Atypical Femoral Fracture in a Patient without Bisphosphonate or Denosumab Exposure-A Case Report

Introduction: Atypical femoral fractures (AFF) are associated with the use of bisphosphonates (BPs) or denosumab. However, few cases that meet the characteristics of these fractures, as established by the American Society of Bone and Mineral Research, have occurred in patients who have never used antiresorptive drugs. Case Report:We report a case of AFF in a 67-year-old woman who had never used antiresorptive medications. The history and comorbidities of the patient, the characteristics of the fracture, and the subsequent treatment are presented. Conclusion: AFFs may occur even in patients who have never been exposed to BPs or denosumab. The absence of antiresorptive osteoporosis therapy and the lack of radiographic focal periosteal reaction in the lateral femoral cortex, as in our case, can make it difficult to detect and prevent the disorder. Prolonged use of proton pump inhibitors and Vitamin D deficiency-related osteomalacia may contribute to the occurrence of these fractures. Further studies are required to accurately understand all inciting factors contributing to the development of AFFs. Keywords: Atypical femoral fractures, subtrochanteric fractures, denosumab, bisphosphonates, antiresorptive drugs.

Impact of Femoral Stem Prosthesis Tip On Femoral Cortex After Primary Total Hip Arthroplasty (THA)

Background: The mechanisms of pain after total hip arthroplasty (THA) is not clear, which may be related to its impact on the femoral cortex caused by improper prosthesis placement. This study was to explore the the impact of the femoral stem prosthesis on the femoral cortex after implantation, and its relationship with postoperative thigh pain. Methods: Totally 172 patients who underwent primary THA were retrospectively analyzed, who were divided into the impact (n=25) and non-impact (n=147) groups. Contact or penetration of the femoral stem prosthesis tip with the distal femoral cortex was defined as impingement. Patients were followed up and recorded.Results: In the patients undergoing primary THA, 25 patients (14.5%) had impact, including 7 males and 18 females. Most of the patients in the impact group were women of small stature. In the impact group, the postoperative thigh pain was more obvious, and the Harris Hip score (HHS) was lower, compared with the non-impact group (P < 0.05). The regression analysis showed that height (OR=1.196; 95%CI: 1.059-1.351; P=0.004) and prosthesis implant angle (PIA) (OR=0.208; 95%CI: 0.074-0.584; P=0.003) were important risk factors for distal femoral cortical impingement in patients who underwent THA. Conclusions: Patients with short stature should have adequate preoperative planning for primary THA, to prevent increased risk of postoperative thigh pain due to impinging femoral stem implants.

EVALUATON OF CALCAR GRAFTING IN HIP HEMIARTHROPLASTY FOR COMMINUTED INTER-TROCHANTERIC FEMUR FRACTURES IN ELDERLY

Introduction: Treating intertrochanteric fractures in elderly with osteosynthesis is challenging, and is attributed to multiple factors like poor bone stock, difcult fracture pattern, and non orthopaedic complications arising due to periods of recumbency associated with internal xation. Hip replacement has come forward as a viable option for treating these cases, but it has its own share of difculties, such as limb length discrepancy, implant subsidence, long term implant stability and a greater cost. This study aimed at evaluating the utility if calcar strut grafting in dealing with these issues. Material And Methods: A total of 30 patients, with age more than 60 years, with comminuted intertrochanteric fractures, with postero-medial bone deciency, were treated with hemiarthroplasty, with augmentation with calcar strut grafting. The graft was prepared from the calcar region of the head and neck part of the femur and placed between the decient medial femoral cortex and medial edge of the implant. Result: In 24 out of the 30 patients, the graft got incorporated at its place without displacement. Shortening was seen in 4 patients, of which 2 reported a shortening of more than 2 centimetres. Conclusion: We can concludethat hemiarthroplasty has come forward as a viable and safe treatment modality for management of comminuted inter-trochanteric fractures in elderly patients.Calcar grafting as described here is useful in minimizing the subsidence of the implant and in maintaining the limb length, it facilitates early rehabilitation and quicker return normal activities

Defining ‘undersizing’ in short-stem total hip arthroplasty: the importance of sufficient contact with the lateral femoral cortex

Introduction: Undersizing is 1 of the main reasons for early implant failure. Adequate sizing in short-stem total hip arthroplasty can be challenging and, so far, lacks key decision criteria. Methods: We included 191 calcar-guided short stems. All patients underwent standardised digital anteroposterior imaging pre- and post-surgery and during follow-up. Preoperative planning was performed digitally. Planned stem sizes were retrospectively assessed and compared with the implanted sizes. Additionally, adequate sizing was analysed by determining whether the stem made intraoperative contact with the lateral distal femoral cortex. Implant migration was assessed by Ein-Bild-Roentgen-Analysis Femoral-Component-Analysis 5 years after surgery. Influence of different Dorr types and postoperative centrum-collum-diaphyseal angle (CCD) categories on lateral femoral cortical contact were analysed. Additionally, the Harris Hip Score (HHS) was assessed at final follow-up. Stem-revision rate was documented. Results: Implanted stems were at least 2 sizes smaller than those at the preoperative planning in 49 (25.7%) cases. The stem made contact with the lateral distal femoral cortex in only 130 hips (68.1%). Mean subsidence was significantly higher in the no-contact group (2.07 mm, range −7.7 to 1.7) than in the contact group (1.23 mm, range −4.5 to 1.8) at the final follow-up ( p = 0.0018). Stems at least 2 sizes smaller than those at preoperative planning showed a significantly higher prevalence of non-contact (46.9% vs. 26.8%) ( p = 0.009). Those undersized stems were more likely found in varus hips. No influence of the Dorr classification and the different CCD categories on the probability of achieving sufficient cortical contact was found. HHS showed no intergroup differences. Conclusions: Stems that did not make intraoperative contact with the lateral femoral cortex showed significantly increased axial migration at mid-term follow-up. Thus, the investigated criteria regarding the definition of undersizing in short-stem THA should be acknowledged. No obvious mid-term consequences were noted regarding revision rate. Long-term results are mandatory.

High incidence of tunnel collision in combined ACL reconstruction and LET

Aims and Objectives: Lateral extra-articular tenodesis (LET) procedures are being increasingly performed as concomitant procedures to both primary and revision intra-articular ACL reconstructions with the purpose of controlling excessive anterolateral rotatory instability and to reduce tension on the ACL graft. There is, however, a lack of evidence on benefits and pitfalls of different femoral LET attachment positions. The purpose of this study was to assess the risk of tunnel convergence in combined ACL and LET procedures comparing two different femoral attachment sites (Lemaire and MacIntosh). Materials and Methods: 10 fresh-frozen cadaver knees were examined. In each specimen an anatomic ACL femoral tunnel and two LET tunnels were drilled applying the Lemaire and MacIntosh position. Following knee dissection, minimal distances between ACL and LET tunnels were directly measured on the lateral femoral cortex. Furthermore, computed tomography (CT) scans were obtained to measure inter-tunnel convergence and lateral femoral condyle (LFC) width. Based on the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence. Results: Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while inter-tunnel conflicts were not observed. Collisions emerged in both, small (n=4) and large (n=3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh position was 3.1±4.6 mm and 9.8±5.4 mm, respectively. Conclusion: A high risk of tunnel convergence was observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction can significantly reduce the risk of tunnel collision. These findings help to intraoperatively raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures. Adjustments on ACL reconstruction techniques and especially on the femoral fixation have to be considered when applying an additional Lemaire reconstruction.

High Risk of Tunnel Convergence in Combined Anterior Cruciate Ligament Reconstruction and Lateral Extra-articular Tenodesis

Background: Lateral extra-articular tenodesis (LET) is being increasingly added to primary and revision anterior cruciate ligament (ACL) reconstruction to address residual anterolateral rotatory instability. However, currently there is a lack of knowledge on how close the femoral tunnels are when combining these procedures. Purpose/Hypotheses: To assess the risk of tunnel convergence in combined ACL and LET procedures using 2 different surgical techniques (Lemaire and MacIntosh). It was hypothesized that the risk of tunnel convergence would be greater when using the more distally located Lemaire position. The authors further hypothesized that tunnel proximity would be influenced by knee size. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric knees were used for this study. In each specimen, an anatomic ACL femoral tunnel and 2 LET tunnels were drilled using the Lemaire and MacIntosh positions, respectively. After knee dissection, minimal distances between each ACL and LET tunnel were directly measured on the lateral femoral cortex. Furthermore, computed tomography scans were obtained to measure intertunnel convergence and lateral femoral condyle (LFC) width. On the basis of the average LFC width, knees were divided into large and small knees to determine a relationship between knee size and tunnel convergence. Results: Convergence of ACL and LET tunnels occurred in 7 of 10 cases (70%) using the Lemaire attachment position. All tunnel collisions occurred directly on the lateral femoral cortex, while intertunnel (intramedullary) conflicts were not observed. Collisions emerged in both small (n = 4) and large (n = 3) knees. Critical tunnel convergence did not occur using the MacIntosh position. The mean minimal distance between the LET and ACL tunnel using the Lemaire and MacIntosh positions was 3.1 ± 4.6 mm and 9.8 ± 5.4 mm, respectively. Conclusion: Tunnel convergence was more frequently observed in combined ACL and LET reconstruction using the Lemaire technique, independent of the knee size. LET femoral tunnel positioning according to the MacIntosh reconstruction was not associated with tunnel collision. Clinical Relevance: These findings help to raise the awareness for the risk of tunnel convergence in combined ACL and LET procedures. Surgeons may contemplate adjustments on the ACL femoral tunnel drilling technique or fixation device when applying an additional Lemaire procedure. However, in the absence of clinical outcome studies comparing different LET techniques, it remains unclear which technique is superior in a clinical setting.