with cementlcss acetabular components was successful. Although there is no aseptic loosening and a low incidence of osteolysis at the latest follow-up evaluation, polyethylene wear cannot be avoided and can lead to expansile osteolysis near the cups. This kind of osteolysis usually had no obvious clinical symptoms but it can be diagnosed early on radiographs. So radiographical follow-up for cementless acetabular components is very important.

Cementless total hip arthroplasty with structural allograft for massive acetabular defect in hip revision

Objective： To study retrospectively 20 hip revison patients treated by cementless total hip arthroplasty with structural allograft. Methods： Twenty patients suffering from aseptic loosening of an uncemented cup complicated by a large defect underwent cementless total hip arthroplasty with structural allograft and were followed up for at least 5 years. Clinical results were evaluated by Harris score and leg length measurements. Radiographic analysis included implants migration, graft absorbance, osteolysis and liner wear. Results： No cup loosening or graft reabsorption was found at final follow-up. Clinical improvements in pain and functional status were demonstrated during the follow-up period. The mean Harris hip scores improved from 29 preoperatively （range 20-41） to 81 postoperatively （range 73-89）. Conclusion： Our study shows that cementless total hip arthroplasty with allograft is a good way for massive defect in aeetabular bone stock.

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

Objective: To explore the clinical efficacy of the treatment of comminuted trochanteric fractures and trochanteric osteotomy non union in revision total hip arthroplasty with tension band fixation. Methods: A retrospective review of 295 revision total hip operations performed between 1992 and 1998 was undertaken. Twenty hips of 19 patients with comminuted fractures or nonunion of the greater trochanter were stabilized with tension band technique. Multiple 2.0 mm k wires and tension band wires were placed through the intact cortex distally and the abductor tendon proximally in the pattern "8". Results: The average follow up was 30 months. The Harris Hip Score improved on average from 45 preoperatively to 89 at follow up. Sixteen hips with intra operative trochanteric fracture through osteolytic bone and four hips with symptomatic trochanteric nonunion were approached with tension band fixation. Perioperative loss of fixation in one patient required a repeated surgery. The same fixation at the second operation achieved an uneventful healing. Two patients had a 2 cm proximal migration of one K wire without loss of bony fixation. The trochanteric fractures healed with no further proximal wire migration. One patient had loss of fixation with trochanteric escape at 6 weeks post operatively. The patient has abductor weakness with Trendleburg limp but without pain. On average, radiographic examination showed that healing occurred at 16.6 weeks postoperatively. Six patients developed grade 1 heterotopic ossification and two patients grade 3. All were asymptomatic. None of the 19 patients experienced a dislocation during the follow up. Conclusions: Tension band fixation for greater trochanter can enhance the success rate of revision total hip arthroplasty without a deficient abductor mechanism.

Delayed cementless total hip arthroplasty for neglected dislocation of hip combined with complex acetabular fracture and deficient bone stock

Total hip arthroplasty （THA） for an un- treated acetabular fracture is technically challenging and the long-term result is not so favorable. A 45-year-old fe- male patient with untreated column and comminuted poste- rior wall fracture of the acetabulum was treated in our insti- tution by reconstruction of the posterior wall using iliac strut autograft and plate stabilization of the posterior col- umn with cancellous grafting and cementless THA in a single stage. At 3 years＇ follow-up, the patient was independently mobile without limb length discrepancy. Radiological evalu-ation showed well integrated components and bone grafts. No evidence of aseptic loosening or osteolysis was found. This report aims to emphasize that bony acetabular recon- struction allows the use of primary hip components, which improves prosthesis longevity and preserves bone stock for a future revision.

Femoral head fracture without hip dislocation

Femoral head fractures without disloca- tion or subluxation are extremely rare injuries. We report a neglected case of isolated comminuted fracture of femoral head without hip dislocation or subluxation of one year duration in a 36-year-old patient who sustained a high en- ergy trauma due to road traffic accident. He presented with painful right hip and inability to bear full weight on right lower limb with Harris hip score of 39. He received cementless total hip replacement. At latest follow-up of 2.3 years, functional outcome was excellent with Harris hip score of 95. Such isolated injuries have been described only once in the literature and have not been classified till now. The purpose of this report is to highlight the extreme rarity, pos- sible mechanism involved and a novel classification system to classify such injuries.

QualiW of life following total hip arthroplasW in patients with acetabular fractures, previously managed by open reduction and internal fixation

Purpose： Total hip replacement （THR） is one of the most successful and cost-effective surgical procedures and remains the treatment of choice for long-term pain relief and restoration of function for patients with diseased or damaged hips. Acetabular fractures managed either conservatively or operatively by fixation tend to present later with secondary joint changes that require THR. In this study we evaluated the functional outcome and quality of life achieved by such patients. Methods： Our study was carried out as a retrospective trial by recruiting patients who underwent THR from June 2006 to May 2012. A total of 32 patients were included with a mean age of 46.08 years ranging from （25-65） years. We evaluated the quality of life in the patients using scoring techniques of Short Musculoskeletal Functional Assessment （SMFA） and the 12-1tem Short Form Health Survey （SF-12）. Functional outcome was assessed using Harris Hip Score （HHS）. Results： The mean HHS of the patients was 84.3 with a range from 56 to 100. The SMFA averaged 13.3. The SF-12 score averaged 49.1. The correlation of the HHS with SF-12 was positive （p - 0.001 ） while with SMFA there was a negative correlation （p - 0.001 ）. Conclusion： From this study it is inferred that the functional outcome of THR and quality of life in pa- tients who had acetabular fractures and were initially managed by open reduction and internal fixation is good.

Combined use of extensively porous coated femoral components with onlay cortical strut allografts in revision of Vancouver B2 and B3 periprosthetic femoral fractures

Background Periprosthetic femoral fractures following total hip arthroplasty are getting more prevalent. The aim of this study was to evaluate the clinical results of combined use of uncemented extensively porous coated femoral components with onlay cortical strut allografts in revision of Vancouver type B2 and B3 periprosthetic femoral fractures. Methods Thirteen hips after total hip arthroplasty in 13 patients who suffered a Vancouver B2 or B3 periprosthetic fracture were treated with an uncemented extensively porous coated femoral component combined with onlay cortical strut allografts. Each patient was assigned a Harris hip score, and a visual analog scale （VAS） score for pain and satisfaction. Radiographs were examined for component stability, fracture site and allograft-host union and allograft reconstruction. Results At an average of 5.3-year follow-up, no patient required repeat revision. The average Harris hip score was （71.8±6.3） points, the pain VAS score was （16.6±4.3） points, and the patient satisfaction VAS score was （81.5±5.7） points Radiographic examination showed no detectable loosening of the prostheses, and 12 cases were presented fixation by osseointegration and the other one was stable fibrous ingrown fixation. All fractures united for （5.2±1.4） months in average. And all onlay strut allografts united to host bone for about （11.5±2.6） months. Conclusions Combined use of uncemented, long stemmed, extensively porous coated implant with cortical onlay strut allografts can achieve good clinic results and high rate of union for both fracture site and allograft-host bone junction. This technique could be used routinely to augment fixation and healing of Vancouver B2 and B3 periprosthetic fractures.

Femoral component revision using extensively porous-coated cementless stem

To evaluate the clinical and radiographic results of extensively porous-coated femoral stem in revision of total hip arthroplasty （THA）. Methods： From January 1999 to December 2003, fifteen hips of fifteen cases received revision of THA with extensively porous-coated femoral stem. There were six males and nine females. The average age was 66 years （ranging 58-82 years ）. The reason for the revision was aseptic loosening in 10 cases, septic loosening in 2, femoral shaft fracture around loose implant in 2, and femoral revision for malposition of the femoral component in 1. All the patients were clinically evaluated using Harris hip score and radiographically evaluated both preoperatively and postoperatively at regular follow-up intervals. Results： No patients were lost for follow-up. The average length of follow-up was 2.3 years （ range, 1-5 years）. The average preoperative Harris hip score was 42 points, which was improved to 89 points at latest follow-up. The latest follow-up showed that bone in-growth occurred in fourteen stems and solid fibrous fixation in one. Complications consisted of femoral shaft fracture in two cases （1 undisplaced distal femur fracture and 1 cortical perforation at the tip of the prosthesis）, and postoperative dislocation in one. There was no mechanical failure of the stem in this study. Conclusions ： Satisfactory results of short-term clinical and radiographic follow-up have been achieved in using extensively porous-coated femoral stem for revision of THA. It should be noticed that the straight, 203 mm stem should be used with caution in short people.