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Purpose Short stems are increasingly used in in total hip arthroplasty (THA) because of advantages in bone and soft tissue preservation and reconstruction of hip geometry. Short stems can be inserted in a more varus position compared to conventional straight stems. This poses the risk of final varus misplacement of the femoral component, which is not intended in all femoral short stems. Methods We wanted to evaluate the effect of a high varus stem positioning in MIS THA on hip offset, leg length and femoral canal fill index. A series of 1052 consecutive THAs with a singular cementless femoral short stem and press-fit cup was retrospectively screened for inclusion. One hundred six patients with unilateral THA and a contralateral healthy hip met the inclusion criteria. Measurements were carried out on preoperative and 3 months anterior–posterior postoperative radiographs. Patients were divided into Group A (varus stem alignment ≤ 3°) and Group B (varus stem alignment > 3°). Results Hip offset (HO) increased significantly in Group B by 4 mm (p = 0.013). No influence on leg length difference was detected in both groups. Preoperative CCD angle was significantly lower in Group B (p p p = 0.003; CF III p = 0.002). Conclusion High varus stem alignment > 3° leads to a statistically significant but minor increase in HO and poses the risk of stem undersizing. A preoperatively low genuine CCD angle pose a risk for varus stem positioning.

El éxito del uso del cemento acrílico en el reempazo articular fue una de las contribuciones de Sir John Charnley en 1958. El polimetilmetacrilato es parte de un grupo de polímeros conocidos com polietilenos, que tienen en común una base de carbono, con diferente longitud en su cadena. Existen generaciones de polimetilmetacrilato yendo desde la primera, en la cual se mezclaba y empaquetaba manualmente el cemento en canal medular y en acetábulo sin rimar, hasta la tercera en la cual se incluye aspirado y presurización del canal femoral, técnicas de mezclado y centrifugado, y modificaciones en implantes. El uso del cemento fue un avance importante en la artroplastia de cadera, sin embargo, conforme avanzó su historia y uso, los fallos de las prótesis fueron atribuidos a la conocida como “enfermedad del cemento”. Tomando en cuenta esto y las complicaciones que su utilización podría provocar se empezó a cuestionar la seguridad y funcionamiento de esta técnica. Sin embargo, los componentes cementados muestran buenos resultados a largo plazo, dejando en evidencia que no existe fundamento para el cese de la utilización del cemento en artroplastias. Asimismo, se observó que los implantes cementados tienen mejores resultados en cuanto a tasa de revisión y fracturas periprotésicas. Esto concluye que el uso del cemento, bajo ciertas indicaciones y técnicas adecuadas, representa una excelente opción para la fijación de implantes utilizados en el reemplazo articular.

Femoral hernias make up 2–4 % of the total number of patients with hernias [1], the results of their treatment do not tend to improve [2–6].The aim of the study was to establish the incidence of atrophy of the pubic periosteum in patients with femoral hernia and to analyze the possible methods of surgery in their treatment.Material and methods. The analysis of the treatment of 249 patients with femoral hernias for the period from 1996 to 2021 was carried out. There were 61 men (24.5%), women – 188 (75.5%). in 14 (5.6%), atrophy of the pubic periosteum was revealed during operations. Since 2009, patients with femoral hernia and atrophy of the pubic periosteum began to use the "Method for the treatment of inguinal and femoral hernias" (patent for invention No. 2445002, authors V.I. Belokonev, A.V. Vavilov, A.V. Zharov, Yu. V. Ponomareva, A.G. Nogoga) [11], which was performed by inguinal access.Conclusions. In 5.6% of patients with femoral hernia and a long history, under the influence of the hernial sac, atrophy of the pubic periosteum occurs.A method of treating femoral and inguinal hernias by closing the hernial orifice with an elastic mesh with a protrusion at the medial edge of the mesh corresponding to the distance from the medial edge of the pupar ligament at the level of the femoral vein to the lower edge of the superior horizontal branch of the pubic bone (patent for invention No. 2445002) is an effective method of treating patients with hernias with destruction of the pubic bone periosteum in the femoral canal.

The paper presents the morphometric results of the deep femoral ring and tensiometric study of the fascial tendinous structures of the inguinal area. On the basis of the obtrained findings a technique of femoral hernioplasty has been proposed., В статье приведены результаты морфометрии глубокого бедренного кольца и тензиометрическое исследование фасциально-сухожилковых структур пахового участка На основе полученных данных предложен способ стегновой герниопластики., У статті наведені результати морфометрії глибокого стегнового кільця і тензіометричне дослідження фасціально-сухожил-кових структур пахвинної ділянки. На основі отриманих даних запропоновано спосіб стегнової герніопластики.

Performing classical methods of plasty in patients with femoral hernia is possible if Cooper's ligament – the pubic periosteum – is preserved. Patients with a long history of femoral hernia develop thinning and atrophy of the pubic periosteum. The aim of the study was to establish the possibilities of instrumental research methods to determine the preservation or atrophy of the pubic periosteum in patients with femoral hernia. It was found that using the X-ray method and CT before the operation, it was not possible to establish the preservation or atrophy of the pubic periosteum in the area of the femoral canal. With ultrasound, it is possible to visualize the pubic periosteum in young patients.

Background The extraction of a femoral stem during the revision hip arthroplasty can be a daunting task and can lead to catastrophic complications for the patient. A sound technique employed intraoperatively helps in the speedy recovery of the patient and reduces the risk of future surgical interventions. In this study, we present a medium-term outcome of our novel Lancaster cortical window technique which can be used for the removal of cemented or uncemented femoral stems. Methods The study was conducted at a specialist centre in the north-west of the UK from January 2014 to May 2019. This is a retrospective case series where patients were treated surgically using the Lancaster cortical window technique for removal of the femoral implant during a revision hip arthroplasty. Patient’s electronic notes and radiographs were used to evaluate the functional and radiological outcome. Results In this study, 18 patients were managed surgically using the novel Lancaster window technique. The mean age of all the patients was 81.5 years, and the male to female ratio was 10:8. Fifteen patients underwent revision surgery for aseptic loosening of the femoral and acetabular components. The rest of the three patients had revision surgery for a broken femoral stem, intraoperative femoral canal perforation while implanting a total hip replacement femoral stem and infection. Twelve femurs were replanted with uncemented long femoral stems and six with long cemented stems. The cortical window osteotomy united in all the patients in 4.2 months (mean). The mean follow-up of these patients is 20.9 months, and none of them had any implant subsidence or loosening at the time of their last follow-up. Conclusion We believe Lancaster cortical window technique can be safely used for the removal of cemented stems during revision hip arthroplasty without the need for expensive equipment.

Made available in DSpace on 2021-07-14T10:22:57Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-06-21. Added 1 bitstream(s) on 2021-07-14T11:28:53Z : No. of bitstreams: 1 S0102-09352021000300571.pdf: 520711 bytes, checksum: b19ccb0761e26b5e495452f2e571b5bf (MD5) O resultado da artroplastia total do quadril (ATQ) em cães está diretamente relacionado ao planejamento cirúrgico. O templating radiográfico pré-operatório da ATQ deve ajudar o cirurgião a prever o tamanho da prótese e o formato do fêmur, o que permitirá um preenchimento ideal da metáfise proximal pelo implante, garantindo, assim, fixação primária estável. O índice de alargamento do canal (Canal Flare Index - CFI) obtido em radiografias tem sido utilizado como fator de risco de complicações para a técnica em humanos e cães. No entanto, as radiografias podem fornecer apenas dados limitados para a seleção de próteses não cimentadas e a avaliação do seu encaixe no canal femoral, devido a fatores como ampliação radiográfica e rotação femoral. Portanto, a avaliação tridimensional baseada na tomografia computadorizada (TC) pode ser uma ferramenta vantajosa para a mensuração do CFI. O objetivo deste estudo foi comparar a medida anatômica com os valores de CFI obtidos na radiografia craniocaudal e na TC. Radiografias craniocaudais utilizando feixe radiográfico horizontal (CR), tomografia computadorizada e medidas macroscópicas anatômicas (A) foram obtidas de 45 fêmures de 23 cadáveres caninos. As diferenças entre os valores de CFI obtidos na radiografia (CFI-R), na tomografia computadorizada no eixo transversal (CFI-TT) e no eixo longitudinal (CFI-TL), em comparação com os valores de CFI obtidos nas medições macroscópicas - padrão-ouro - (CFI-A) e os limites de concordância de 95% (LOA) entre os valores, foram avaliadas pelo método de Bland-Altman. As dimensões obtidas pelas técnicas de TC apresentaram maior diferença média dos valores anatômicos, e as do CFI também foram diferentes (P=0,032). Nas condições experimentais, a radiografia craniocaudal forneceu a medida mais precisa do CFI (diferença média: 0,087 ± 0,42) para representar o padrão-ouro deste estudo. The outcome of total hip arthroplasty (THA) in dogs is directly related to surgical planning. Templating of radiographs prior to THA should help the surgeon anticipate prosthesis size and femoral shape allowing canal fill of the proximal metaphysis by the implant ensuring primary stable fixation. The canal flare index (CFI) obtained from radiograph has been used as a measure of risk of complications for the technique in human beings and dogs. However, standard radiographs only provide limited data for the selection of cementless prostheses and the assessment of their fit within the femoral canal, due to factors like radiographic magnification and femoral rotation. Therefore, three-dimensional evaluation based on computed tomography (CT) may be a better tool for CFI measurement. The aim of this study was to compare anatomical measurement with CFI values obtained from craniocaudal radiography and CT. Craniocaudal radiographs using a horizontal radiographic beam (CR), CT, and anatomical macroscopic measurements (A) were obtained from 45 femurs from 23 canine cadavers. The differences between the values of CFI obtained from radiograph (CFI-R), computed tomography on transverse (CFI- TT) and longitudinal axis (CFI-TL) compared to the CFI obtained from macroscopic measurements - gold standard - (CFI-A), and 95% limits of agreement (LOA) between the values, were evaluated by the Bland-Altman method. Dimensions obtained from CT techniques had a greatest mean difference from anatomical and CFI values were also different (P=0.032). Under the experimental conditions, the craniocaudal radiograph, provided the most accurate measurement of the CFI (mean difference: 0.087 ± 0.42). Universidade Estadual Paulista, Faculdade de Ciências Agrárias e Veterinárias Universidade Brasil Centro Universitário de Lavras Universidade Federal do Espírito Santo Universidade Federal dos Vales do Jequitinhonha e Mucuri, Instituto de Ciências Agrárias Universidade Estadual Paulista, Faculdade de Ciências Agrárias e Veterinárias

Introduction Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter. Materials and methods Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p Results Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 o±2.6o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1o±8.7o vs. 8.2o±1.7o respectively, p=0.267). The narrow canal unlocked group (13.7o±2.4o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94o±2.13o and 10.2o±1.7o respectively, than in the narrow or wide canal locked specimens, 2.4o±0.2o and 4.2o±0.5o respectively (p Conclusion Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

PURPOSE OF REVIEW: To describe the (1) indications, (2) preoperative precautions, and (3) stepwise technical details of modern femoral stem cemented fixation. RECENT FINDINGS: Femoral stem cementation provides excellent implant longevity with a low periprosthetic fracture rate among patients with compromised bone quality or aberrant anatomy. Unfamiliarity with the details of modern cementation techniques among trainees who may lack frequent exposure to cementing femoral stems may preclude them from offering this viable option to suitable patients in later stages of their careers. As such, maximizing benefit from cemented femoral stem fixation among suitable candidates is contingent upon the meticulous use of modern cementation techniques. SUMMARY: In addition to proper patient selection, modern cementation techniques emphasize the use of (1) pulsatile lavage of the femoral canal, (2) utilization of epinephrine-soaked swabs, (3) vacuum cement mixing, (4) retrograde cement introduction, (5) cement pressurization, and (6) the use of stem centralizers. Furthermore, identifying and optimizing the preoperative status of at-risk patients with pre-existing cardiopulmonary compromise, in addition to intraoperative vigilance, are essential for mitigating the risk of developing bone cement implantation syndrome. Further research is required to assess the utility of cemented femoral stem fixation among younger patients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12178-020-09681-5.

Objectives The objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. Methods Computed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. Results Substantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. Conclusions Considering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.

Salvage total hip arthroplasty (THA) may be required to manage femoral neck fracture implant failures, avascular necrosis and secondary hip arthritis. Cannulated cancellous screws can become stripped or incarcerated during the initial implantation and pose hardware removal issues. We present a novel technique for safe screw removal in a 62- year-old female patient with a painful right hip. She had undergone cancellous screw fixation for a fracture of the neck of femur ten years ago. There was avascular necrosis with screw cut out leading to secondary hip arthritis necessitating THA. Intra-operatively cannulated cancellous screw along the inferior femoral neck region was incarcerated. After posterior dislocation of the head, the neck was osteotomised, and the screw threads were exposed for possible extraction. However, the thickened femoral neck region with solid cortical bone prevented the screw disengagement in either direction. The screw along the femoral trochanter region was cut with a Harrington cutter and the remaining screw disengaged with careful removal of bony spicules and controlled anticlockwise rotations, to remove the screw in around fifteen minutes. Arthroplasty could be completed uneventfully thereafter. We could remove the screw while avoiding an iatrogenic fracture along the calcar region and excessive bone loss along the screw track. The femoral canal remained uncompromised. The anticipation of a difficult implant removal with a thorough understanding of the devices and techniques, is an invaluable asset to the operating surgeon. With a simple tool and novel technique in a difficult situation, we can save on operating time and minimise complications.

Background: For a successful total hip arthroplasty, the final position of the trial rasp should be adopted by the femoral stem to achieve correct positioning. This study aimed to characterize the discrepancy of the stem and rasp position in vivo of a widely used dual-tapered straight stem with rectangular cross section that is known to have an oversized stem with respect to the rasp. Methods: The distances between the tip of the greater trochanter and the shoulder of the implant and rasp were measured on 39 intraoperatively acquired fluoroscopic image pairs. Leg-length discrepancy was also measured clinically before and after surgery. Results: A paired t-test showed a significant average protrusion of the femoral stem with respect to the final rasp position of 2.63 mm (standard deviation = 2.3 mm, P < .001), while 88% of the cases had no leg-length discrepancy after surgery. The quantified stem protrusion was statistically significant but did not reach clinical relevance and was easily mitigated in our study. Conclusions: The quantified stem protrusion appears to be clinically manageable, as only 2 cases required attenuation of stem positioning: in one case by the use of a femoral head with a shorter neck and in the other case by rerasping the femoral bed. Neither case was associated with the most extreme differences in position of the stem with respect to the final rasp. In addition, the used stem shows good overall outcomes in other studies. It appears that factors other than stem and rasp position play a critical role to the surgeon and for total hip arthroplasty success.

International audience; Introduction: Le choix de l'abord chirurgical pour la réalisation d'une arthroplastie totale de hanche (ATH) ne fait pas consensus en orthopédie. Il existe un regain d'intérêt ces dernières années pour les voies antérieures mini-invasives (VAMI) dites anatomiques. Cependant, leur retentissement minoré n'a pas été confirmé par des imageries. Aussi nous avons mené une étude prospective destinée à : (1) évaluer l'infiltration graisseuse (IG) des muscles péri-articulaires de hanche, (2) analyser l’évolution de cette IG dans le temps. Hypothèse: Une ATH par VAMI induit une IG sur les muscles péri-articulaires antéro-latéraux adjacents à l'abord. Matériels et méthodes: Une série continue mono-opérateur d'ATH par VAMI sur table orthopédique a été réalisée par un opérateur entraîné. Des IRM (1,5Tesla OPTIMA MR360) ont été réalisées en préopératoire, puis à 3 mois et 1 an de la chirurgie. L'analyse de l'IG musculaire selon la classification de Goutallier était réalisée par un radiologue indépendant sur l'ensemble des muscles péri-articulaires de hanche. La comparaison était effectuée entre les IRM préopératoires et celles à 3 mois et 1 an à l'aide de tests de Wilcoxon. Résultats: Soixante-neuf IRM ont été réalisées sur 23 patients. Deux n’étaient pas interprétables du fait de mouvements du patient lors de l'acquisition préopératoire. Aucune complication peropératoire ni postopératoire n'a été rapportée dans cette série après 1 an de suivi. Tous les patients présentaient des hanches indolores sans boiterie à 1 an de l'intervention. L'analyse de l'IG montrait une aggravation significative de cette dernière entre les IRM préopératoires et celles à 3 mois (p = 0,02) et 1 an (p = 0,0007) au niveau du muscle obturateur interne ainsi qu’à 1 an (p = 0,04) au niveau du muscle piriforme. Aucune différence significative n’était retrouvée sur les autres muscles. Le muscle droit fémoral, les muscles jumeaux supérieurs et inférieurs ainsi que le muscle carré fémoral n’étaient pas analysables. Discussion: Notre hypothèse de départ n’était pas confirmée mais nous avons retrouvé un résultat paradoxal avec la mise en évidence d'une IG musculaire, cependant celle-ci n’était pas antéro-externe mais postérieure au niveau des muscles pelvi-trochantériens à la suite d'ATH par VAMI. Ces lésions pourraient être secondaires à des désinsertions ou des dénervations de ces muscles lors de l’élévation du fémur pour l'implantation fémorale. Niveau de preuve: IV; série prospective de cas.

This study aimed to determine the risk factors of aseptic loosening (AL) in complex revision total knee arthroplasty (TKA) cases using rotating hinge knee prosthesis. Patients who had undergone re-revision rotating hinge prosthesis surgery between January 2012 and December 2017 were included. Parameters related to AL were retrospectively reviewed. For this purpose, 31 aseptic loosening patients and 30 control patients were included in the study. Various risk factors were evaluated. Risk factors for AL after re-revision were determined using univariate and multiple logistic regression analyses. Thirty-one AL patients and 30 control patients were included. In the AL group, tibial tantalum cone and impaction grafting were performed significantly less frequently than the control group (p = 0.002 and p < 0.001). Logistic regression analysis revealed that smoking, right-sided TKA, and large femoral canal anteroposterior diameter were factors that increased the risk of AL after re-revision, while tibial tantalum cone decreased the risk of loosening. Smokers had an 11.847-fold higher risk for AL; right-sided TKA led to a 4.594-fold higher risk for AL. However, the presence of a tibial tantalum cone was associated with an 8.403-fold lower risk for AL. We conclude that smoking, right-sided prosthesis, and large femoral canal diameter increased the risk of AL, while tantalum cone and impaction grafting reduced this risk in patients who underwent re-revision surgery with rotating hinge prosthesis after TKA.

Background. According to the considerably contradictory information across the international literature, both the anatomical and transtibial reconstruction of the anterior cruciate ligament (ACL), under similar conditions, yield good functional results from treatment. Therefore, it is important to evaluate the comparative effectiveness and the prospects of certain methods of ACL reconstruction. The purpose of this study was to analyze the possibilities and advantages of anatomical technologies for the reconstruction intervention. Aim. To compare the outcomes of ACL reconstructions among adolescent children using different methods. Materials and methods. The outcomes of 94 arthroscopic reconstructions of the ACL in adolescents were analyzed. The patients were categorized into 3 groups: Group 1 included 32 patients (34%) who underwent isometric plastic surgery of the ACL, wherein the femoral canal was formed using the transtibial technique. Group 2 included 30 patients (32%) who underwent anatomical plastic surgery of the ACL, with the formation of the femoral canal through additional anteromedial arthroscopic access. Group 3 included 32 patients (34%) who underwent the all-inside anatomical reconstruction of the ACL. Results. A comparative analysis of the outcomes of reconstruction of the ACL among adolescents revealed that the anterior-posterior and rotational stability of the knee joint was better in group 3 patients than in groups 1 and 2 patients. In fact, the group 3 patients showed a significantly less positive pivot-shift (0 degree to 87.5%; I+ the extent of 12.5%) than the group 1 patients (0 degree 46.8%; I+ degree 25%; II+ degree and 21.9%; III+ degree and 6.3%), followed by the group 2 patients (0 degree to 86.6%; I+ degree 6.7%; II+ degree of 6.7%). Conclusion. Considering the safety aspects of intra-articular structures and for the better anatomical orientation of the femoral canal, the all-inside method of ACL reconstruction yielded better outcomes of postoperative anterior-posterior and rotational stability of the knee joint.

Trochanteric osteotomy is a technique that allows expanded exposure and access to the femoral canal and acetabulum for a number of indications. There has been renewed interest in variants of this technique, including the trochanteric slide osteotomy (TSO), extended trochanter osteotomy (ETO), and the transfemoral approach, for both septic and aseptic revision total hip arthroplasty (THA). Osteotomy fixation is crucial for achieving union, and wire and cable-plate systems are the most common techniques. TSO involves the creation of a greater trochanter fragment with preserved abductor attachment proximally and vastus lateralis attachment distally. This technique may be particularly useful in the setting of abductor deficiency or when augmented acetabular exposure is needed. ETO is a posterior-laterally based extensile approach that has been successfully utilized for aseptic and septic indications; most series report a greater than 90% rate of union. The transfemoral approach, as known as the Wagner osteotomy, is an extensile femoral approach and is more anterior-based than the alternate posterior-based ETO. It may be particularly useful for anterior-based approaches and anterior femoral remodelling; rates of union after this approach in most reports have been close to 100%.Cite this article: EFORT Open Rev 2020;5:477-485. DOI: 10.1302/2058-5241.5.190063

Leg-length changes at total hip arthroplasty (THA) may result from too proximal position of the femoral component, i.e. not being sunk deep enough into the femoral canal due to the size and shape of both medullary canal and implant. Some femoral implants are designed to achieve such fixation in the mediolateral dimension, while others also engage the bone anteroposteriorly. Our aim was to examine the relationship between proximal femoral morphology, osseointegration and leg-length equalization at THA. We asked whether the Dorr classification, femoral cortical index and canal flare index on preoperative radiographs had significant impact on THA aseptic loosening rates and post-operative leg-length discrepancy (LLD). Literature review included original articles on proximal femoral morphology with post-operative LLD and other clinical outcomes of THA, published in the last decade. Case reports and biomechanical studies without clinical data were excluded. Higher femoral cortical index and/or canal flare index (corresponding to the Dorr type A) increases the risk of leg lengthening at THA. This is particularly notable in femoral stems with metaphyseal fixation, where high canal flare index has also been linked to osseointegration failure and implant loosening. On the other hand, lower canal flare index (corresponding to the Dorr type C) is more prevalent in the elderly population and increases late periprosthetic fracture rates and stress shielding. Even the most commonly used cementless femoral stems cannot offer optimal fit to intra-/extramedullary geometry or offset restoration in up to 30% of clinical cases. Femoral morphology can have significant impact on post-operative LLD and osseointegration of cementless THA. Quantitative measurements of the proximal femoral canal may improve the choice of a particular implant and fixation method.

Femoral hernia is the protrusion of a peritoneal sac through the femoral ring into the femoral canal lying deep and inferior to the inguinal ligament. The hernia sac usually contains preperitoneal fat, omentum, bowel, or fluid. Ultrasound is recommended as the first-line investigation for diagnosing clinically occult femoral hernias in nonemergency settings, whereas CT is the imaging of choice in emergency settings. High accuracy of the ultrasound in clinically occult femoral hernia is further validated with further CT and MRI. In this article, we propose sonographic detection of the physiological peritoneal fluid herniating through capacious femoral ring manifesting as a “speech bubble/speech box appearance.” This is a potentially invaluable sonographic sign for clinically occult femoral hernias, differentiating them from inguinal hernias and cysts of the canal of Nuck in females and preventing inadvertent attempts to aspirate.

OBJECTIVES This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail. DESIGN Retrospective cohort study. SETTING Academic Level I Trauma Center, Southeastern US. PATIENTS/PARTICIPANTS Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures. OUTCOME MEASUREMENTS Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05. RESULTS Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up. CONCLUSIONS Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Periprosthetic fracture is a leading reason for readmission following total hip arthroplasty. Most of these fractures occur during the early postoperative period before bone ingrowth. Before ingrowth occurs, the femoral component can rotate relative to the femoral canal, causing a spiral fracture pattern. We sought to evaluate, in a paired cadaver model, whether the torsional load to fracture was higher in collared stems. The hypothesis was that collared stems have greater load to fracture under axial and torsional loads compared with collarless stems. Methods Twenty-two cadaveric femora (11 matched pairs) with a mean age of 77 ± 10.2 years (range, 54 to 90 years) were harvested. Following dissection, the femora were evaluated with use of a dual x-ray absorptiometry scanner and T scores were recorded. We utilized a common stem that is available with the same intraosseous geometry with and without a collar. For each pair, 1 femur was implanted with a collared stem and the contralateral femur was implanted with a collarless stem with use of a standard broaching technique. A compressive 68-kg load was applied to simulate body weight during ambulation. A rotational displacement was then applied until fracture occurred. Peak torque prior to fracture was measured with use of a torque meter load cell and data acquisition software. Results The median torque to fracture was 65.4 Nm for collared stems and 43.1 Nm for uncollared stems (p = 0.0014, Wilcoxon signed-rank test). The median T score was -1.95 (range, -4.1 to -0.15). The median difference in torque to fracture was 29.18 Nm. As expected in each case, the mode of failure was a spiral fracture around the implant. Conclusions Collared stems seemed to offer a protective effect in torsional loading in this biomechanical model comparing matched femora. Clinical relevance These results may translate into a protective effect against early periprosthetic Vancouver B2 femoral fractures that occur before osseous integration has occurred.

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has become increasingly popular, largely due to utilization of a true internervous and intermuscular plane. However, recent literature has demonstrated an increased rate of femoral implant subsidence with this approach. Hence, different femoral implants, such as the tri-tapered femoral stem, have been developed to facilitate proper component insertion and positioning to prevent this femoral subsidence. The purpose of this study was to evaluate the subsidence rate of a tri-tapered femoral stem implanted utilizing a DAA, and to determine if the proximal femoral bone quality affects the rate of subsidence. Methods. A retrospective analysis of 155 consecutive primary THAs performed by a single surgeon was conducted. Age, gender, primary diagnosis, and radiographic measurements of each subject were recorded. Radiological evaluations, such as bone quality, femoral canal fill, and implant subsidence, were measured on standardized anteroposterior (AP) and frog-leg lateral radiographs of the hip at 6-week and 6-month postoperative follow-up evaluations. Results. The average subsidence of femoral stems was 1.18 ± 0.8 mm. There was no statistical difference in the amount of subsidence based on diagnosis or proximal femora quality. The tri-tapered stem design consistently filled the proximal canal with an average of 91.9 ± 4.9% fill. Subsidence was not significantly associated with age, canal flare index (CFI), or experience of the surgeon. Conclusion. THA utilizing the DAA with a tri-tapered femoral stem can achieve consistent and reliable fit regardless of proximal femoral bone quality.