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Kim JT, Park JW, Go JJ, Jung SH, Park B, Lee YK. What features of stem increase the risk of intraoperative femoral fracture during cementless primary hip arthroplasty? Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05482-4. [PMID: 39126454 DOI: 10.1007/s00402-024-05482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Cementless fixation has become increasingly popular in hip arthroplasty due to its shorter operation time, easier technique, biologic fixation, and avoidance of bone cement implantation syndrome compared to cemented fixation. However, intraoperative periprosthetic femoral fracture (IOPFx) is a disconcerting complication during cementless hip arthroplasty. Our purpose was to identify the features of cementless stem that increase the risk of IOPFx during primary hip arthroplasty. MATERIALS AND METHODS We retrospectively reviewed all 4806 hip arthroplasties that was performed in a single institution from May 2003 to December 2020. Age at the index arthroplasty, sex, body mass index, physical status, ambulatory function, side of the operation, operational history, cause of the index arthroplasty, type of arthroplasty, surgical approach, surgeon, implant information, and events during the operation were investigated. The shoulder geometry and length of stem were also reviewed. The event of interest was narrowed down to IOPFx among various records of intraoperative events. RESULTS We found IOPFx of 2.6% among all the hips operated with cementless stem. In the multivariable analysis, female (OR = 1.52), childhood hip disease (OR = 2.30), stove-pipe femur (OR = 2.43), combined approach (OR = 2.60), and standard length of stem (OR = 1.59) were found to be significant risk factors of IOPFx. CONCLUSIONS In conclusion, a stem with a standard length is significantly associated with risk of IOPFx compared to a shortened stem. These findings highlight the importance of careful consideration in terms of the risk of IOPFx when standard length cementless stem is chosen.
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Affiliation(s)
- Jung-Taek Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Ajou Medical Center, Suwon, Korea
| | - Jung-Wee Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, South Korea
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Jin Go
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, South Korea
| | - Se Hee Jung
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon-si, South Korea
| | - Bumhee Park
- Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon-si, South Korea
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, South Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, South Korea.
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea.
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Zhang C, Xiong B, Wang J, Li Y, Xie B, Liu D, Zhang G, Chen W, He H. Factors influencing the survival status of the hip joint in post-collapse femoral head necrosis. J Orthop Surg Res 2024; 19:472. [PMID: 39127688 DOI: 10.1186/s13018-024-04964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Despite hip function typically deteriorating in the post-collapse stage of osteonecrosis of the femoral head (ONFH), some patients can still demonstrate long-term favorable hip function, a state termed "survival with collapse". This study aims to identify the characteristics of patients suitable for "survival with collapse" in cases of ONFH. METHODS This cross-sectional study included 65 patients (87 hips) diagnosed with post-collapse ONFH for ≥ 3 years (average 9.1 years, range 3-23 years). Hip function was assessed using the Harris Hip Score (HHS). Demographic, clinical, and radiographic data were compared between the favorable group (HHS > 80) and the poor group (HHS ≤ 80). Independent protective factors for hip function were identified by multivariate analysis and receiver operating characteristic (ROC) curve analysis was further applied to evaluate these factors' diagnostic efficacy. RESULTS The favorable and poor groups included 46 and 41 hips, respectively. Significant differences were found in body mass index (BMI), Association Research Circulation Osseous (ARCO) stage, collapse degree, Japanese Investigation Committee (JIC) classification, necrotic size, and hip subluxation between the two groups (p < 0.05). Multivariate logistic regression identified collapse < 3 mm(OR:14.49, 95%CI: 3.52-59.68, p < 0.001), JIC types B (OR: 11.08, 95% CI: 1.07-115.12, p < 0.05) and C1(OR: 5.18, 95% CI: 1.47-18.20, p < 0.05) as independent protective factors for hip function, while BMI (OR: 0.76, 95% CI: 0.59-0.97, p = 0.029) was an independent risk factor. ROC curve analysis demonstrated that both collapse degree (AUC = 0.798, sensitivity = 91.3%, specificity = 68.3%, p < 0.0001) and JIC classification (AUC = 0.787, sensitivity = 80.4%, specificity = 73.2%, p < 0.0001) had satisfactory diagnostic value for hip function. Combining JIC classification and collapse degree (AUC = 0.868, sensitivity = 76.1%, specificity = 85.4%, p < 0.0001) significantly enhanced diagnostic efficacy compared to using either alone (p < 0.05). CONCLUSION In ONFH, femoral head collapse does not necessarily determine a poor prognosis. Patients with mild collapse (< 3 mm) and preserved anterolateral wall are more likely to retain satisfactory hip function, making them candidates for "survival with collapse."
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Affiliation(s)
- Cheng Zhang
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Binglang Xiong
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Junyu Wang
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Yan Li
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Bin Xie
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Daobing Liu
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China
| | - Guangyi Zhang
- Beijing University of Chinese Medicine, No.11 North Third Ring Road East, Chaoyang District, Beijing, 100029, China
| | - Weiheng Chen
- The Third Affiliated Hospital of Beijing University of Chinese Medicine, No.51 Xiaoguan Street, outside Andingmen, Chaoyang District, Beijing, 100029, China
| | - Haijun He
- Department of Orthopedics, Wangjing Hospital of China Academy of Chinese Medical Sciences, No.6 Wangjing Zhonghuannan Road, Chaoyang District, Beijing, 100102, China.
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Ido H, Osawa Y, Takegami Y, Hiroto F, Ozawa Y, Imagama S. Factors related to collapse progression in Japanese Investigation Committee classification type B osteonecrosis of the femoral head. INTERNATIONAL ORTHOPAEDICS 2024; 48:2033-2040. [PMID: 38806819 DOI: 10.1007/s00264-024-06221-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE This study aimed to identify factors related to collapse progression in Japanese Investigation Committee classification type B osteonecrosis of the femoral head (ONFH) and to identify patients who would benefit from surgical treatment. METHODS This study included 41 patients (56 hips) with type B ONFH with a minimum follow-up of three years. Based on a ≥ 3 mm collapse progression in ONFH, we categorised patients into two groups: collapse progression and no collapse progression. Sagittal and coronal computed tomography images were used to measure the necrotic region relative to the intact femoral head diameter. The ratios of the necrotic regions of transverse and vertical diameter in coronal and sagittal images are defined as mediolateral transverse and mediolateral vertical, anteroposterior transverse and anteroposterior vertical, respectively. Demographic data and these imaging findings were compared between the two groups. We established a cut-off value for predicting collapse progression through receiver operating characteristic analysis and determined survival rates. RESULTS Type B ONFH had a 17.8% collapse progression rate. The mediolateral transverse, mediolateral vertical, anteroposterior transverse, and anteroposterior vertical were significantly higher in the collapse progression group (P < 0.01). Mediolateral transverse was an independent risk factor of collapse progression (hazard ratio, 1.27; 95% confidence interval, 1.03-1.57; P = 0.03), with an optimal cut-off of 45.6%. The 5-year survival rates with collapse progression as the endpoints were 57.0 and 94.9% in the mediolateral transverse of ≥ 45.6 and < 45.6%, respectively. CONCLUSION A mediolateral transverse of ≥ 45.6% predicts collapse progression in patients with type B ONFH.
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Affiliation(s)
- Hiroaki Ido
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan
| | - Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan.
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan
| | - Funahashi Hiroto
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan
| | - Yuto Ozawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya-shi, 466-8550, Japan
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Ko YS, Kang SY, Kim HS, Yoo JJ. Computed Tomography Evaluation of Alumina Ceramic-on-Ceramic Total Hip Arthroplasty With More Than 20 years of Follow-Up: Is a Follow-Up Computed Tomography Scan Necessary? J Arthroplasty 2024:S0883-5403(24)00679-X. [PMID: 38944063 DOI: 10.1016/j.arth.2024.06.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Ceramic-on-ceramic (CoC) bearings have been increasingly used in total hip arthroplasty (THA) because of their superior wear resistance and biocompatibility. However, there is a scarcity of reports on the computed tomography (CT) evaluation of CoC bearings with more than 10 years. The aim of this study was to evaluate the long-term CT results of THA using CoC bearings for more than 20 years of follow-up. We hypothesized that there would be no wear, osteolysis, or ceramic fracture. METHODS Between November 1997 and June 2003, 956 hips underwent THA using alumina-on-alumina bearings at a tertiary referral hospital. Among them, 107 hips were assessed, all of which underwent a CT examination more than 20 years after the index surgery. The mean age at the time of surgery was 41 years, and a CT scan was performed at an average of 22.0 years postoperatively (range, 20.0 to 25.1). The CT scans were thoroughly assessed for osteolysis, stem notching, and ceramic component fracture. RESULTS No loosening was observed in the acetabular cup or femoral stem. Stem notching was observed in 3 hips (2.8%). In the CT scan taken after a minimum of 20 years of follow-up, 1 case (0.9%) of osteolysis around the cup and 2 cases (1.9%) of osteolysis around the femoral stem were noted. Suspected chip fractures of the ceramic insert were discovered in 4 cases (3.7%). Despite these findings, the patients remained asymptomatic, and no subsequent surgical intervention was needed after close follow-up. CONCLUSIONS Routine CT examinations for patients who underwent THA using CoC bearings over 20 years ago revealed unexpected findings, such as osteolysis and suspected chip fractures of the ceramic liner. However, routine CT scans may not be universally necessary. The CT evaluation in this cohort should be selectively performed for patients who have relevant clinical symptoms. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Young-Seung Ko
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea; Department of Orthopaedic Surgery, Hallym university Dong-Tan Sacred Heart Hospital, Hwaseong, South Korea
| | - Sang Yoon Kang
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Hong Seok Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
| | - Jeong Joon Yoo
- Department of Orthopedic Surgery, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, South Korea
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Kang SY, Ko YS, Kim HS, Yoo JJ. Outcome and complication rate of total hip arthroplasty in patients younger than twenty years: which bearing surface should be used? INTERNATIONAL ORTHOPAEDICS 2024; 48:1381-1390. [PMID: 38217722 PMCID: PMC11076316 DOI: 10.1007/s00264-023-06086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/29/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE Total hip arthroplasty (THA) in younger patients remains controversial due to concerns regarding long-term implant survival and potential complications. This study aimed to evaluate long-term clinical outcomes, complications, differences in complication and revision rates by bearing surfaces, and Kaplan-Meier survival curves for THA in patients under 20 years old. METHODS A retrospective review was conducted for 65 patients (78 hips) who underwent THA between 1991 and 2018. Their mean age was 18.9 years. Their clinical outcomes were assessed using the Harris Hip Score (HHS). Radiological outcomes were evaluated based on the presence of loosening, osteolysis, and heterotopic ossification. Complications such as dislocation, periprosthetic fractures, and infections were assessed. The mean follow-up period was 13.2 years (range, 5.0-31.2 years). RESULTS The mean HHS improved from 44.6 to 90.1. There were two cases of dislocation. However, no periprosthetic fracture, deep infection, or ceramic component fracture was noted. There were 19 revisions of implants. Eighteen of 19 hips were operated with hard-on-soft bearings in the index surgery (p < 0.01). The 23-year survivorship was 97.8% for THA using ceramic-on-ceramic bearings, while the 31-year survivorship was 36.7% using hard-on-soft bearings. CONCLUSION THA in patients under 20 years old yielded promising clinical and radiological outcomes, although polyethylene-bearing-related concerns persisted. Previously operated patients with hard-on-soft bearing should be meticulously examined during the follow-up. As ceramic-on-ceramic bearing showed excellent survivorship in this particular cohort, we recommend the use of this articulation as the bearing of choice.
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Affiliation(s)
- Sang Yoon Kang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Young-Seung Ko
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hong Seok Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | - Jeong Joon Yoo
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Park CW, Jeong SJ, Cho K, Kim SY, Lim SJ, Park YS. Bearing-Related Complications of Total Hip Arthroplasty Using Fourth-Generation Ceramic-On-Ceramic Articulations: Does Articular Noise Increase Over Time? J Arthroplasty 2024:S0883-5403(24)00454-6. [PMID: 38735552 DOI: 10.1016/j.arth.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND We previously reported the mean 6-year outcomes of total hip arthroplasty (THA) using fourth-generation ceramic-on-ceramic (CoC) articulations. With extended observations, this study aimed to report the mean 12-year outcomes focusing on bearing-related complications of CoC THA. METHODS We reviewed primary CoC THAs performed between May 2009 and April 2012 at a single institution. Of the 831 hips (739 patients), 716 hips (635 patients) that satisfied a minimum 10-year follow-up were included. The mean age at operation was 54 years (range, 16 to 83). The occurrence of bearing-specific complications, including ceramic fractures and noise generation, was evaluated. The mean follow-up duration was 12 years (range, 10 to 14). RESULTS A total of 2 (0.3%) ceramic liner fractures occurred, as previously reported. No additional ceramic fractures were observed during the extended follow-up period. However, the cumulative incidence of audible noise increased from 6.4 (48 of 749) to 8.2% (59 of 716). Of the 59 hips with noise, 26 (44.1%) developed noise within 1 year, whereas 13 (22.0%) presented with noise more than 5 years after THA. The noise was described as clicking in 35 hips (4.9%) and as squeaking in 24 hips (3.4%). No revision surgeries were performed for noise, except in 2 cases of concomitant liner fractures. The implant survivorship free of any revision was 98.1% at 12 years. CONCLUSIONS No additional ceramic fractures were identified in this extension study at a minimum follow-up of 10 years. However, the prevalence of articular noise has increased from 6.4 to 8.2% since the previous report. Possible late-onset noise should be considered when performing CoC THA in younger patients.
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Affiliation(s)
- Chan-Woo Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Jin Jeong
- Department of Orthopedic Surgery, Myongji hospital, Hanyang University School of Medicine, Goyang, South Korea
| | - Kyungjun Cho
- Department of Orthopedic Surgery, Osan Hankook Hospital, Osan, South Korea
| | - Si Yeon Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Jae Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Youn-Soo Park
- Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Wu T, Guo S, Jiang Y, Shi W, Wang Y, Li T. Ceramic fragmentation after total hip arthroplasty: two case reports and literature review. Front Surg 2024; 11:1357301. [PMID: 38444899 PMCID: PMC10912464 DOI: 10.3389/fsurg.2024.1357301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/09/2024] [Indexed: 03/07/2024] Open
Abstract
Background Ceramic fragmentation is a rare but serious complication after total hip arthroplasty (THA). We reviewed the PubMed literature from 1990 to 2023 and found only 31 case reports of ceramic fragmentation after THA. Our case reports help to expand understanding of this rare complication. We shared our surgical experience and identified an ideal material for revision surgery, which can serve as a useful reference for other orthopedic surgeons to perform ceramic fragmentation revision surgery in the future. We also analyzed the possible causes, diagnosis, and treatment opinions of ceramic fragmentation. Case presentation This study presents two cases of ceramic fragmentation after THA. One patient had ceramic head fragmentation 10 years after the primary THA, and one patient had ceramic liner fragmentation 5 years after the primary THA. Both patients presented with pain, and one patient also reported a clicking sound in the hip. The two patients described here had BMIs of 23.7 and 23.1, respectively. Both patients' ceramic fragmentation were due to aseptic loosening, not periprosthetic joint infections, as confirmed by negative microbiological cultures. Radiographic examinations of both patients revealed radio-opaque wear debris around the hip joint prostheses and we describe the surgical protocols and intraoperative findings in both cases in detail. Conclusion Our cases and the literature suggest that ceramic fragmentation can occur at any time after THA. The most immediate symptoms are pain and noise, but some patients may be asymptomatic. Ceramic on polyethylene bearings is recommended for revision surgery whenever possible; metal bearings should be avoided.
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Affiliation(s)
- Tingyu Wu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Sijia Guo
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yaping Jiang
- Department of Oral Implantology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Weipeng Shi
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yingzhen Wang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Osawa Y, Seki T, Takegami Y, Okamoto M, Iida H, Imagama S. Extension of the Antero-Posterior Necrotic Regions Associated With Collapse Cessation in Osteonecrosis of the Femoral Head. J Arthroplasty 2024; 39:387-392. [PMID: 37574032 DOI: 10.1016/j.arth.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Collapse cessation is of utmost importance following a long period of collapse due to osteonecrosis of the femoral head (ONFH). This study investigated the relationship between collapse cessation and the extent of the necrotic regions of ONFH. METHODS Overall, 74 patients who had symptomatic ONFH (collapse < 3 mm) at the first visit with a minimum follow-up of 3 years were included in this study. Patients were categorized based on collapse progression or cessation into the progression and stable groups. The extent of the antero-posterior (AP) and medio-lateral necrotic regions between the groups was assessed using sagittal and coronal sections of T1-magnetic resonance imaging. Additionally, the most effective cutoff value was determined from the receiving operating characteristic curve where collapse cessation could be obtained, while the survival rates were determined with collapse progression as the endpoints were evaluated. RESULTS Overall, 45 and 29 patients were in the progression and stable groups, respectively. The AP and medio-lateral necrotic regions were significantly different (P < .01 and P < .01, respectively) between the progression and stable groups. A cutoff value of 62.1% of the AP necrotic regions was determined from the receiving operating characteristic curve analysis. The 5-year survival rates with collapse progression as the endpoints were 5.4 and 77.8% in the AP necrotic regions of ≥62.1 and <62.1%, respectively (P < .01). CONCLUSIONS Cases with AP necrotic regions of ≤62.1% can be expected to have collapse cessation, which could be a useful index for ONFH treatment strategies. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Taisuke Seki
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masanori Okamoto
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroki Iida
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Kim HS, Lee HJ, Lee SJ, Yoo JJ. Ceramic-on-Ceramic or Metal-on-Polyethylene: The Bearing of Choice after Ceramic Component Fracture in Total Hip Arthroplasty along with Concise Follow-Up of the Previous Cohort. Orthop Surg 2023; 15:2864-2871. [PMID: 37749775 PMCID: PMC10622264 DOI: 10.1111/os.13889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE We previously reported the questionable result of reoperation using metal-on-polyethylene (MoP) bearing after the fracture of the ceramic component. After the report, we abandoned the use of MoP; instead, we used ceramic-on-ceramic (CoC) bearing. This report aimed to present the outcome of reoperation to CoC bearing after ceramic component failures along with the longer-term outcome of the previously reported cohort with an MoP bearing. RESULTS The mean follow-up of the MoP cohort was extended from 4.3 years to 8.8 years. Metallosis had occurred in three of nine patients of the previous cohort, which all required re-reoperations. Two hips from 11 patients with revision to CoC had re-reoperations due to ceramic liner fracture and non-union of the osteotomized fragment, respectively. No metallosis and wear occurred in the cohort revised with CoC articulation. Otherwise, there were no adverse changes in radiographs and no impairment in functions. METHODS We conducted an extended prospective evaluation of a previous cohort consisting of six head fractures and three liner fractures. In this cohort, the patients underwent a bearing change to metal-on-polyethylene. Additionally, we retrospectively analyzed 11 cases of third-generation ceramic bearing fractures, comprising nine head fractures and two liner fractures. These cases were subsequently treated with a bearing change to fourth-generation CoC. We assessed clinical and radiological outcomes, including complication rates, in both groups. CONCLUSION We recommend the latest CoC as the bearing of choice in reoperation after the fracture of ceramic components. In the case of an MoP bearing after the ceramic component fracture, the risk of metallosis seemed high in the early postoperative period.
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Affiliation(s)
- Hong Seok Kim
- Department of Orthopedic SurgerySeoul National University HospitalSeoulSouth Korea
- Department of Orthopedic Surgery, College of MedicineSeoul National UniversitySeoulSouth Korea
| | - Han Jin Lee
- Department of Orthopedic SurgeryHanil General HospitalSeoulSouth Korea
| | - Soong Joon Lee
- Department of Orthopedic Surgery, SMG‐SNU Boramae Medical CenterSeoul National University College of MedicineSeoulSouth Korea
| | - Jeong Joon Yoo
- Department of Orthopedic SurgerySeoul National University HospitalSeoulSouth Korea
- Department of Orthopedic Surgery, College of MedicineSeoul National UniversitySeoulSouth Korea
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Shen X, Luo J, Tang X, Chen B, Qin Y, Zhou Y, Xiao J. Deep Learning Approach for Diagnosing Early Osteonecrosis of the Femoral Head Based on Magnetic Resonance Imaging. J Arthroplasty 2023; 38:2044-2050. [PMID: 36243276 DOI: 10.1016/j.arth.2022.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The diagnosis of early osteonecrosis of the femoral head (ONFH) based on magnetic resonance imaging (MRI) is challenging due to variability in the surgeon's experience level. This study developed an MRI-based deep learning system to detect early ONFH and evaluated its feasibility in the clinic. METHODS We retrospectively evaluated clinical MRIs of the hips that were performed in our institution from January 2019 to June 2022 and collected all MRIs diagnosed with early ONFH. An advanced convolutional neural network (CNN) was trained and optimized; then, the diagnostic performance of the CNN was evaluated according to its accuracy, sensitivity, and specificity. We also further compared the CNN's performance with that of orthopaedic surgeons. RESULTS Overall, 11,061 images were retrospectively included in the present study and were divided into three datasets with ratio 7:2:1. The area under the receiver operating characteristic curve, accuracy, sensitivity, and specificity of the CNN model for identifying early ONFH were 0.98, 98.4, 97.6, and 98.6%, respectively. In our review panel, the averaged accuracy, sensitivity, and specificity for identifying ONFH were 91.7, 87.0, and 94.1% for attending orthopaedic surgeons; 87.1, 84.0, and 89.3% for resident orthopaedic surgeons; and 97.1, 96.0, and 97.9% for deputy chief orthopaedic surgeons, respectively. CONCLUSION The deep learning system showed a comparable performance to that of deputy chief orthopaedic surgeons in identifying early ONFH. The success of deep learning diagnosis of ONFH might be conducive to assisting less-experienced surgeons, especially in large-scale medical imaging screening and community scenarios lacking consulting experts.
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Affiliation(s)
- Xianyue Shen
- Department of Orthopedics, The Second Hospital of Jilin University
| | - Jia Luo
- College of software, Jilin University
| | - Xiongfeng Tang
- Department of Orthopedics, The Second Hospital of Jilin University
| | - Bo Chen
- Department of Orthopedics, The Second Hospital of Jilin University
| | - Yanguo Qin
- Department of Orthopedics, The Second Hospital of Jilin University
| | - You Zhou
- College of software, Jilin University
| | - Jianlin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, Jilin province, PR China
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11
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Moon JK, Lee S, Kim CH, Yoon JY, Lee S, Lee KS, Yoon PW. Forte ceramic-on-delta ceramic cementless total hip arthroplasty: an 8- to 15-year follow-up study. Arch Orthop Trauma Surg 2023; 143:5475-5483. [PMID: 36871241 DOI: 10.1007/s00402-023-04793-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/22/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Forte ceramic head on delta ceramic liner articulation showed satisfactory midterm results without ceramic-related complication. We aimed to investigate the clinical and radiological outcomes of cementless total hip arthroplasty (THA) with forte ceramic head on delta ceramic liner articulation. MATERIALS AND METHODS Overall, 107 patients (57 men, 50 women; 138 hips) who underwent cementless THA with forte ceramic head on delta ceramic liner articulation were enrolled. The mean follow-up duration was 11.6 years. For the clinical assessments, Harris hip score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), presence of thigh pain, and presence of squeaking were evaluated. Radiographs were assessed to search for osteolysis, stem subsidence, loosening of implants. Kaplan-Meier survival curves were evaluated. RESULTS The mean HHS and WOMAC improved from 57.1 and 28.1 preoperatively to 81.4 and 13.1 at the final follow-up, respectively. Nine revisions (6.5%) were performed; 5 hips for stem loosening, 1 hip for ceramic liner fracture, 2 hips for periprosthetic fracture, and 1 hip for progressive osteolysis around cup and stem. Thirty-two patients (37 hips) complained squeaking, in which 4 cases (2.9%) were identified as ceramic-related noises. After a mean follow-up period of 11.6 years, 91% (95% CI 87.8-94.2) were free from revision of both femoral and acetabular components due to any reason. CONCLUSIONS Cementless THA with forte ceramic-on-delta ceramic articulation showed acceptable clinical and radiological results. Serial surveillance of these patients should be performed due to the possibility of cerami- related complications such as squeaking, osteolysis, and ceramic liner fracture.
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Affiliation(s)
- Jun-Ki Moon
- Department of Orthopedic Surgery, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University, Gwangmyeong, Republic of Korea
| | - Seonjeong Lee
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, College of Medicine, Chung-Ang University Hospital, Chung-Ang University, Seoul, Republic of Korea
| | - Jae Youn Yoon
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Ilsan, Republic of Korea
| | - Sunhyung Lee
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Kang-Sik Lee
- Biomedical Engineering Research Center, Asan Institute For Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Pil Whan Yoon
- Department of Orthopedic Surgery, Asan Medical Center, College of Medicine, Ulsan University, Asan Medical Center 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
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12
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Ouyang W, Meng Y, Guo G, Zhao C, Zhou X. Efficacy and safety of traditional Chinese medicine in the treatment of osteonecrosis of the femoral head. J Orthop Surg Res 2023; 18:600. [PMID: 37580744 PMCID: PMC10424453 DOI: 10.1186/s13018-023-04086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Hip joint-preserving treatment options for osteonecrosis of the femoral head (ONFH) have been a research hotspot in recent years. The combination of Chinese and Western medicine has been used in clinical practice to treat early- and mid-stage ONFH. However, there is still a lack of high-quality evidence to verify the effectiveness and safety of this approach. OBJECTIVE To systematically evaluate the clinical efficacy and safety of the combination of traditional Chinese medicine (TCM) with Western medicine in the treatment of early- and mid-stage ONFH. METHODS Multiple electronic databases were searched to identify the randomized controlled trials (RCTs) examining the use of TCM in the treatment of ONFH. Based on the inclusion and exclusion criteria, eligible studies were selected, and the quality of the studies was evaluated using the risk of bias assessment tool recommended by the Cochrane system Evaluator manual 5.1.0. The meta-analysis of the included data was performed using Review Manager 5.4.1 software and Stata 17.0 software. RESULTS A total of 47 RCTs involving 3266 subjects were included in the meta-analysis. The results are observed: (1) Harris score: TCM + Western medicine versus Western medicine (SMD = 1.25, 95% Cl: 1.02 to 1.48, P < 0.00001), TCM + physiotherapy versus physiotherapy (SMD = 2.26, 95% Cl: 1.42 to 3.10, P < 0.00001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = 1.28, 95% Cl: 1.03 to 1.53, P < 0.00001); (2) Visual analogue scale score: TCM + Western medicine versus Western medicine (SMD = -3.99, 95% Cl: -7.41 to -0.57, P = 0.02), TCM + physiotherapy versus physiotherapy (SMD = -0.99, 95% Cl: -1.44 to -0.54, P < 0.0001), and TCM + hip preservation surgery versus hip preservation surgery (SMD = -1.08, 95% Cl: -1.75 to -0.40, P = 0.002); (3) Imaging improvement: TCM + physiotherapy versus physiotherapy (RR = 1.42, 95% Cl: 1.15 to 1.76, P = 0.001) and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.21, 95% Cl: 1.11 to 1.31, P < 0.0001); and (4) Occurrence of adverse reaction: TCM + Western medicine versus Western medicine (RR = 0.73, 95% Cl: 0.28 to 1.92, P = 0.53), TCM + physiotherapy versus physiotherapy (RR = 0.46, 95% Cl: 0.03 to 7.33, P = 0.58), and TCM + hip preservation surgery versus hip preservation surgery (RR = 1.11, 95% Cl: 0.36 to 3.45, P = 0.86). CONCLUSION TCM combined with Western medicine is an effective and safe approach for the treatment of ONFH. However, due to the low quality and quantity of the included studies, additional large-scale, high-quality studies are required to verify the above conclusions. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/#recordDetails , CRD42023392030.
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Affiliation(s)
- Wensi Ouyang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China
- Hospital Affiliated to Changchun University of Traditional Chinese Medicine, Changchun, 130021, China
| | - Yubo Meng
- Hospital Affiliated to Changchun University of Traditional Chinese Medicine, Changchun, 130021, China
| | - Guimei Guo
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China
- Hospital Affiliated to Changchun University of Traditional Chinese Medicine, Changchun, 130021, China
| | - Changwei Zhao
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China.
- Hospital Affiliated to Changchun University of Traditional Chinese Medicine, Changchun, 130021, China.
| | - Xiaoling Zhou
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China.
- Hospital Affiliated to Changchun University of Traditional Chinese Medicine, Changchun, 130021, China.
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13
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Li Z, Niu EL, Fu J, Zhou YG, Chai W, Hao LB, Chen JY, Xu C. A Nomogram That Characterizes a Patient's Odds of Developing Squeaking After Fourth-generation Ceramic-on-ceramic THA. Clin Orthop Relat Res 2023; 481:1322-1336. [PMID: 36749832 PMCID: PMC10263255 DOI: 10.1097/corr.0000000000002573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/05/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although ceramic-on-ceramic (CoC) bearings result in the lowest wear rate of any bearing combination, postoperative squeaking remains worrisome. However, data concerning squeaking in long-term follow-up studies are still lacking, especially for fourth-generation CoC THA. QUESTIONS/PURPOSES (1) After keeping the prosthesis in place for 10 years, what percentage of patients treated with fourth-generation CoC THA implants report squeaking, and are there points in time when squeaking occurs more frequently? (2) What are the characteristics, association with hip function, and factors associated with squeaking? (3) Can we create a nomogram that characterizes a patient's odds of experiencing squeaking based on the factors associated with it? METHODS Between January 2009 and December 2011, 1050 patients received primary THAs at our institution, 97% (1017) of whom received fourth-generation CoC THAs because this was the preferred bearing during this period. Of the 1017 eligible patients, 5% (54) underwent THAs performed by low-volume surgeons, 3% (30) were implanted with cemented prostheses, 2% (22) died, 1% (10) were immobile, 1% (six) underwent revision surgery, and 17% (169) were lost to follow-up before 10 years, leaving 726 patients for analysis here at a mean of 11 ± 1 years. In the study cohort, 64% (464) were male and 36% (262) were female, with a mean age of 44 ± 13 years at primary THA. We extracted data about articular noise from follow-up records in our institutional database and used a newly developed questionnaire to ascertain the percentage of patients who reported squeaking at the latest follow-up interval. Although not validated, the questionnaire was modeled on previous studies on this topic. The longitudinal pattern for squeaking was explored to find timepoints when squeaking occurs more frequently. Based on the questionnaire data, we calculated the percentages of frequent, reproducible, and avoidable squeaking. Hip function was evaluated with the Harris Hip Score and WOMAC score and compared between the squeaking and nonsqueaking groups. Factors associated with squeaking, which were examined in a multivariate analysis, were used to develop a nomogram. RESULTS At 10 years, 16% (116 of 726) of patients reported squeaking. Two squeaking peaks were determined, at 0 to 1 year and 8 to 10 years. Frequent, reproducible, and avoidable squeaking accounted for 42% (36 of 86), 20% (17 of 86), and 41% (35 of 86), respectively. The mean Harris Hip Score (93 ± 4 versus 94 ± 5; p = 0.81) and WOMAC score (16 ± 13 versus 15 ± 13; p = 0.23) did not differ between patients with squeaking and those without. After controlling for potential confounding variables such as etiology and head offset, we found that patients younger than 46 years (odds ratio 2.5 [95% confidence interval 1.5 to 5.0]; p < 0. 001), those who were male (OR 2.0 [95% CI 1.1 to 3.5]; p = 0.04), those having a total flexion and extension arc of less than 50° (OR 2.0 [95% CI 1.2 to 3.3]; p = 0.02), and those with the Corail hip implant (OR 4.1 [95% CI 2.1 to 7.7]; p < 0. 001) were more likely to report squeaking. We created a nomogram that can be used at the point of care that can help clinicians identify patients at a higher risk of experiencing squeaking; this nomogram had good performance (area under the receiver operating characteristic curve of 77%). CONCLUSION As a potential late complication, squeaking after fourth-generation CoC THA is of concern and may be related to increased stripe wear. We recommend that surgeons use this nomogram to assess the odds of squeaking before selecting a bearing, especially in patients at high risk, to facilitate shared decision-making and improve patient satisfaction. Future external validation of the model is still needed to enhance its applicability.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Zhuo Li
- School of Medicine, Nankai University, Tianjin, PR China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Er-Long Niu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- 305 Hospital of PLA, Beijing, PR China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Yong-Gang Zhou
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Wei Chai
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Li-Bo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Ji-Ying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
| | - Chi Xu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, PR China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, PR China
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Osawa Y, Takegami Y, Kato D, Okamoto M, Iida H, Imagama S. Hip function in patients undergoing conservative treatment for osteonecrosis of the femoral head. INTERNATIONAL ORTHOPAEDICS 2023; 47:89-94. [PMID: 36102980 DOI: 10.1007/s00264-022-05569-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Once collapsed, osteonecrosis of the femoral head (ONFH) generally obtains collapse cessation naturally and surgical intervention can be avoided in the long term. This study aimed to investigate the process of hip function and secondary osteoarthritis changes in ONFH patients undergoing conservative treatment. METHODS We included 54 patients with symptomatic ONFH at the first visit with a minimum follow-up of three years with conservative treatment. Patients were divided into two groups based on collapse cessation < 3 mm (stable group) or progression to > 3 mm (progression group). Additionally, we investigated age, sex, body mass index (BMI), etiology, contralateral side hip joint, the Japanese Investigation Committee (JIC) type classification, Harris hip score (HHS), Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ), and survival rate with secondary osteoarthritis as the endpoint. RESULTS The stable and progression groups had 31 and 23 patients, respectively. No significant differences in age, sex, BMI, and aetiology were observed between the two groups, except for the contralateral side hip joint and JIC type classification. The HHS and JHEQ were significantly improved at the final follow-up than at the first visit in the stable group. However, there were no significant differences in HHS and JHEQ at the final follow-up than at the first visit in the progression group. The five year survival rates with secondary osteoarthritis as the endpoint were significantly higher in the stable group (100%) than in the progression group (32.5%). CONCLUSION Hip joint function improved by continuing conservative treatment in ONFH patients with collapse cessation < 3 mm.
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Affiliation(s)
- Yusuke Osawa
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Daisaku Kato
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masanori Okamoto
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Iida
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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