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Introduction This study aimed to analyze the clinical outcomes of femoral neck fractures (FNF) in patients treated with a femoral neck system (FNS, DePuy Synthes), which is a recently introduced device. Methods This study included 43 patients who underwent osteosynthesis using FNS for with a minimum follow-up of 6 months. The researchers examined the patients’ demographic factors and radiologically evaluated the fracture type and fixation status, bone union, and postoperative complications. Results Radiological bone union was confirmed in 39 patients (90.7%), and the mean time to union was 3.6 months. Two cases of nonunion, one case of lag screw cut-out, and one case of osteonecrosis were confirmed; all four cases later underwent arthroplasty. The mean time to reoperation was 4.5 months. Meanwhile, five patients underwent implant removal after the bone union, and distal locking screw stripping was noted in three patients. All three patients required metal plate cutting to remove the implants. Conclusion Osteosynthesis of FNF using the newly introduced FNS showed satisfactory outcomes and excellent mechanical stability without any postoperative complications. However, distal locking screw failure during implant removal should also be considered.

Introduction Core decompression (CD) is a treatment modality used to prevent progression of subchondral collapse and arthritic change in osteonecrosis of the femoral head (ONFH). This study aimed to evaluate the outcomes of CD with autologous bone graft to promote rapid bone formation and early postoperative ambulation. Methods This study included 13 patients who received CD for ONFH (≤ 2mm head collapse) with a minimum follow-up of two years. We implanted autologous bone blocks obtained from the decompression tract into the decompressed necrotic area, and the remaining space was filled with 5–10 cc of allograft bone chips or left empty. We then evaluated patients’ clinical and radiographical outcomes. Results The mean visual analog scale improved from 4.7 at admission to 3.1 at the latest follow-up (P = 0.039). The mean modified Harris hip score also improved from 59.8 to 73.2 ( P = 0.027). Mild osteoarthritic changes were noted in most patients (11/13, 84.6%), and the hip survival rate (no further surgeries required) was 76.9%. Three patients underwent total hip arthroplasty due to residual hip pain (mean time to reoperation, 12.7 months). Conclusion Core decompression showed favorable clinical outcomes without any surgery-related complications. This technique may be recommended for the treatment of ONFH.

This study aimed to analyze the epidemiologic characteristics of patients who underwent hip arthroplasty using the Korean nationwide database and investigate the recent trends in implant fixation methods and bearing surface selection. We aimed to compare clinical characteristics and differences with the results from the registry of other western countries. We analyzed the data collected by the Health Insurance Review and Assessment Service database of Korea from 2007 to 2011 and the Main Surgery Statistical Yearbook from 2014 to 2018, published by the National Health Insurance Service. The number and rate of patients who underwent hip joint arthroplasty per 10,000 persons have been steadily increasing since 2007. There was a big difference in mean age and preoperative diagnosis of patients between the bipolar hemiarthroplasty and total hip arthroplasty groups. Most patients underwent surgery using a cementless biological fixation method, and the cemented fixation method was selectively used for a small portion of old aged osteoporotic patients. In relation to the use of bearing surfaces, the registry data showed that ceramic-ceramic bearings were used at an overwhelmingly high rate (81%) in Korea compared to other countries. The reason was attributable to various factors, such as patient’s age or economic status, differences in the health insurance system between countries, and recently reported complications, such as ceramic fracture or noise.

Background Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage’s efficacy in preventing infection after TJA. Methods MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties. Results We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties. Conclusion We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.

Backgrounds The basic method of surgical treatment for extracapsular hip fractures (ECFs), including intertrochanteric fracture and basicervical fracture (BCF), is osteosynthesis. Intramedullary nails are among the most commonly used fixation devices for these fractures. Our study aimed to report the clinical outcomes of ECF treatment with two different nail devices and to analyze the risk factors associated with screw cut-out. Methods We retrospectively reviewed the medical records of 273 patients (300 cases) from a single institution who underwent surgical treatment for ECF between January 2013 and October 2018. Overall, 138 patients were eligible for the study and were divided into two groups according to the osteosynthesis device used. We evaluated the clinical outcomes of fracture surgery and performed univariate and multivariate regression analyses to identify risk factors associated with screw cut-out in each group. Results We used proximal femoral nails (group 1) to treat 83 patients and cephalomedullary nails (group 2) to treat 55 patients. Nine cut-outs (group 1, 6 cases; group 2, 3 cases) occurred during follow-up. The patients’ high body mass index (BMI) (p = 0.019), BCFs (p = 0.007), non-extramedullary reduction in the anteroposterior and lateral planes (p = 0.032 and p = 0.043, respectively), and anti-rotation screw pull-outs (p = 0.041) showed a positive correlation to screw cut-out in the univariate analysis of group 1. In group 2, only BCFs was positively correlated (p = 0.020). In the multivariate analysis of group 1, the patients’ BMIs (p = 0.024) and BCFs (p = 0.024) showed a positive correlation with cut-out. Meanwhile, the multivariate analysis of group 2 did not identify any factors associated with cut-out. Conclusions The cut-out risk was significantly higher in the BCF cases, regardless of the nail design used. Considerable attention should be paid to treating such unstable fractures. We expect that new-generation nails using a helical blade, or interlocking derotation and interlocking screws may improve surgical outcomes.

Incomplete fractures are assumed to occur in the intertrochanteric area as fractures at other sites, but reports of incomplete intertrochanteric fractures (IIFs) are rare. In 1999, Schultz et al. defined isolated greater trochanter fractures (GTFs) as IIFs when intertrochanteric extension is observed on magnetic resonance (MR) images. On multiplanar reformation computed tomography (MPR CT) images acquired for further study of apparently isolated GTFs, we noted incomplete cortical breakage in the intertrochanteric area. We then found that the fracture line was incomplete on plain radiographs in some intertrochanteric fractures. We evaluated IIFs and apparently isolated GTFs using MPR CT and analyzed the fracture patterns of IIFs that were confirmed using MPR CT.Between February 2006 and June 2019, 36 cases of IIF were detected using MPR CT in 36 patients. They were 17 women and 19 men with a mean age of 74.7 years (range, 26-94 years). Plain radiographs and MPR CT images were evaluated by two experienced orthopedic surgeons. In addition, MR imaging was performed in 5 cases.Plain radiographs showed no evidence of fracture in 2 cases, isolated GTF in 7 cases, and IIF in 27 cases. In all cases, incomplete cortical breakage in the intertrochanteric area was confirmed on MPR CT images. Cortical breakage was located in the anterior portion of the intertrochanteric area, whereas the posterior portion remained intact in all cases. The detection rate of cortical breakage was higher on coronal or sagittal images than that on axial images. On MR images of 5 cases, intertrochanteric extensions were found in the medullary space. All extensions originated in the greater trochanter area and extended anteriorly in the axial plane and inferomedially in the coronal plane. On the T1-weighted mid-coronal image, the extension reached or passed the midline in 3 cases, and cortical breakage was detected in only 2 cases.In all cases of IIF, cortical breakage was detected in the anterior portion of the proximal femur, leaving the posterior cortex intact. This finding is notably different from that of intertrochanteric extension (from posterior to anterior) detected on MR images of isolated GTFs.

Background: Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI. Methods: MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS). Results: Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = −0.24, P = .83) and NAHS (MD = −2.08, P = .09). Conclusion: Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.

The current trend of using short femoral stems in total hip arthroplasty (THA) is associated with angular deviation of the femoral stem towards the native femoral axis. The purpose of this study was to compare the difference in stem tilt angle between two different stems with a similar design except for the stem length.This is a retrospective review of 66 patients who underwent primary THA between April 2012 and May 2016, using a trans-gluteal direct lateral approach by a single surgeon. We evaluated the femoral stem tilt angle in both the coronal and sagittal planes and performed multivariate logistic regression analysis to evaluate possible risk factors. We also simulated the range of motion (ROM) of the hip joint using three-dimensional computer-aided design software (SolidWorks, 2016) to examine the clinical significance of femoral stem tilt.The mean coronal tilt angle was 1.8° ± 1.0° in the conventional stem group and 1.6° ± 1.1° in the short stem group, showing no statistically significant difference between the groups (Anterior femoral stem tilting in the sagittal plane was prominent when the shorter stem was used, and anterior tilting was responsible for decreased ROM in hip extension.

Aim The purpose of this study was to investigate the demographic characteristics and prevalence of postoperative venous thromboembolism (VTE) in delayed hip fracture patients referred to our hospital (a tertiary referral center), and further verify the effect of intensive prophylaxis protocol in preventing the occurrence of VTE. Methods We retrospectively evaluated 264 hip fracture patients whose surgery was delayed by >24 h. The patients were divided into two groups, according to the VTE prophylaxis protocol (conventional vs intensive). We evaluated the time from injury to surgery, and analyzed the prevalence of postoperative symptomatic VTE between the groups. The patient outcome measures, including in-hospital mortality and 30-day-mortality after hip surgery, were also evaluated. Results The mean time from injury to operation was 127.4 h (95% confidence interval 92.2-162.7 h). The incidence of postoperative symptomatic VTE was 5.9% in the conventional prophylaxis group and 0.8% in the intensive prophylaxis group. The intensive prophylaxis group had a significantly lower incidence of postoperative VTE (P = 0.036). Eight patients with deep vein thrombosis on preoperative screening who underwent inferior vena cava filter insertion did not develop postoperative symptomatic VTE. Logistic regression analysis results also showed that the protocol statistically reduced the development of VTE (odds ratio 0.14, 95% CI 0.02-1.21, P = 0.042). Conclusions Delayed hip fracture surgery resulted in a higher incidence of VTE in patients who received conventional prophylaxis; however, our intensive prophylaxis protocol successfully prevented postoperative symptomatic VTE, including pulmonary embolism. Geriatr Gerontol Int 2020; 20: 1151-1156.

This study aimed to evaluate the clinical outcomes of using contralateral-side laterally bent intramedullary nails (IMNs) in bowed atypical femur fractures (AFFs). We retrospectively reviewed bowed AFFs treated with contralateral-side laterally bent IMNs. In total, 20 patients with 25 cases of AFFs were included. Surgical outcomes including bone union time, complications, femoral bowing, and leg length discrepancy (LLD) were evaluated. We evaluated the surgical safety of performing contralateral-side intramedullary nailing with its intraoperative and postoperative complications and compared the LLD. The average age was 76.8 years (range 67–86 years), and all of patients were female. There were 10 cases of complete AFFs and 15 cases of incomplete AFFs. Fourteen patients (70%) had a history of bisphosphonate (BP) use with an average of 74.5 months of its use. In the complete AFF cases, reduction of the fractures was tried to restore the patients’ normal anatomical geometry. The average lateral gap was 0.6 mm (0–1 mm), and the average medial gap was 1.6 mm (1–3 mm). All cases achieved bone union without secondary intervention. There were no intraoperative fractures or postoperative complications. The average bone union time was 22.0 weeks and 9.2 weeks in complete and incomplete AFFs, respectively. The average preoperative femoral bowing seen in the coronal and sagittal planes was 10.1° and 16.1°, respectively, while the average postoperative bowing was 6.6° and 11.3°, respectively. The average change of angle was 3.5° in the coronal plane and 4.8° in the sagittal plane. The mean change of LLD was 5.7 mm. The use of contralateral-side laterally bent IMNs in treating bowed femurs showed excellent clinical outcomes without complications. In severely bowed femurs, this technique can be safe and useful.

Backgrounds One of the most significant complications after a femoral neck fracture is osteonecrosis of the femoral head (ONFH). The concomitant use of single-photon emission computed tomography (SPECT) with computed tomography (CT) increases the sensitivity for detecting the anatomic location and severity of ONFH. In this study, we evaluated the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head. Methods A total of 30 patients who had multiple pinnings for femur neck fractures were included in this study. We classified the perfusion status into three groups: normal perfusion, decreased perfusion, and avascular groups, and compared the occurrence of femoral head necrosis between them. For quantitative analysis, we evaluated the uptake ratio of both femur heads (head-to-head uptake ratio). If the patient’s contralateral hip was incomparable, we measured the uptake ratio from the superior dome of the ipsilateral acetabulum (head-to-acetabulum uptake ratio). Results Twenty-four patients out of 30 achieved bone union, whereas the others developed ONFH. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85–1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28–0.38). In contrast, the ratio was 1.30 (95% CI: 1.03–1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P Conclusions SPECT/CT was useful in evaluating the perfusion status of the femoral head, showing high accuracy in predicting the occurrence of avascular necrosis. To demonstrate the reliability and validity of SPECT/CT, further prospective studies on a larger scale are warranted.

Objective We sought to evaluate the feasibility of temporary bridge occipitocervical fixation temporary bridge occipitocervical fixation (T-BOCF) for comminuted atlantoaxial fractures. Methods A 57-year-old man presented with multiple trauma including a comminuted, undisplaced atlantoaxial fracture; subdural hemorrhage; skull base fracture; scalp laceration; right second finger tendon injury; and right distal femur open fracture. T-BOCF was performed to preserve neck motion while providing rigid stability to atlantoaxial fracture. Occipital plate and bilateral lateral mass screws were inserted at C3, C4, and C5, avoiding the fracture site; this was followed by rod connection without fusion. The screw-rod construct was removed after confirmation of bone union in the fracture site 12 months after the initial operation. Results Computed tomography performed at 12 months after the operation demonstrated solid bone union. Dynamic radiographs taken 12 months after implant removal demonstrated a flexion-extension range of motion of 16 degrees at C0‒C2 and 19.8 degrees at C2‒C7. The total flexion-extension range of motion was 35.8 degrees. Conclusions T-BOCF is a viable option for treatment of comminuted, undisplaced atlantoaxial fractures. The technique is easier than direct C1‒C2 fusion and can avoid complications associated with occipitocervical fusion or C1‒C2 screw fixation. The blood supply to the fracture site is preserved by avoiding subperiosteal stripping, and semispinalis cervicis insertion at the C2 spinous process is also circumvented. Furthermore, neck motion is preserved after implant removal.

CASE A 20-year-old military recruit presented with pain in his left hip. He was referred by the military hospital for osteonecrosis of the femoral head in both hip joints. Plain radiographs and magnetic resonance imaging showed a marked collapse in the left femoral head; however, the patient was diagnosed as having subchondral fatigue fractures of the femoral head (SFFFH) after a thorough review of previous sequential images. Arthroscopic debridement and labral repair were performed. At 3 years after surgery, the patient was symptom-free and second-look hip arthroscopy revealed the articular defect filling with fibrocartilage on the femoral head. CONCLUSION In a young patient, hip arthroscopy can be a successful joint preserving treatment option even for collapsed SFFFH.

The present study investigated the minimum 2-year outcomes of hip arthroscopy for femoroacetabular impingement (FAI) and concomitant labral tears in Asian patients.Patients who underwent hip arthroscopy for both FAI and concomitant labral tears between January 2012 and December 2017 were included. Patients with hip osteoarthritis of Tönnis grade ≥2, previous hip surgery, or followed for less than 2 years were excluded. Clinical assessments were performed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the rates of achieving threshold values of the minimal clinically important difference and patient acceptable symptomatic state at the latest follow-up. Plain radiographs were acquired pre- and postoperatively for radiologic assessments.A total of 73 patients (90 hips, 58 male, 15 female; mean age 34.4 years) who underwent hip arthroscopy for FAI and concomitant labral tears were enrolled. Forty-three hips (47.8%) had cam-type, 7 (7.8%) had pincer-type, and 40 (44.4%) had mixed-type FAI. The mean follow-up duration was 5.2 years. In cam- and mixed-type FAI hips, the mean α angle significantly decreased from 66.7 ± 8.28° preoperatively to 44.9 ± 3.78° postoperatively (95% confidence interval [CI] 19.6°-22.8°; P.001). The mean modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index increased from 74.8 ± 13.2 and 75 ± 12.7 preoperatively to 93 ± 8.1 (95% CI 15.4-20.9; P = .001) and 89.4 ± 8.4 postoperatively (95% CI 11.8-17; P = .001), respectively. Seventy-four hips (82.2%) crossed the minimal clinically important difference, and 85 hips (94.4%) had achieved the patient acceptable symptomatic state. There were 2 cases of pudendal nerve palsy and 1 case of sciatic nerve palsy. No additional surgeries were required.Hip arthroscopy can be an effective treatment for FAI and concomitant labral tears in Asian patients as demonstrated in this study, with improved PRO scores and reoperation rates. Longer-term studies with larger cohorts are necessary.Level IV, case series.

We aimed to present the clinical outcomes of multiple drilling and multiple matchstick-like bone allograft for large osteonecrotic lesions of the femoral head as a joint-preserving surgery. Between March 2014 and March 2018, 57 patients (77 hips) who underwent multiple drilling and multiple matchstick-like bone allograft for large lesions (≥ 30%) in osteonecrosis of the femoral head (ONFH) were included. Harris hip scores (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were obtained preoperatively and at the latest follow-up. Plain radiographs were obtained every 3 months. Femoral head collapse ≥ 2 mm was defined as a radiological failure, and conversion to total hip arthroplasty (THA) was regarded as a clinical failure. After exclusion of 5 patients (5 hips) who lost to follow-up, 52 patients (34 men, 18 women; 72 hips) were finally enrolled. The mean follow-up period was 3.4 (range 2–4.5) years. Nineteen hips (28.4%) required conversion to THA at a mean of 21.6 (range 6–42) months postoperatively. In the remaining 53 hips (71.6%) with clinical success, the mean HHS and WOMAC improved from 63 and 31.3 preoperatively to 80.6 and 16.3 at the final follow-up, respectively (p

Skin adhesives are used to close clean surgical wounds. We aimed to investigate the incidence of skin adhesive-related contact dermatitis and the characteristics that differentiate it from a surgical site infection.We retrospectively analyzed patients whose surgical wound was closed using a liquid skin adhesive (Dermabond Prineo skin closure system, Ethicon, NJ) by a single surgeon between March 2018 and June 2020. Medical records were reviewed to evaluate complications indicating contact dermatitis, including wound infections and hematomas.We included 143 patients (men, 59; women, 84; mean age, 60.8 years). No patient had an early surgical site infection or wound dehiscence, but 4 (2.8%) developed postoperative contact dermatitis (week 7, 1; week 4, 2; day 9, 1). Manifestations included eczema and pruritus, without local heat or wound discharge. All cases resolved without complications, including infection.Contact dermatitis occurred in 2.8% of patients who received liquid skin adhesive, and the symptoms differed from those of surgical site infection. Patients should be informed about the risk of contact dermatitis before applying a liquid skin adhesive.

BackgroundAcetabular labral tears cause of pain in patients with symptomatic hip dysplasia. To date, no structured grading system has been developed to evaluate labral tears in these patients. The present study describes a new system of grading labral tears in patients with acetabular dysplasia.MethodsThe data of 66 patients who underwent hip arthroscopy for symptomatic hip dysplasia from March 2014 to February 2018 were reviewed. Labral tears were classified into four groups, based on the occurrence of chondrolabral junction (CLJ) disruption, capsulolabral recess (CLR) disruption, and labral displacement. Labral tears without instability were classified as grade 1 or 2. Partial delamination or blistering of the labrum with minimal fraying at the CLJ was classified as grade 1, whereas labral tears with CLJ disruption were classified as grade 2. Unstable labral tears with CLR disruption followed by CLJ disruption, but without labral displacement, were classified as grade 3, whereas unstable labral tears with CLR and CLJ disruption, but with labral displacement, were classified as grade 4. The radiological and clinical characteristics of patients in each grade were determined including by simple radiographs and MRI/MR arthrography, as were concomitant findings, including rupture of the ligamentum teres, articular cartilage damage, and presence of a paralabral cyst. The surgical options selected for each grade and clinical outcomes, including modified Harris hip scores (mHHS) and Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) scores, were evaluated. Spearman's correlation analyses were performed to assess whether labral tear grade correlated with baseline characteristics, the incidence of concomitant injuries, and the severity of osteoarthritis (OA). The Wilcoxon test for paired data was performed to compare treatment results with pain scores.ResultsThe study cohort included six men and 53 women of mean ± SD age 39.9 ± 13.0 years (range, 15-66 years). Of the 66 hips, seven (10.6%), 10 (15.2%), 30 (45.5%), and 19 (28.8%) were classified as grades 1-4, respectively. Symptom duration (P = 0.017), preoperative Tönnis OA grade (P < 0.001), cartilage damage (P < 0.001), and the presence of a paralabral cyst (P = 0.001) correlated significantly with baseline tear grade. In all groups, mHHS and WOMAC scores improved after surgical treatment.ConclusionsArthroscopic findings of labral tears in patients with hip dysplasia differed from the conventional classification. The classification system proposed in this study will likely be useful for determining the degree of labral tear in patients with hip dysplasia and for predicting treatment outcomes.

Background Hereditary multiple exostoses (HME) is an autosomal dominant disorder. The lesion in the proximal femoral metaphysis can bring about hip dysplasia and subsequent degenerative arthritis. Due to its rare prevalence, there have been a few case reports of total hip arthroplasty (THA) for osteoarthritis secondary to HME. The aim of this study was to report mid- to long-term outcomes of THA in HME patients and discuss special considerations that should be taken into account during surgery. Methods We retrospectively evaluated the clinical and radiological results of THA for osteoarthritis secondary to HME in 11 hips of 9 patients after a minimum follow-up of 5 years (mean, 9.9 years). There were 3 men (3 hips) and 6 women (8 hips), with a mean age of 53.6 years (range, 46.8-58 years) at the index surgery in this study. Harris hip score (HHS) was used for clinical outcome assessment, and radiologically, implant stability, radiolucent lines, liner wear, and any sign of osteolysis or implant loosening were evaluated. Postoperative complications including infection, deep vein thrombosis, and dislocations were also investigated. Results Cemented stems and cementless cups with the conventional polyethylene liner were used in bilateral hips of a single patient. In the other cases, cementless implants were used with ceramic-on-ceramic bearings. The mean HHS improved from 34.8 preoperatively to 92.5 postoperatively. Polyethylene liner wear and osteolysis were observed in 1 patient with cemented stems. Radiolucent lines were observed in 2 different cases. However, the femoral stems remained stable. There were no surgery-related complications except heterotopic ossification during follow-up. Conclusions Despite the several surgical considerations, the mid- to long-term clinical and radiological outcomes of THA in HME patients were satisfactory. The abnormal, wide mediolateral diameter of the proximal metaphysis should be considered in selecting and inserting the stem with adequate anteversion. Leg length discrepancy was also common, so teleradiographs should be obtained before surgery. Intraoperative leg length evaluation might be difficult due to the morphologic changes in the proximal femur after mass excision and individual bone length differences.

Purpose The purpose of this study was to evaluate the clinical outcome of arthroscopic treatment for recalcitrant external snapping hip. Materials and Methods Between September 2011 and June 2013, we evaluated 7 patients (10 cases) with snapping hip who were refractory to conservative treatments for at least 3 months. Two patients (4 cases) were impossible to adduct both knees in 90°of hip flexion. Surgery was done in lateral decubitus position, under spinal anesthesia. We made 2 arthroscopic portals to operate the patients, and used cross-cutting with flap resection technique to treat the lesion. We performed additional gluteal sling release in those 2 patients (4 cases) with adduction difficulty. Average follow-up length was 19 months (range, 12-33 months). Clinical improvement was evaluated with visual analog scale (VAS), modified Harris hip score (mHHS), and also investigated for presence of limping or other complications as well. Results The VAS decreased from 6.8 (range, 6-9) preoperatively to 0.2 (range, 0-2) postoperatively, and the mHHS improved from 68.2 to 94.8 after surgery. None of the patients complained of post-operative wound problem or surgical complications. Conclusion The clinical outcome of arthroscopic treatment for recalcitrant external snapping hip was encouraging and all patients were also satisfied with the cosmetic results.

Medial collateral ligament (MCL) release is one of the essential steps toward the achievement of ligament balancing during the total knee arthroplasty (TKA) in patients with varus deformity. When the varus deformity is severe, complete release of the MCL until balanced is often required. However, it is believed that complete MCL release may lead to catastrophic laxity. The purpose of this prospective study is to compare the medial joint gap opening in postoperative valgus stress radiograph in patients with complete MCL release against patients with partial release. Out of 209 primary TKAs performed for degenerative osteoarthritis, complete MCL release was required in 33 cases (group I) by sub-periosteal detachment at proximal tibia using periosteal elevator. For the remaining 176 knees (group II), partial release of MCL was done. At postoperative 6 months and 1 year, both groups were evaluated for comparing the joint gap on valgus stress radiographs using modified Telos device in 0°, 45°, and 90° of flexion. Additional parameters which were analyzed included preoperative varus and valgus stress radiographs in full extension and pre- and postoperative mechanical alignment in each group. The knee range of motion (ROM) and clinical scores were evaluated at 1-year follow-up. The mean values of the joint opening on the postoperative valgus stress test with the knee joint extended, and in the 45° and 90° flexed states at 6 months and at 1 year postoperatively in group I were not statistically significantly different from those of group II. The clinical scores also did not show a statistically significant difference between two groups. There was a statistically significant difference in ROM between two groups, pre- and postoperatively and the difference was 5°, respectively. This study suggests that complete MCL release for ligament balancing is a safe procedure and does not lead to postoperative laxity.

Purpose: The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes. Methods: 10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively. Results: Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20°, volar flexion 15°, radial deviation 0°, ulnar deviation 15°. Conclusion: Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist.