Yong-Chan Ha

Ceramic liner fracture after cementless alumina-on-alumina total hip arthroplasty.

Advances in technology have reduced the risk of fracture of ceramic total hip arthroplasty implants, but concerns remain about fracture of both components. We retrospectively reviewed 133 patients (157 hips) who had cementless alumina-on-alumina total hip arthroplasties with a sandwich-type acetabular component. Six patients (seven hips) died and five patients (six hips) were interviewed by telephone (95% followup). The 122 patients (144 hips) examined had a minimum followup of 36 months (average, 45 months; range, 36-68 months). All acetabular cups and femoral stems were radiographically stable at the last followup. Five hips in five patients (3.5%) were revised because of ceramic liner fractures. Ceramic liner fractures occurred at a mean of 35 months (range, 24-48 months) postoperatively. Acetabular cups in the fracture group (n = 5) were more anteverted than those in the nonfracture group (n = 139). In three patients the fracture apparently occurred during squatting, resulting in hyperflexion and wide hip abduction. Early ceramic liner fracture was associated with impingement associated with excessive anteversion of the acetabular cup in Korean patients who habitually squat.Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Isolated fracture of the ceramic head after third-generation alumina-on-alumina total hip arthroplasty.

BACKGROUND While most reports of component fracture following alumina-on-alumina total hip arthroplasty have involved the acetabular liner, few have involved fracture of the alumina femoral head. In the present multicenter study, we investigated ceramic head fractures in a cohort of patients who underwent third-generation alumina-on-alumina total hip arthroplasty. METHODS We performed a retrospective study of 312 patients (367 hips) who underwent alumina-on-alumina total hip arthroplasty without cement at four participating centers with the use of a 28-mm BIOLOX forte femoral head and a BIOLOX forte liner from July 2001 to October 2003. Three hundred and five patients (359 hips) were evaluated at a mean of forty-five months postoperatively. Clinical follow-up with use of the Harris hip score and radiographic evaluation were performed at six weeks; at three, six, and twelve months; and every six months thereafter. Retrieved ceramic implants were examined by means of visual inspection. RESULTS Five hips (1.4%) in five patients were revised because of a ceramic head fracture during the follow-up period. The ceramic head fractures occurred during normal daily activities at a mean of 22.6 months postoperatively. A short neck had been used in all five hips in which a fracture occurred, compared with 121 (34.2%) of the 354 hips in which a fracture did not occur (p = 0.009). The fracture involved a circular crack along the circumference of the thinnest portion of the head component at the proximal edge of the bore. The fracture also involved multiple vertical cracks extending radially along the longitudinal axis from the circumference of the circular crack line to the lower edge of the head component. CONCLUSIONS In the present study, the rate of ceramic head fracture associated with one design of a short-neck modular alumina femoral head was 1.4% (five of 359). The extent to which these findings are generalizable to other designs that utilize this type of femoral head is unknown.

Prediction of Collapse in Femoral Head Osteonecrosis: A Modified Kerboul Method with Use of Magnetic Resonance Images

BACKGROUND The hypothesis that the combined necrotic angle measurement from magnetic resonance imaging scans predicts the subsequent risk of collapse in hips with femoral head necrosis was tested. METHODS Thirty-seven hips with early stage osteonecrosis in thirty-three consecutive patients were investigated. With use of the modified method of Kerboul et al., we measured the arc of the femoral surface involved by necrosis on a midcoronal as well as a midsagittal magnetic resonance image (rather than an anteroposterior and a lateral radiograph) and then calculated the sum of the angles. On the basis of the magnitude of the resulting combined angle, hips were classified into four categories: grade 1 (<200 degrees), grade 2 (200 degrees to 249 degrees), grade 3 (250 degrees to 299 degrees), and grade 4 (>/=300 degrees). After the initial evaluations, the hips were randomly assigned to a core decompression group or a nonoperative group. Patients underwent regular follow-up until femoral head collapse or for a minimum of five years. RESULTS Seven grade-4 hips and sixteen grade-3 hips had development of femoral head collapse by thirty-six months. Six of the nine grade-2 hips and none of the five grade-1 hips collapsed (log-rank test, p < 0.01). None of the four hips with a combined necrotic angle of </=190 degrees (the low-risk group) collapsed, all twenty-five hips with a combined necrotic angle of >/=240 degrees (the high-risk group) collapsed, and four (50%) of the eight hips with a combined necrotic angle between 190 degrees and 240 degrees (the moderate-risk group) collapsed during the study period. CONCLUSIONS The Kerboul combined necrotic angle, as ascertained with use of magnetic resonance imaging scans instead of radiographs, is a good method to assess future collapse in hips with femoral head osteonecrosis. LEVEL OF EVIDENCE Prognostic Level I. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Incidence and mortality following hip fracture in Korea.

The authors evaluated the incidence of hip fracture and subsequent mortality in Korea using nationwide data obtained from the Health Insurance Review and Assessment Service. This study was performed on patient population, aged 50-yr or older who underwent surgical procedures because of hip fracture (ICD10; S720, S721). All patients were followed using patient identification code to identify deaths. Crude hip fracture rates increased from 191.9/100,000 in 2005 to 207.0/100,000 in 2008 in women and from 94.8/100,000 in 2005 to 97.8/100,000 in 2008, in men respectively. Crude mortality within 12 months after hip fracture showed a similar trend (18.8% in 2005 and 17.8% in 2007). The mean of standardized mortality ratio of hip fracture was 6.1 at 3 months, 3.5 at 1 yr, and 2.3 at 2 yr post-fracture. The increasing incidence and the high mortality after hip fracture are likely to become serious public health problems and a public health program should begin to prevent hip fractures in Korea.

Alumina-on-alumina total hip arthroplasty: a concise follow-up, at a minimum of ten years, of a previous report.

We previously reported the five-to-six-year results of the use of third-generation alumina-on-alumina bearings in a consecutive series of 100 primary cementless total hip arthroplasties. This report presents the longer-term outcomes of these same bearings, at a minimum of ten years postoperatively. Eighty-six of eighty-eight hips available for the study retained the original bearings at the time of the latest follow-up. Thirteen hips were associated with noise, and six hips demonstrated fretting of the femoral neck on radiographs. Two hips required a change of the bearings because of a ceramic head fracture. The ten-year survival rate of the alumina-on-alumina total hip prostheses, with revision of any implant for any reason as the end point, was 99.0%. On the basis of those results, we concluded that the rate of survival of primary cementless total hip prostheses with third-generation alumina-on-alumina bearings is excellent at ten years. However, the risk of ceramic fracture, noise, and impingement between the metal neck and the ceramic liner should be a concern to surgeons, and patients should be informed of these risks before surgery.

Bisphosphonate use and increased incidence of subtrochanteric fracture in South Korea: results from the National Claim Registry

SummaryWe evaluated trends in the incidences of typical and atypical hip fracture in relation to bisphosphonate use in Korea from 2006 to 2010, using nationwide data obtained from the Health Insurance Review and Assessment Service (HIRA).IntroductionRecently, atypical hip fractures in the subtrochanteric region have been reported among patients on bisphosphonate. However, the association between atypical hip fracture and bisphosphonate is controversial. We evaluated trends in the incidences of typical and atypical hip fracture in relation to bisphosphonate use in Korea from 2006 to 2010, using nationwide data obtained from the HIRA.MethodsAll new visits or admissions to clinics or hospitals for a typical and atypical hip fractures were recorded nationwide by HIRA using the ICD-10 code classification. Typical and atypical hip fractures were defined as femoral neck/intertrochanteric and subtrochanteric fracture, respectively. Bisphosphonate prescription data were also abstracted from the HIRA database.ResultsThe absolute number of typical and atypical hip fracture increased during the study period. Although age-adjusted incidence rates of typical hip fractures were stable in men and women, those of atypical hip fractures increased in women. Nationally, the annual numbers of prescriptions of bisphosphonate also increased during the study period.ConclusionsThe results of this study suggest a possible causal relationship between bisphosphonate use and the increased incidence of atypical hip fracture in Korea.

Dislocation After Total Hip Arthroplasty: A Randomized Clinical Trial of a Posterior Approach and a Modified Lateral Approach

We compared the dislocation rate of total hip arthroplasty between posterior approach and lateral approach in a prospective randomized trial. One hundred ninety-six hips were randomly chosen for a posterior approach with a posterior soft tissue repair (99 hips) or a lateral approach (97 hips). The average duration of follow-up was 37.9 months. Three hips (3%) dislocated in the lateral group, whereas none from the posterior group dislocated. At the final follow-up, the Harris hip score and limping were similar in the 2 groups. The joint stability obtained by the posterior soft tissue repair in the posterior approach group seemed to produce more favorable result when compared to the stability obtained from the lateral approach group.

Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures

This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (SD 4.4), 12.9 weeks (SD 6.2) and 12.3 weeks (SD 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups. This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications.

Effectiveness of Multimodal Pain Management After Bipolar Hemiarthroplasty for Hip Fracture: A Randomized, Controlled Study

BACKGROUND Appropriate pain management affects outcome after hip fracture surgery. Although multimodal pain management is commonly used for pain control for patients undergoing elective surgery, few studies have evaluated its use in those undergoing hip fracture surgery. This prospective randomized study was designed to determine the clinical value of multimodal pain management with preemptive pain medication and intraoperative periarticular multimodal drug injections in patients undergoing bipolar hip hemiarthroplasty. METHODS Of eighty-two cognitively intact elderly patients about to undergo bipolar hemiarthroplasty after a hip fracture, forty-three were randomly assigned to receive preemptive pain medication and intraoperative periarticular injections (Group I) and thirty-nine were assigned to not receive preemptive medication and injections (Group II). These two groups were compared with regard to the pain level on postoperative days one, four, and seven; at discharge; and when they started walking and standing exercises. Total amounts of fentanyl used, the frequency of use of patient-controlled analgesia, patient satisfaction at discharge, and perioperative complications were recorded. RESULTS Group I had a lower pain level than Group II on postoperative days one and four, but no intergroup difference in pain level was observed on postoperative day seven. The total amount of fentanyl used and the frequency of use of patient-controlled analgesia were also lower in Group I. Patient satisfaction at discharge was higher in Group I. No significant intergroup differences were found in the times until the patients walked or performed standing exercises or in the complications. CONCLUSIONS Multimodal pain management provides additional pain relief until the fourth postoperative day, improves patient satisfaction at discharge, and reduces total narcotic consumption for postoperative pain management after hip hemiarthroplasty for hip fractures.

Persistence with intravenous zoledronate in elderly patients with osteoporosis

SummaryThe present study evaluates the proportion of patients who had re-infusion of intravenous zoledronate after first administration and identifies the factors that contribute to discontinuation.IntroductionIn terms of persistence, annual administration of zoledronate seems to overcome a shortcoming of oral bisphosphonate. However, little information is available concerning persistence with intravenous zoledronate for osteoporosis in a usual care setting. The aim of this study was to assess the persistence of intravenous zoledronate after first administration and to identify the factors that contribute to its discontinuation.MethodsA questionnaire survey concerning the second administration of zoledronate was performed on 259 patients, who had been administered with first intravenous zoledronate injection between January 2009 and December 2009, when they visit for second injection. The questionnaire asked whether patients were administered a second zoledronate injection or not, and non-persistent patients were asked why they declined the second infusion.ResultsOne hundred and ninety-two patients revisited our outpatient clinic a year after first visit, and 94 patients (36.3%, 94/259) agreed to a second injection. Of the 136 patients that completed the questionnaire, 47 refused second administration and requested a change to oral bisphosphonate. Thirty-nine of the 47 patients (83%) stated that post-infusion syndrome was the reason why they refused the second administration.ConclusionAlthough the effects of annual intravenous zoledronate are guaranteed to last for a year, this study shows that only a third of patients agree to second administration. The factors associated with discontinuation were male gender, adverse effects (especially post-infusion syndrome) and under-explanation of intravenous drug. These findings should be of concern to clinicians and indicate that patients should be informed before the administration.