Comparison of Outcomes of Long Versus Short Cephalomedullary Nails for the Fixation of Intertrochanteric Femur Fractures: A Systematic Review and Meta-analysis of 14,547 Patients

Purpose

Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF.

Methodology

PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1.

Results

Fourteen thousand five hundred forty-seven patients were included in this review.

Primary Outcomes

Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30 days and within 1 year.

Secondary Outcomes

Statistically significant shorter duration of surgery (MD-17.83 (95% CI - 22.03, - 13.63, p < 0.05), less intra-operative blood loss (MD - 62.65, 95% CI - 97.13 to - 28.17, p =  < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen.

Conclusion

With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter version of nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00915-5.

Long-term survival of CLS Spotorno femoral stem: a systematic review of literature

BACKGROUND

CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems.

RESEARCH QUESTION

Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes?

METHODOLOGY

Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done.

RESULTS

All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3-27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08-91.23, p < 0.01). The improvement in scores from preoperative values (of 43.9 points) were comparable to Corail (43.8) and Exeter (45) stems. Thigh pain was seen in only 41 cases out of 1097 hips.

CONCLUSION

Despite the limitations due to high heterogeneity of the cumulative data, the review suggests that CLS Spotorno femoral stems provides excellent long-term survival and good hip function. These outcomes are comparable to other commonly utilized femoral stems like the Corail and Exeter.

LEVEL OF EVIDENCE

IV.

Autonomic Denervation Dermatitis: A Relatively Undocumented 'ADD'itional Complication of Total Knee Replacements and Other Surgeries Around the Knee

BACKGROUND

Infrapatellar branch of the saphenous nerve lies subcutaneously and supplies the anterolateral aspect of knee below the patella. It is extremely susceptible to iatrogenic injuries during the surgeries around the knee, mainly total knee replacements (TKRs). Post operatively the patients present with localised area of numbness and in some instances a traumatic eczematous reaction termed autonomous denervation dermatitis (ADD) is witnessed, leading to skin manifestations that range from a simple rash to extensive lesions.

METHODOLOGY

A review of literature was conducted with search of relevant articles from Medline (PubMed), Embase, and Scopus which discussed eczematous skin lesions secondary to total knee replacements. Additionally, we noted studies which described these lesions in other surgeries around the knee like arthroscopies and fracture fixations.

RESULTS

Eight studies including atleast one case after TKR were reviewed. There was only one cohort study while the remaining included case reports and small case series. There were 69 cases of ADD appearing after TKR. The appearance of the skin lesions was lateral to the incision in 30/34 operated knees and on both sides of the incision in four knees after TKRs. Bilateral lesions were seen in only six patients of TKRs. There was no functional limitation caused by these lesions and they resolved either spontaneously or after using topical steroids.

CONCLUSION

ADD is a relatively uncommonly reported complication of TKRs, which can reduce patient satisfaction and increase surgeon apprehension. Although all cases of nerve damage do not manifest as cutaneous lesions, steps to minimise the damage to the nerve intra operatively should be taken. The diagnosis requires a high index of suspicion, and should not be dispelled as a simple allergic reaction without adequate investigations. Patients should be counselled to alleviate unnecessary fear and apprehensions.

Ruptured Popliteal Cysts Mimicking Deep Vein Thrombosis in Well-Functioning Total Knee Replacements: Report of Two Cases and Review of Literature

Background

Implant wear and loosening with eluding metal/polythene debris are commonly implicated in the occurrence of Baker’s cysts in post-operative total knee replacement (TKR) patients, who present with post-operative pain and swelling, mimicking deep venous thrombosis. However, we present two symptomatic cases presenting with ruptured Baker’s cysts post-TKRs, with no evidence of implant loosening or wear.

Cases Report

The 1st patient was a 55-year-old male, who underwent TKR for Grade 4 bilateral knee osteoarthritis and presented with acute onset of pain and swelling over the left popliteal fossa, which progressed to involve the calf. Radiographs showed no sign of infection or loosening, and venous color Doppler and magnetic resonance imaging (MRI) showed a hy-poechoic collection in the intermuscular plane at the upper part of popliteal fossa. Histological examination of the aspirated fluid showed mixed features of cystic fluid and a resolving hematoma. There was complete resolution of the 4 months with rest and graduated physiotherapy.

The 2nd patient was a 51-year-old female who developed the cystic swelling 2 years after the surgery, and the ultrasound showed hypoechoic echoes in a Baker’s cyst-like collection. Cytological findings were suggestive of hemorrhagic nature of the aspirate, without any evi-dence of polyethylene debris, and the cultures were sterile. She became asymptomatic over 4 weeks with conservative management; the swelling resolved after 3 months.

Conclusion

Majority of the cases in literature show implant loosening as cause of popliteal cysts after TKRs, however present cases highlight alternative mechanisms, and there are good chances of self-resolution of cysts with conservative treatment in such cases.

Core decompression with bone marrow aspirate concentrate in post collapse avascular necrosis of hip: A systematic review and meta-analysis

BACKGROUND

Avascular necrosis (AVN) of femoral head is commonly seen in middle age groups and in its advanced stages, it is a common indication for total hip replacements (THRs). These patients invariably require revision surgeries in their lifetime and modalities to delay the first arthroplasty are necessary. Core decompression (CD) with bone marrow aspirate concentrate (BMAC) have proved successful in early stages of AVN, but their role in advanced stages remains unclear. The present review was done to assess the same.

RESEARCH QUESTION

Is CD and BMAC combination effective in delaying radiographic progression and THRs in post collapse stages of AVN hip?

METHODOLOGY

A systematic review and meta-analysis was conducted to determine the overall efficacy of CD and BMAC in post collapse stages of AVN hip and to specifically compare primary outcomes like radiographic progression along with need of THR, with CD alone.Three data bases (PubMed, EMBASE and SCOPUS) were searched to identify relevant articles.

RESULTS

The present review included 12 studies with 3 studies included in the meta-analysis. There were 270 hips across the 12 studies out of which 196 hips were treated with CD + BMAC.

PRIMARY OUTCOMES

39.8% cases worsened from stage 3 to stage 4, while the overall incidence of THR in stages 3 and 4 was 38.3%. On comparison with CD alone the combination of CD + BMAC did not show any enhanced efficacy in either delaying progression (Odds ratio of 1.41 (95% CI = 0.55-3.62) or in conversion to THR (Odds Ratio: 0. 92; 95% CI = 0.41-2.06).

CONCLUSION

CD can be considered in stage 3 of AVN in younger population to delay the need of arthroplasty, before severe head distortion and arthritis sets in, and can be supplemented with bone strut grafts or tantalum rods, for supporting the articular cartilage. BMAC that has shown better results in early AVN, has not shown any additional benefits when compared to CD alone in advanced cases.

30-Day Mortality Rate in Hip Fractures Among the Elderly with Coexistent COVID-19 Infection: A Systematic Review

PURPOSE

Hip fractures in the elderly require a multi-disciplinary approach and are associated with increased morbidity and mortality. The current COVID-19 pandemic has affected substantially this high-risk population group. This present review was done to ascertain whether or not the pandemic has affected the 30-day mortality and outcomes of hip fracture in the elderly.

RESEARCH QUESTION

Does the coexistence of COVID-19 infection and hip fractures in the elderly increase the mortality rates?

METHODOLOGY

A systematic review and meta-analysis were conducted using three databases (PubMed, EMBASE and SCOPUS) to compare the mortality rates between COVID-19 positive/suspect and COVID-19 negative patients. The secondary outcomes included comparison of in-hospital mortality, complication rate and length of hospital stay. Risk of bias assessment was done using the MINORS tool.

RESULTS

The present review included 20 studies. Primary outcome: A significantly higher 30 day mortality rate was seen in COVID-19 positive/suspect patients with an Odds ratio of 6.09 (95% CI 4.75-8.59, p < 0.00001). Secondary outcome: We observed significantly higher rates of inpatient mortality [OR 18.22, (95% CI 7.10-46.75], complication rate (OR 9.28, 95% CI 4.46-19.30), and length of hospital stay (MD: 4.96, 95% CI 2.86-7.05) in COVID-19 positive/suspect patients as compared to COVID-19 negative patients.

CONCLUSION

COVID-19 has deteriorated the outcomes in elderly patients with hip fractures and associated with higher rates of mortality in the short term. A multidisciplinary approach is needed to contain this "pandemic within a pandemic" and improve the overall outcome to survival.

Status of Hip Arthroscopy in India: A Short Questionnaire Based Survey and Review of Literature

BACKGROUND

Hip arthroscopy is a minimally invasive technology for diagnostic and therapeutic interventions in various hip disorders. Over the past decade or so, the technology and understanding related to this surgery have improved by leaps and bounds; however, in India the overall pace has been limited. The present review highlights the status of hip arthroscopy in the Indian context.

METHODOLOGY

A small survey with five questions related to practice of hip arthroscopy among Indian orthopaedic surgeons was conducted. Additionally a PubMed database search was conducted to recognise and assess studies pertaining to hip arthroscopy originating from India.

RESULTS

Forty-two responses were received for the questionnaire, out of which 38 surgeons performed hip arthroscopy in their practice; the overall numbers were very low with only one respondent performing more than 50 surgeries in a year. For 84.2% of the respondents, the practice was limited to less than ten surgeries per year. 63.2% of the surgeons affirmed that there has been no change in their practice of hip arthroscopies over the past 5 years, signifying the slow growth and limited application of the technique. Only nine studies pertaining to the topic were available in the literature search, out of which five were case reports. The most common indication was removal of intraarticular foreign bodies, followed by joint debridement and lavage, synovial biopsies and femoroacetabular impingement (FAI). The outcomes in all the studies were satisfactory.

CONCLUSION

Hip arthroscopy is in its nascent stages in India and much is still needed to be done for better implementation of the technique on a wider scale. Adequate training and continued medical education programme, with exposure to the experts in the field, will go a long way in better utilisation of the surgery in India.

Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients

BACKGROUND

Several functional scoring tools are available to evaluate the outcomes of total hip replacements (THRs) for diseased or damaged hips. Majority of these scores were devised in western countries and their cross-cultural compatibilities are rarely demonstrated. The World Health Organisation quality of life (WHO QOL-BREF) questionnaire with 4 domains, is one of the best known multilingual instruments for such assessment. Its reliability has never been demonstrated for THRs and the present study was conceptualised for the same.

METHODS

THRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients.

RESULTS

The number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8); showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach's alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000).

CONCLUSION

WHO QOL-BREF is a potent tool to assess the quality of life in patients undergoing THRs. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Efficacy of orthobiologic adjuvants to core decompression for hip preservation in avascular necrosis hip

Head preserving modalities in avascular necrosis (AVN) hip are variably effective in early stages, and further options that could prevent head distortion and osteoarthritis are needed. Core decompression (CD) is the most commonly used surgery in the early stages of osteonecrosis with variable rates of success. The present review aimed to determine the effectiveness of bone marrow aspirate concentrate (BMAC), platelet-rich plasma (PRP), bone morphogenetic proteins (BMP) or their combination with CD in early stages of AVN hip, prior to collapse of femoral head. Additionally, any newer unexplored modalities were also searched for and ascertained. PubMed and SCOPUS databases were searched for relevant articles in English language describing CD with aforementioned orthobiologics. We analysed a total of 20 studies published between 2011 and 2020. There were 6 retrospective and 14 prospective studies. PRP showed improved survival and functional outcomes; however, with only three studies, there is inconclusive evidence for its routine utilization. BMAC enhances the efficacy of CD which can further be increased by culture and expansion of cells or combining it with PRP to stimulate growth. In conclusion, CD with BMAC works more efficiently than CD alone prior to collapse of femoral head in AVN. However, PRP needs more evidence for extensive application. Addition of PRP to BMAC or culturing the latter could further enhance the potency of CD + BMAC combination. Very limited data is available for the efficacy of BMP-7 and the role of intraosseous bisphosphonates should be evaluated for a cheaper and potential alternative.

Common hip conditions requiring primary total hip arthroplasty and comparison of their post-operative functional outcomes

BACKGROUND

Primary osteoarthritis of hip has been widely reported to be the leading cause for total hip replacement (THR) in the world. The other common causes are avascular necrosis of hip, inflammatory diseases and trauma sequelae. We report the prevalence of these disease as studied retrospectively at a tertiary healthcare centre and discuss the common age groups and sex ratios of these patients as compared to the West. Additionally, we compare the outcomes of these surgeries based on the aetiologies for which they were done.

METHODOLOGY

Patients who underwent primary THR in our institute within six years were called and retrospectively analysed. Revision cases were excluded. All the surgeries were done by a single experienced arthroplasty surgeon. On follow ups, functional scores were assessed using standard Harris hip score (HHS) and quality of life scores were assessed using the Short musculoskeletal functional assessment (SMFA) score.

RESULTS

118 hips in 99 patients (M:F- 3.2:1) with a mean age group of 43.22 years, were operated over a period of six years. Non traumatic avascular necrosis (AVN) of hip topped the list in our study with 42.4% of cases, followed by post-traumatic sequelae (30.5%). These were followed subsequently by primary osteoarthritis (OA) (14.4%) and the remaining were inflammatory pathologies (IA). The HHS of patients with non traumatic AVN hip, traumatic sequelae and primary osteoarthritis were significantly superior to inflammatory arthritis with a p value of 0.001, 0.001 and 0.016 respectively. Additionally the short musculoskeletal functional assessment score was also significantly higher in IA than AVN, OA and post trauma groups (p = 0.001, 0.037 and 0.002 respectively); where a higher score denotes inferior outcomes.

CONCLUSION

In our part of the world, non traumatic AVN hip is the commonest indication for primary hip arthroplasty, followed by traumatic sequelae. The frequency of males undergoing hip arthroplasty is much more than females and at a younger age as compared to the West. Additionally, the functional outcomes in cases of inflammatory arthritis are inferior as compared to the other indications, probably because of associated contractures, deformity and spinal issues.

Bilateral Quadriceps Rupture in an Elite Weight Lifter: A Case Report and Review of Literature

Simultaneous bilateral quadriceps tendon ruptures (QTR) are rare injuries in sportspersons; weightlifting, involving sudden eccentric contraction of the bilateral quadriceps, has the potential to cause this injury. We present a case of an elite weightlifter with bilateral quadriceps tear occurring during the "jerk" part of clean and jerk phase of weightlifting; single stage bilateral end to end repair was done, followed by 3 weeks of cast immobilisation. He then underwent a supervised rehabilitation protocol, leading to graduated strengthening of the muscles. He went back to competitive sport after 2 years and participated in a national championship after 5 years. Detailed questioning revealed a history of anabolic steroid use in the early phase of his career; a literature review showed only seven cases of this injury pattern in weightlifting/bodybuilding sports, and five of these seven had a definitive history of anabolic steroid use. Bilateral QTR may be a pointer to predisposing factors like use of steroids, which should be diligently identified. Good outcomes are possible after early surgical repair and rehabilitation, with high rates of return to sports.

Greater trochanteric versus piriformis fossa entry nails for femur shaft fractures: Resolving the controversy

BACKGROUND

Intramedullary nailing is the treatment of choice for shaft of femur fractures in adults. Antegrade nails involve entry through either piriformis fossa (PE) or greater trochanteric (GT) tip. The superiority of one entry point over the other is a matter of debate, and the present review was done to determine the same.

RESEARCH QUESTION

Is GT entry for antegrade femur nailing superior to the PE for shaft femur fractures in adults?

OBJECTIVE

The present systematic review was conducted to determine the superiority of one entry point over the other by comparing the outcome parameters like operative time, exposure to fluoroscopy, mal-unions, non unions, abductor weakness, varus malalignment and Harris Hip scores (HHS).

METHODOLOGY

Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles that directly compared GT with PE for nailing in shaft femur fractures in adults.

RESULTS

We analysed a total of 9 studies published between the years 2011-2017. There were 5 retrospective and 4 prospective studies, out of which 3 were randomised. The total number of patients was 256 in GT group and 460 in PE group.

OUTCOMES

There was significant superiority of GT entry over PE on meta analysis; lesser operation time: standard mean difference (SMD): -21.01; lesser exposure to fluoroscopy : SMD: 36.36; lesser incidence of abductor weakness: Odd's ratio (OR): 14.35; better functional outcome (HHS): SMD -2.48.

CONCLUSION

GT entry nails are superior to PE nails for treating shaft of femur fractures in adults. They have a shorter learning curve and better functional outcomes, however the rates of union are comparable in both.

Correction to: Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis

The original version of this article unfortunately contained a mistake. The correct information is given below. In abstract, the last sentence of the "Primary outcomes" section should read as: Mortality at 1 year was the same in both the groups.

Tuberculosis of lunate as an isolated intraosseous osteolytic lesion in an adult: a diagnostic challenge

In an endemic zone of tuberculosis (TB), osseous involvement is a relatively common presentation. Spine and long bones are the the most common nidus of TB. Smaller bones and joints are relatively less involved. Thorough clinical examination and history of typical constitutional symptoms like weight loss, fever and loss of appetite are the diagnostic aids for initiating early treatment. Wrist and hand involvement is a rare occurrence and often presents atypically without any obvious symptoms or signs. This results in delayed diagnosis and worse outcome. TB of lunate without articular involvement is a very rare subset and we present such an isolated case of TB involving the lunate, without any typical symptoms, with the patient complaining of vague pain without any restriction of joint mobility. TB was diagnosed with the aid of radiology, haematology and histopathology. 18 months of multidrug antitubercular treatment was given, to which the patient responded well.

Epidemiology of pelvic fractures in adults: Our experience at a tertiary hospital

PURPOSE

Pelvic fractures are severe injuries and are often associated with multiple system injuries, exacerbating the overall outcome. In India, the incidence of pelvic fractures is on a rise due to suboptimal roads and traffics but related literature regarding the overall epidemiology of these injuries is scarce and scanty. Our aim was to study the epidemiology of patients admitted with pelvic fractures at a level 1 trauma centre in India.

METHODS

A 16-month (between September 2015 and December 2016) prospective observational study was carried out on trauma patients with pelvic fractures at a level 1 trauma centre of a tertiary care hospital. Demography of patients, mechanism of injuries and complications were recorded prospectively.

RESULTS

We observed 75 patients who presented with pelvic fractures, where 56 were males and 19 were females. Mean age of the study population was 37.57 years. Road traffic accidents were the most common mode of injuries. Lateral compression injuries were the most common pattern. Associated injuries frequently encountered were lower extremities and acetabulum fractures, blunt abdominal trauma, urogenital injuries and head injuries. Out of the 75 patients, 52 were treated surgically and 23 were managed by conservative methods. Associated injuries of the extremities, head, abdomen and urogenital system indicated a longer hospital stay.

CONCLUSION

Pelvic fractures, although belong to a relatively rare trauma subset, cause a high morbidity and mortality with considerable burden on the economy. Proper road safety training and driving etiquettes along with its strict implementation in true sense and spirit are the need of the hour.

Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis

BACKGROUND

Management of fractures of neck of femur in the elderly is largely joint sacrificing, with hemiarthroplasties being the most common entity used. Cemented and uncemented, both the techniques, are universally accepted; however, the former has been more time tested, despite its theoretical disadvantage in the form of cement embolism leading to intra-operative complications. Uncemented stems have been ever evolving with newer designs to increase incorporation, stability and durability. They have their own reported sets of disadvantages like subsidence and fractures. However, overall there is no established gold standard out of the two.

OBJECTIVE

The present systematic review and meta-analysis of current literature was conducted, so as to determine the superiority of one technique over the other by comparing the primary outcomes like hip function, residual pain, local and general complications and mortality. Additionally secondary outcomes like duration of surgery, blood loss and re-operations were analysed as well.

METHODOLOGY

Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles of last 10 years that directly compare uncemented and cemented hemiarthroplasties, and based on our inclusion and exclusion criteria, article selection was done.

RESULTS

We analysed a total of six randomised controlled studies dated from 2008 to 2017.

PRIMARY OUTCOMES

There was a significant difference in post-operative ability to ambulate at 1 year, between 2 groups with odds ratio 0.45 (95% CI 0.29-0.67, p = 0.0001) favouring cemented hemiarthroplasty. Prosthesis-related complications like fractures and subsidence and general complications like lung complications were more in uncemented group. Mortality at 1 year was more in cemented group.

SECONDARY OUTCOMES

Mean surgical time was lesser in uncemented cases. There was no difference in blood loss and re-operation rates.

CONCLUSION

Cementing techniques are here to stay, until a better, durable and more stable uncemented stem evolves, that could lessen the complications related to uncemented surgeries and match the cemented implants in pain relief and ambulation.

Reliability of Modified Harris Hip Score as a tool for outcome evaluation of Total Hip Replacements in Indian population

BACKGROUND

Standard Harris Hip Score (HHS) is a validated tool, to measure the functional status of an individual and has been traditionally used to assess the condition of a patient with hip pathologies. Harris hip score in its standard form includes a physician's physical examination component which has a high inter-observer variability. A modified version of HHS (MHHS) was devised and brought into use, but has not been validated as an outcome measure, post total hip replacement (THR) in Indian population.

METHODS

101 patients with 122 hips for whom THR was done, were followed up, and HHS and MHHS were recorded at a minimum followup of 6 months.

RESULTS

The mean MHHS was 78.97 with a standard deviation of 15.017. There was positive correlation between the two functional outcome scores with a p value of 0.001. MHHS was found to be reliable with a significant intraclass correlation coefficient (p = 0.001).

CONCLUSION

MHHS is a reliable and valid tool to measure functional outcome in patients undergoing Total Hip Replacements.

Acute venous thromboembolism in Indian patients of isolated proximal femur fractures

INTRODUCTION

Venous Thromboembolism (VTE) has a variable incidence in trauma patients and fatal embolism can be the very first manifestation. Proximal femur fractures result from high velocity trauma in younger age groups and could require prolonged immobilisation, which is associated with increased risk of VTE. Therefore we sought to determine the occurrance of VTE in patients with proximal femur fractures.

OBJECTIVES

The present study was initiated to assess the occurrance of deep vein thrombosis (DVT) or pulmonary embolism in isolated proximal femur fractures and identify the requirement of routine thromboprophylaxis in such patients.

METHODS

It was a prospective study conducted over a period of one and a half years. All patients, presenting with isolated proximal femur fractures were included. Patients having any other known risk factors for DVT were excluded, so that the proximal femur fracture remained their only acquired risk for DVT. All the patients were evaluated clinically and with help of diagnostic modalities like Color Doppler with compression ultrasound, D-dimer assays and CT venogram, if indicated. Patients were followed up till 8 weeks post-operatively.

RESULTS

A total of 66 patients with fractures of proximal femur were assessed, out of which there were 42 males with mean age of 48.1 years and 24 females with mean age of 58.3 years. A total of 9 cases of radiologically proved DVT were observed. Clinical DVT was seen in 5 of these cases (54%). Complete resolution of thrombus was noted in all the patients, evaluated by Color Doppler at 6 weeks, post diagnosis. Although the majority of the cases (6) occurred in patients beyond 50 years of age, this was not statistically significant.

CONCLUSION

DVT is common in patients with proximal femur fractures and the provision for screening both clinically and radiologically, should be made routine in all such patients. In case of delay in surgery and patient being bed ridden, we recommend thromboprophylaxis in this subset of trauma patients.

Simultaneous, Non-traumatic, Bilateral Neck Femur Fractures in Uremic Renal Osteodystrophy: A Report of Three Cases and Literature Review

Introduction

Bilateral, simultaneous, non-traumatic, pathological femur neck fractures due to renal osteodystrophy (RO) in chronic renal failure cases are uncommon but are increasingly being reported in the literature. Seizure episodes due to uremic encephalopathy could lead to such fractures.

Case Reports

We describe three cases of patients with end-stage renal disease and RO, who presented with bilateral, non-traumatic femur neck fractures after episodes of grand mal con-vulsions. We also review the literature for all such similar cases and briefly discuss the path-ophysiology of RO and the management of these pathological fractures.

Conclusion

Spontaneous, pathological, bilateral neck femur fractures are increasingly being reported in chronic renal failure patients with high morbidity and mortality. These fractures tend to be missed as the patients are generally immobilized and bed ridden due to the renal disease. Early diagnosis with high index of suspicion in patients with hip pain followed by supervised treatment with the involvement of a nephrologist is of uttermost importance.

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

PURPOSE

Total hip replacement (THR) is one of the most successful and cost-effective surgical procedures and remains the treatment of choice for long-term pain relief and restoration of function for patients with diseased or damaged hips. Acetabular fractures managed either conservatively or operatively by fixation tend to present later with secondary joint changes that require THR. In this study we evaluated the functional outcome and quality of life achieved by such patients.

METHODS

Our study was carried out as a retrospective trial by recruiting patients who underwent THR from June 2006 to May 2012. A total of 32 patients were included with a mean age of 46.08 years ranging from (25-65) years. We evaluated the quality of life in the patients using scoring techniques of Short Musculoskeletal Functional Assessment (SMFA) and the 12-Item Short Form Health Survey (SF-12). Functional outcome was assessed using Harris Hip Score (HHS).

RESULTS

The mean HHS of the patients was 84.3 with a range from 56 to 100. The SMFA averaged 13.3. The SF-12 score averaged 49.1. The correlation of the HHS with SF-12 was positive (p =0.001) while with SMFA there was a negative correlation (p =0.001).

CONCLUSION

From this study it is inferred that the functional outcome of THR and quality of life in patients who had acetabular fractures and were initially managed by open reduction and internal fixation is good.