Ramprasad Kancherla

Trabecular metal acetabular revision system (cup-cage construct) to address the massive acetabular defects in revision arthroplasty.

The increasing number of total hip replacements in the younger clique has added to the demand for revision procedures. Revision situations are often encountered with infection, loss of bone stock and bone defects. There are various methods of reconstruction of acetabular defects. The management options of type 3B Paprosky acetabular defects are limited with allograft and conventional cages. Trabecular metal technology has evolved to address these bone defects. Trabecular metal acetabular revision system (TMARS) cup-cage construct is a new technique to address massive acetabular defects. We describe a case of failed hip reconstruction done for a Giant cell tumour of proximal femur managed by a two stage procedure, initial debridement and second stage reconstruction of acetabulum with TMARS cup-cage construct and femur with allograft prosthesis composite.

Femoral head-neck offset in the Indian population: A CT based study.

Background: Femoroacetabular impingement has been postulated as the important cause of primary osteoarthritis in non dysplastic hips. We postulated that the rarity of primary osteoarthritis of hip in Indian population could be attributable to morphological differences, specifically to a lower prevalence of abnormal head–neck morphology. We conducted an anthropometric study to evaluate the prevalence of abnormal head–neck offset in Indian population and to correlate it with the low prevalence of primary osteoarthrosis in the Indian population. Materials and Methods: The computed tomography (CT) images of 85 apparently normal hips were analysed. An axial image was created parallel to the central axis of the femoral neck and passing through the center of the femoral head using coronal scout view. This image was then used to calculate alpha and beta angles and the head–neck offset ratio. The measurements were made by two independent observers on two different occasions. Results: The prevalence of abnormal head–neck offset ratio was 11.7% and the mean alpha and beta angles were 45.6° and 40.6°, respectively. Pearson correlation coefficients for intra-observer and inter-observer agreement were, respectively, 0.84 and 0.80 for alpha angle, 0.80 and 0.77 for beta angle and 0.78 and 0.75 for head–neck offset ratio. The values were similar to those reported in the western population. Conclusion: The differences in the prevalence of hip osteoarthritis in Indian and western populations are not attributable to variation in the prevalence of abnormal head–neck offset.

Simultaneous bilateral femoral neck stress fractures in a young military cadet: a rare case report

Simultaneous bilateral femoral neck stress fracture in healthy young adult is one of the very rare clinical entities that an orthopedic surgeon may encounter once in lifetime. Bilateral femoral neck stress fractures have been very well documented in elderly and osteomalacia patients; however, its simultaneous occurrence in a healthy adult is challenging to diagnose and manage. This article describes a 34-year-old man a military personnel who sustained bilateral stress femoral neck fractures, during a routine training activity. The patient was come to our institution, and a full endocrine evaluation was performed and proved unremarkable. He underwent closed reduction and internal fixation of the fractures using cannulated screws on both the sides. At 1-year follow-up, the fractures went on to complete union. Despite strict non-weight-bearing instructions for initial 3-month period, patient bore weight on the limbs resulting in varus union on the left side. Our case emphasizes the significance of obtaining a complete and thorough medical history on physical examination and appropriately counseling patients regarding activity level even after successful fixation.

The extremes in orthopaedics! Whom to blame?

Traditional medicines especially the herbal paste is routinely prescribed by the herb sellers. The unsupervised combinations and preparations are easily available in our part of world. The demand and supply of such irrational combination is only based on the principle that anything natural is safe. Drugs and preparations made by the people who lack the scientific knowledge of traditional herbal medicines adversely affect the consumer. We put forward few complications that resulted after herbal paste application in those who already had visited the specialist but opted the easily available unsupervised herbal preparations.

Is the increase in bone mineral density after hip resurfacing uniform across the femoral neck

We admired the work of Willis-Owen and his colleagues on bone remodelling after hip resurfacing presented in their article “Bone mineral density in the femoral neck increases after hip resurfacing: a cohort with five-year follow-up” [1]. Hip resurfacing has evolved as an alternative to total hip arthroplasty in young adults and has shown promising short- and mid-term results when prudent selection criteria were adopted. It is supposed to simulate the normal hip biomechanics and physiological bone remodelling with preservation of the proximal femoral bone stock. The authors have demonstrated an increase in the bone mineral density (BMD) of the femoral neck after hip resurfacing at five years which resembles physiological remodelling. The whole femoral neck (R1) was analysed as one region and calculations were made. Several finite-element analyses and original articles of case series in the literature reveal that bone remodelling is not uniform across the entire femoral neck [2–4]. The superolateral area adjacent to the implant has evinced a relative stress shielding [2]. Albeit, the significance and implications of differential degrees of BMD of the femoral neck have not been well defined. All the studies available have shown their results of BMD at a maximum of two years. We feel that such a prime study with a unique follow up of five years should have thrown light on this differential density and drawn some conclusions. This would have evoked more interest and provided insight into the remodelling of the femoral neck after hip resurfacing. Although the surgical procedure was described, the cementing technique used was not explained in detail. Cementing of the implant guide pin has been shown to decrease the strains in the head and neck resulting in stress shielding [5]. The level of bonding of the stem may alter the loading pattern after resurfacing. The authors have not commented on femoral neck notching and narrowing in their cases at five years follow-up as these would have gained significance amidst the factors influential in the replication of normal physiological loading and long-term implant survival. Although the limitation of not being able to correlate the BMD changes with implant positioning was acknowledged, overall information about the BMD, implant positioning, and femoral neck notching as well narrowing would have made the article more edifying. Could Willis-Owen and his colleagues please comment?

Transverse Tarsal and Tarsometatarsal Cuboid Subluxation: A Case Report

Level of Evidence: V, Expert Opinion