Göran O. Sjödén

Case reports: two femoral insufficiency fractures after long-term alendronate therapy.

Bisphosphonates are widely used for treatment of postmenopausal osteoporosis. Although short-term safety and efficacy of these drugs have been investigated and documented, an increasing number of recent reports draw attention to the possible correlation between long-term alendronate therapy and the occurrence of insufficiency fractures in the proximal femur owing to what is known as severely suppressed bone turnover. We describe two femoral insufficiency fractures in two women receiving long-term alendronate therapy. The first woman sustained a periprosthetic fracture at the tip of the femoral stem whereas the other woman had a fracture in the subtrochanteric region. We analyze the characteristics and natural course of these two unique fractures, and emphasize the importance of being aware of the possible correlation between long-term alendronate therapy and insufficiency femoral fractures.

Subtrochanteric displaced insufficiency fracture after long‐term alendronate therapy—a case report

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Pressure-pain threshold algometric measurement in patients with greater trochanteric pain after total hip arthroplasty.

BackgroundThe evaluation of tenderness associated with greater trochanteric pain (GTP) syndrome is amenable to bias and depends on the examiners experience. In this study, we tested whether the use of an electronic pressure algometer enhanced the reliability of this evaluation. Patients and MethodsPressure-pain threshold (PPT) was measured with an electronic algometer in 18 patients who developed GTP after total hip arthroplasty and in matched controls. Both groups were evaluated with visual analog scale. ResultsThe PPT measurements showed large interindividual variability across patients. The correspondence of the PPT measurements in asymptomatic patients was good. We found good validity for the algometer used. The PPT ratio of 0.8 (affected vs. unaffected side) can be used as a cut-off ratio. The PPT measurements at the greater trochanter (local pain) were significantly lower than at the ilio-tibial band (radiated pain). There was no correlation between PPT measurements and visual analog scales. Despite the acceptable sensitivity and specificity of pressure algometer, because of low positive predictive value and large interindividual variability, pressure algometer has a limited value as a screening test. ConclusionsThe examination of tenderness associated with GTP is facilitated by the used algometer. It is the intraindividual body-side PPT differences that yield the most sensitive measurement for the assessment of deep pain. A cut-off value of 0.8 can be used for diagnostic purposes. Interindividual differences might be considerable and could mask pathologic diagnostic findings.

Greater trochanteric pain after total hip arthroplasty: the incidence, clinical outcome and associated factors.

We evaluated any residual pain around the hip joint 11 to 23 months post-surgery in 172 consecutive patients who underwent total hip arthroplasty (THA) for primary or secondary osteoarthritis during 2002 at Sundsvall Hospital, Sweden. Patients with suspected greater trochanteric pain (GTP) were matched with controls from the same cohort. The two groups were assessed with the Western Ontario and McMaster Universities Arthrosis Index (WOMAC) and were examined for localised tenderness over the trochanteric area by algometer. The pre- and postoperative radiographs including femoral offset were evaluated. We found that 21 patients (12%) had GTP with a male to female ratio of 1:6. The WOMAC index revealed a reduction in the clinical outcome in this group. An associated factor of significance was postoperative uncorrected lengthening of the operated limb equal to or more than one centimetre. We found no correlation between the prevalence of GTP and body weight or length, femoral offset or size of the prosthetic components used.

Dual mobility cups for preventing early hip arthroplasty dislocation in patients at risk: experience in a county hospital

Dislocation remains a major concern after hip arthroplasty. We asked whether dual mobility cups (DMC) would improve early hip stability in patients with high risk of dislocation. We followed 34 patients (21 females, 13 males) treated between 2009 and 2012 with cemented DMC for hip revisions caused recurrent hip prosthetic dislocation or as a primary procedure in patients with high risk of instability. Functional outcome and quality of life were evaluated using Harris Hip Score and EQ-5D respectively. We found that the cemented DMC gave stability in 94%. Seven patients (20%) were re-operated due to infection. One patient sustained a periprosthetic fracture. At follow-up (6 to 36 months, mean 18), the mean Harris hip score was 67 (standard deviation: 14) and mean EQ-5D was 0.76 (standard deviation: 0.12). We concluded that treating patients with high risk of dislocation with DMC can give good stability. However, complications such as postoperative infection can be frequent and should be managed carefully.

Clinical and radiological outcome of the Total Evolutive Shoulder System (TESS®) reverse shoulder arthroplasty: a prospective comparative non-randomised study.

PurposeThe aims of this study were to assess the function and quality of life after the Total Evolutive Shoulder System (TESS) reverse shoulder arthroplasty (RSA), to evaluate the radiological stability of the stemless version and to address the effect of arm lengthening and scapular notching (SN) on the outcome.MethodsThis was a prospective comparative non-randomised study. A total of 37 consecutive patients (40 shoulders) underwent TESS RSA between October 2007 and January 2012; 16 were stemless and 26 were stemmed. At a mean follow-up of 39 months (15–66), we evaluated range of motion (ROM), pain and functional outcome with QuickDASH and quality of life with EQ-5D score. Radiologically, component positioning, signs of loosening, SN and arm length difference were documented.ResultsWe found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. No humeral loosening was evident, but there were four glenoid loosenings. In 12 shoulders that developed SN, seven already had scapular bone impression (SBI) evident on initial post-operative radiographs. Glenoid overhang seemed to decrease the risk of SN. Arm lengthening was associated with better EQ-5D but did not influence ROM or functional outcome.ConclusionsReverse shoulder arthroplasty markedly improved shoulder function. SN is of concern in RSA, but proper positioning of the glenoid component may prevent its development.

Cortical comminution in distal radial fractures can predict the radiological outcome

This paper investigates whether cortical comminution and intra-articular involvement can predict displacement in distal radius fractures by using a classification that includes volar comminution as a separate parameter. A prospective multicentre study involving non-operative treatment of distal radius fractures in 387 patients aged between 15 and 74 years (398 fractures) was conducted. The presence of cortical comminution and intra-articular involvement according to the Buttazzoni classification is described. Minimally displaced fractures were treated with immobilisation in a cast while displaced fractures underwent closed reduction with subsequent immobilisation. Radiographs were obtained after reduction, at 10 to 14 days and after union. The outcome measure was re-displacement or union. In fractures with volar comminution (Buttazzoni type 4), 96% (53 of 55) displaced. In intra-articular fractures without volar comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106 of 145) displaced while in non-comminuted fractures (Buttazzoni 1), 16 % (13 of 81 ) displaced. A total of 32% (53 of 165) of initially minimally displaced fractures later displaced. All of the initially displaced volarly comminuted fractures re-displaced. Displacement occurred in 31% (63 of 205) of fractures that were still in good alignment after 10 to 14 days. Regression analysis showed that volar and dorsal comminution predicted later displacement, while intra-articular involvement did not predict displacement. Volar comminution was the strongest predictor of displacement.

Severe Metallosis After Total Elbow Arthroplasty—A Case Report

We present a case of severe metallosis after total elbow arthroplasty in a female patient presenting with manifestations resembling a septic loosening. We discuss the clinical and the operative findings as well as the outcome of this uncommon complication. A review of the literature regarding the pathogenesis, radiographic appearance, and management of metallosis in prosthetic joints is presented.

Association of lateral humeral offset with functional outcome and geometric restoration in stemless total shoulder arthroplasty

BACKGROUND Restoration of shoulder geometry is desirable in total shoulder arthroplasty (TSA) and thought to influence the postoperative clinical outcome. We aimed to study the association of postoperative lateral humeral offset (LHO) changes and clinical outcome, as well as to investigate the ability of stemless anatomic TSA to restore shoulder geometry. METHODS In patients with primary shoulder osteoarthritis who underwent stemless anatomic TSA, the preoperative and postoperative clinical outcome was measured. Shoulder geometry was measured on preoperative computed tomography for the osteoarthritic shoulder and contralateral healthy shoulder and on postoperative computed tomography for the operated shoulder. RESULTS Forty-four patients with a minimum follow-up of 12 months (range, 12-50 months) were available for the study. Postoperatively, the clinical outcome measures improved. The postoperative difference in LHO between the operated shoulder and contralateral healthy shoulder was 1.3 ± 4.6 mm and was correlated with scores on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire at 3 months (Pearson correlation = 0.36, P = .01) and visual analog scale for pain at rest (Pearson correlation = 0.30, P = .03) and with exertion (Pearson correlation = 0.34, P = .01) at 3 months. Lengthening of LHO was associated with worsening shoulder function at 3 months but not at 12 months. The postoperative shoulder geometric parameters were restored postoperatively to acceptable ranges. CONCLUSION The stemless anatomic TSA could restore shoulder geometry in an acceptable manner. At 3 months but not at 12 months, increased LHO had a negative effect on shoulder function and resulted in more shoulder pain at rest and with exertion but did not affect quality of life, health status, or range of motion.

Radiologic assessment of glenohumeral relationship : reliability and reproducibility of lateral humeral offset

BackgroundIt has been shown that anatomical reconstruction is an important step in achieving good function after shoulder arthroplasty. It is essential to reconstruct the distance between the coracoid process and greater tubercle as this relates to the moment arm of the deltoid and rotator cuff muscles. This study evaluated the reliability of measurement of the lateral humeral offset (LHO) on plain radiographs and on computed tomography (CT).MethodsFour independent observers performed measurements of LHO on radiographs and CT from 26 patients awaiting shoulder reconstruction. The interobserver reliability and intraobserver reproducibility were assessed.ResultsInterobserver reliability and intraobserver reproducibility of LHO in axial CT scans were excellent. Plain radiography showed fair to excellent interobserver reliability and variable intraobserver reproducibility.ConclusionCT is a reliable tool to measure LHO supporting its use in preoperative planning. When AP radiography is used for preoperative planning the examiner should be aware of its limitations and standardisation protocols should be considered.