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This study was conducted to identify the factors influencing mechanical failure of cementless acetabular reconstruction for arthropathy after operative treatment of acetabular fractures. Fifty-six patients (56 hips) undergoing cementless total hip arthroplasty were enrolled and followed for a mean of 120 months (range, 60–180 months). The 10-year survival rate, with mechanical failure (radiographic loosening or revision due to aseptic loosening) as the endpoint, was analyzed with respect to sex, age, body mass index (BMI), acetabular bone deficiency, sclerotic changes to the acetabulum, and use of the Trabecular Metal (TM) cup (Zimmer, Inc, Warsaw, Indiana). Mean 10-year survival rates of the acetabular component were as follows: 80% (range, 65%–96%) in males and 100% in females ( P =.032); 77% (range, 60%–95%) in patients younger than 50 years and 91% (range, 82%–100%) in older patients ( P =.027); 88% (range, 78%–98%) in patients with a BMI less than 30 kg/m 2 and 81% (range, 74%–89%) in patients with a BMI of 30 kg/m 2 or higher ( P =.068); 54% (range, 32%–76%) in patients manifesting large acetabular deficiency and 90% (range, 78%–100%) in the remaining patients ( P P =.022); and 82% (range, 73%–100%) in patients who received a conventional shell and 100% in patients who received the TM cup ( P =.039). Male sex, age younger than 50 years, large acetabular deficiency, and sclerotic changes of the acetabulum were significant factors contributing to the mechanical failure of cementless acetabular reconstruction performed for old acetabular fractures treated with open reduction and internal fixation. Use of the TM cup seemed able to prolong the endurance of the acetabular component in the subsequent reconstruction. [ Orthopedics. 2015; 38(10):e934–e939.]

Total hip arthroplasty (THA) for patients with Crowe type IV developmental dysplasia of the hip is technically challenging. This group of patients has a higher incidence of nerve injury during THA. Although neurophysiologic intraoperative monitoring has been developed to provide nerve monitoring, it is not always available. The wake-up test has been used for intraoperative spinal cord monitoring during major spinal surgery, but no study has reported the use of the wake-up test for neurologic monitoring during THA in patients with severe developmental dysplasia of the hip. The authors retrospectively reviewed 22 THA procedures in 20 patients with Crowe type IV developmental dysplasia of the hip who underwent the wakeup test during THA. In the current study, 1 patient could not dorsiflex her foot during the wake-up test. Therefore, the authors immediately reduced the length of limb lengthening by 1 cm. Postoperative drop foot and numbness occurred but resolved completely 2 months later. None of the patients who showed no deficits in motion of the feet during the intraoperative wake-up test had signs of postoperative nerve injury. In the current study, there was no false-positive or false-negative finding. The authors concluded that the wake-up test, which is simple, safe, and reliable, is a useful technique and a possible alternative to neurophysiologic intraoperative monitoring in checking nerve function during THA in patients with severe developmental dysplasia of the hip.

Septic arthritis is the most rapidly destructive joint disease, but its early diagnosis remains challenging; delayed or inadequate treatment, even by expert physicians, can lead to irreversible joint destruction. Between 25% and 50% of patients develop irreversible loss of joint function, which is especially concerning in elderly patients. To understand the factors influencing the outcome of septic arthritis, the authors reviewed patients aged older than 50 years who had undergone debridement surgery for primary septic arthritis at their institution between 1998 and 2008. Ninety-two patients (92 knees) were enrolled in the study; 14 did not meet inclusion criteria and were excluded from the final analysis. Of the 78 included patients, 7 underwent arthrodesis, 22 underwent total knee arthroplasty, 19 were indicated for total knee arthroplasty for severe knee joint osteoarthritis but did not undergo surgery by the end of this study, and the remaining 30 had no or mild symptoms of osteoarthrosis and did not receive any surgical procedure. Staphylococcus aureus was the most common pathogenic agent (38%), followed by mixed bacterial infection (10%). Several factors negatively influenced the final clinical outcome, including delayed treatment, advanced macroscopic staging made during debridement surgery, performing multiple debridement surgeries, and a larger Lysholm score difference pre- and posttreatment. More antibiotics administered, longer duration of antibiotic treatment, and more pathogenic agents present were also significantly correlated with poor outcome. These findings shed new light on the management of septic arthritis. Accurate diagnoses and effective treatments are important for the clinical outcome of knee joint bacterial infection in elderly patients.

The results of total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH) in elderly patients (80 years or older) has not been well defined. The purpose of this retrospective study was to evaluate the clinical course of and the results in noncemented THA for ONFH in elderly patients. Between 1998 and 2007, one hundred seven consecutive hips with ONFH in 103 patients were evaluated. The causes of ONFH were traumatic in 46 (43%) hips and nontraumatic in 61 (57%) hips. All hips were treated with noncemented THA. Average follow-up was 72 months (range, 60–144 months). The functional results improved to statistical significance after THA. However, no significant differences existed between 6 months, 1 year, and 5 years postoperatively. Nine (8.4%) postoperative complications occurred in these 107 hips, including 1 stem loosening, 1 liner wearing, 4 postoperative infections, 2 postoperative dislocations, and 1 pulmonary embolism. Fifteen (14.6%) deaths occurred during follow-up. The progression of ONFH in elderly patients was so rapid and the result of core decompression was so poor that a salvage procedure seemed to have no role in the treatment. Harris Hip Score, Short Form 36 physical function score, and Western Ontario and McMaster Universities Osteoarthritis Index scores significantly improved after noncemented THA. Ninety-two hips had a complete follow-up, and the survivorship of prosthesis was 95% (88/92) with minimal 5-year follow-up. Noncemented THA was effective in the treatment of ONFH in this group of patients.

Open tibial shaft fractures are the most common open fractures, and many complications can occur. During the treatment period, infection leading to osteomyelitis was the most common complication. However, no consensus exists regarding the ideal management for such cases in the literature. The purposes of this retrospective study were to review the treatment of patients with chronic tibial shaft osteomyelitis over the past 14 years who were referred to the authors’ institution and to provide a staged protocol for spontaneous wound healing. The staged protocol included: (1) radical debridement for infected bone and soft tissue; (2) immediate application of Ilizarov’s apparatus for all patients except those needing delayed application; (3) osteotomy in healthy bone; (4) simultaneous distraction–compression osteogenesis and histogenesis; (5) additional docking-site bone grafting; and (6) shifting the external fixator to a locked nail when callus formation was visible at the distraction site. Union was achieved in 15 of 16 patients, with an average external fixation time of 4.5 months (range, 3–6 months). No deformity or leg-length discrepancy greater than 1 cm occurred. In the treatment of chronic osteomyelitis, this staged protocol was safe and successful and allowed for union, realignment, reorientation, and leg-length restoration. Regarding the soft tissues, this technique provides a unique type of reconstructive closure for infected wounds. It is suggested that the staged protocol is reliable in providing successful simultaneous reconstruction for bone and soft tissue defects without flap coverage.

The purpose of this study was to determine the change of fixation strength after adjusting the height of polymethylmethacrylate (PMMA)-augmented pedicle screws. Cement-augmented cannulated pedicle screws with or without PMMA augmentation with a radial hole in the distal third of the screw thread were inserted into synthetic bone blocks used to model osteoporosis. Screws were left unchanged (in situ), screwed in 3 threads, or screwed out 3 threads. The change in screw height was made 24 hours after cement placement. Radiographs of the samples were taken before and after screw adjustment, and pullout strength testing was performed. In the cement group, a radiolucent cavity was present after screwing in due to the screw–cement complex migrating downward, whereas no obvious change in the boneicement complex existed after screwing out. Mean pullout strength was significantly higher in the groups with cement as compared to those without cement. However, in the cement groups, the screw-in group had the lowest mean pullout strength among 3 groups, and the mean pullout strength in the screw-out group was also significantly lower than that in the in situ group ( P Adjustment of pedicle screw height after cement augmentation in a severely osteoporotic spine can significantly reduce the pullout strength of the screw.

Diagnosis of occult hip fractures by initial radiographs remains challenging in the emergency department. Previously, the gold standard for accurate diagnosis of occult hip fractures was magnetic resonance imaging. This study used initial radiographs obtained in the emergency department to evaluate specific signs and measurements as diagnostic references for occult femoral neck fractures in elderly patients. Initial negative radiographs were reviewed for 2 groups of patients: a group with occult femoral neck fractures (n=16) and a group without fractures (n=32). Reviews of initial radiographs and all imaging studies were performed by a senior orthopedist (C-C.C.) and a radiologist (H-T.W.). Diagnostic signs included lateral, medial, anterior, and posterior signs; measurements included elevation of the fat pad and external rotation of the femur. The prevalence of occult femoral neck fracture was 3.3%. Initial radiographs of occult femoral neck fractures were not routinely negative; 14 (87.5%) of 16 patients with fractures had at least 1 radiographic sign. Using the positive lateral or posterior sign as the diagnostic reference, the sensitivity was 0.875 and the specificity was 0.906. When elevation of the fat pad was ⩾1.5 mm, the sensitivity was 0.867 and the specificity was 0.857 for the diagnosis of occult femoral neck fracture. The lateral and posterior signs and elevation of the fat pad ⩾1.5 mm on initial radiographs are recommended as diagnostic references for occult femoral neck fracture. These references are clearly defined and may offer important information for all clinicians and radiologists in the emergency department.

A retrospective study was conducted to evaluate the role of autologous bone graft in treating atrophic nonunion of midshaft clavicle fracture with a limited-contact dynamic compression plate (LC-DCP). Between 1995 and 2008, sixty cases of atrophic nonunion of midshaft clavicle fractures were managed with open reduction and internal fixation with an LC-DCP. The cases were separated into 2 groups to evaluate the effect of autologous bone graft in the enhancement of bone union. In group 1 (n=24), autologous bone graft was not used; in group 2 (n=36), autologous bone graft was used. Pre- and postoperative management were the same in both groups. Radiographic results and functional outcomes according to the Quick Disability of Arm, Shoulder, and Hand score were evaluated. Average follow-up was 25.2 months (range, 24–48 months). No statistically significant difference was found between the 2 groups regarding demography and preoperative functional scores ( P >.05). Operative time and hospital stay were statistically significant longer in group 2 ( P P >.05). Limited-contact dynamic compression plate fixation is an effective method for treating atrophic nonunion of midshaft clavicle fractures. Autologous bone graft was not needed.

Deep vein thrombosis (DVT) is an important complication following total knee arthroplasty (TKA). However, the incidence of DVT is generally underestimated due to subclinical or minor symptoms and signs. In Western countries, prophylactic agents against DVT are administered routinely after TKA. However, in Asia, no regular prophylaxis is generally given to patients undergoing TKA. This article presents a prospective study evaluating the incidence of DVT in 724 consecutive Taiwanese patients who underwent TKA without prophylactic anticoagulation therapy. Of these, 328 patients (45.3%) showed positive Homan’s sign with calf swelling >3 cm. Ultrasonographic examination revealed the overall incidence of DVT to be 8.6% (62/724). The incidence of DVT was significantly higher in women ( P =.035), in patients who underwent bilateral TKA ( P =.002), and in patients with a body mass index ≥30 kg/m 2 ( P =.026). The incidence of DVT appeared to be increased in patients with higher tourniquet time; however, the difference was not statistically significant. In all of the suspected cases of DVT, the symptoms subsided after the administration of enoxaparin with uneventful follow-up. No patient developed pulmonary embolism. Our results showed a relatively high incidence of DVT in an Asian population following TKA. We therefore consider that following TKA, prophylactic anticoagulation therapy should be administered to high-risk patients.

This article describes the effect of closed reduction and internal fixation with 3 different screw configurations for acute completely displaced femoral neck fractures in young adults. From 2001 to 2006, 136 patients (age range, 20–50 years) who had acute unilaterally completely displaced femoral neck fractures were evaluated retrospectively. All fractures were managed with closed reduction and internal fixation with 3 cannulated screws. The follow-up period was 55 months on average (range, 36–90 months). One hundred twenty-two patients were available for final evaluation of union condition and late complication. Twenty-three patients (18.9%) had nonunion, 15 (12.3%) had fixation failure, and 21 (17.2%) had avascular necrosis of the femoral head. The average duration from injury to surgery was 18.4 hours in the union group and 23.3 hours in the nonunion group, with no statistical significance ( P =.196). The average duration from injury to surgery was 17.3 hours in the avascular necrosis of the femoral head group and 22.3 hours in the non-avascular necrosis of the femoral head group, with no statistical significance ( P =.155). Vertical- and separated-type screw configurations resulted in a significantly higher nonunion rate ( P =.001 and P =.0017, respectively) than parallel configuration. The complication rate in treating completely displaced femoral neck fractures with internal fixation in young adults is high, and screw configuration may further affect results.