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Meier MP, Hawellek T, Lehmann W, von Lewinski G. [Tips and tricks of cement removal in the case of revision surgery]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:176-184. [PMID: 37855912 PMCID: PMC10896878 DOI: 10.1007/s00132-023-04453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND In Germany, current revision rates after arthroplasty range between 28-37%. In particular, remaining cement residues are causative for additional revision surgery after periprosthetic joint infection, which is why complete cement removal is of high importance. However, the removal of remaining cement residues often confronts the surgeon with technical challenges. Complication-free and complete cement removal requires extensive preoperative preparation in order to develop the best possible surgical strategy. TREATMENT Special instrument sets to facilitate cement removal in revision cases are available from various manufacturers. In addition to endoluminal approaches, access enhancements such as extended osteotomies exist to facilitate complete cement removal. Finally, the surgeon should be able to give the indication for an intraoperative procedural change after a defined time interval.
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Affiliation(s)
- Marc-Pascal Meier
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Thelonius Hawellek
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Gabriela von Lewinski
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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2
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Oyem PC, Burke ZD, Mesko NW, Nystrom LM. Custom three-dimensional printed implants for reconstruction of oncologic pelvic defects. J Surg Oncol 2024; 129:424-435. [PMID: 37754672 DOI: 10.1002/jso.27465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023]
Abstract
The use of three-dimensional printed implants in the field of orthopedic surgery has become increasingly popular and has potentiated hip reconstruction in the setting of oncologic resections of the pelvis and acetabulum. In this review, we examine and discuss the indications and technical considerations for custom implant reconstruction of pelvic defects.
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Affiliation(s)
- Precious C Oyem
- Cleveland Clinic, Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zachary D Burke
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nathan W Mesko
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Xin P, Yang J, Chen G, Wang Y, Wang Y, Zhang G. Clinical and radiographic outcomes of long monoblock, hydroxyapatite-coated stem in revision hip arthroplasty with extended trochanteric osteotomy: a multicenter study. J Orthop Surg Res 2024; 19:20. [PMID: 38167438 PMCID: PMC10763483 DOI: 10.1186/s13018-023-04377-1] [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: 09/22/2023] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The distally fixed stem used in revision total hip arthroplasty (rTHA) with extended trochanteric osteotomy (ETO) is subject to periprosthetic fracture, stem subsidence, and stress shielding. The prospective multicentric study aimed to assess the clinical and radiographic outcomes, and complications of using the Corail revision stem in rTHA with ETO. METHODS Sixty-four patients undergoing rTHA with ETO using the Corail revision stem between 2019 and 2020 were enrolled in the study. We performed a postoperative follow-up of the patient and obtained radiographs and Harris hip scores (HHSs). These results were used to analyze ETO union, Engh scores, bone remodeling, stem stability and hip function. RESULTS The mean follow-up duration was 34 months (range 23-41). Sixty-two patients who underwent ETOs achieved complete healing at the final follow-up. Fifty-nine hips had bony ingrowth from the osteotomy fragment to the stem without radiolucent lines. The postoperative Engh score was 21.3 ± 3.59 (range 15.5-27.0). Forty-three hips had regeneration in the proximal femur. Two patients had transient thigh pain postoperatively. The postoperative HHS improved from 40.7 ± 16.67 (range 0-67) preoperatively to 82.1 ± 6.83 (range 73-93). CONCLUSION Corail revision stems are a viable and reliable option in rTHA with ETO. This stem had excellent clinical and radiographic outcomes, resulting in a high rate of ETO union and stem survival. The revision stem enabled restoration of proximal bone stock in femurs with prerevision bone defects, which were prepared for the next revision operation. Level of evidence Level IIb, Prospective self-control study.
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Affiliation(s)
- Peng Xin
- Department of Orthopedics, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, Chinese PLA Southern Theater Command General Hospital, Guangzhou, China
| | - Jianfeng Yang
- Department of Orthopedics, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guangxing Chen
- Department of Orthopedics, The Southwest Hospital of Army Medical University, Chongqing, China
| | - Yiming Wang
- Department of Orthopedics, The First Medical Center of Chinese, PLA General Hospital, Beijing, China
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
- Medical School of Chinese People's Liberation Army, Beijing, China
| | - Yan Wang
- Department of Orthopedics, The First Medical Center of Chinese, PLA General Hospital, Beijing, China.
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China.
| | - Guoqiang Zhang
- Department of Orthopedics, The First Medical Center of Chinese, PLA General Hospital, Beijing, China.
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China.
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Mahmood S, Muffly BT, Bradbury TL. The "Inside-Out" Anterior Osteotomy of the Proximal Femur via the Direct Anterior Approach in Revision Hip Arthroplasty. Arthroplast Today 2023; 24:101219. [PMID: 38205058 PMCID: PMC10776325 DOI: 10.1016/j.artd.2023.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/27/2023] [Accepted: 09/03/2023] [Indexed: 01/12/2024] Open
Abstract
Osteotomy techniques used for wide exposure during femoral component revision include the extended trochanteric osteotomy and its modifications. We describe an anterior proximal femur osteotomy technique starting from the inside of the femoral canal at the bone-implant interface and heading outward. The technique is used in conjunction with the extended direct anterior approach and allows direct access to and visualization of the anterior, medial, and lateral bone-implant interfaces. This technique is most useful for the removal of collared, fully hydroxyapatite-coated double-tapered femoral stems, in which bone-implant interfaces need to be accessed for removal of a well-osseointegrated hip arthroplasty implant.
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Affiliation(s)
- Sania Mahmood
- Emory University Orthopaedic and Spine Hospital, Emory Healthcare, Tucker, GA, USA
| | - Brian T. Muffly
- Emory University Orthopaedic and Spine Hospital, Emory Healthcare, Tucker, GA, USA
| | - Thomas L. Bradbury
- Total Joint Specialists, Advanced Center for Joint Replacement, Cumming, GA, USA
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Cacciola G, Giustra F, Bosco F, Aprato A, De Meo F, Cavaliere P, Vezza D, Giachino M, Sabatini L, Massè A. Extended trochanteric osteotomy is a safe procedure in two-stage hip revision: a systematic review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2695-2702. [PMID: 36849679 PMCID: PMC10504093 DOI: 10.1007/s00590-023-03497-y] [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: 01/12/2023] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Extended trochanteric osteotomy (ETO) has proved to be an effective technique in complicated stem removal in femoral aseptic loosening or periprosthetic fracture. Debate remains about its safety in periprosthetic joint infection (PJI). The primary aim of this study is to analyze the ETO reinfection and union rate in two-stage hip revision. MATERIAL AND METHODS A systematic literature review was performed regarding all studies reporting ETO outcomes in the two-stage revision for hip PJI up to October 2022, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. A literature search was conducted in the following databases: MEDLINE/EMBASE, Scopus, Web of Science, and Cochrane. Quality assessment of the articles was performed using the Methodological Index for Non-Randomized Studies. This systematic review was registered in the International Prospective Registry of Systematic Reviews. Patient demographic, clinical, and surgical data were collected. RESULTS This systematic review included and analyzed nine clinical studies with a total of 382 ETO PJI hips in two-stage revision. The overall ETO reinfection rate was 8.9% (34 hips), consistent with the reinfection rate after two-stage revision in patients without ETO. The overall ETO union rate was 94.8% (347 hips), comparable to the ETO union rate in non-septic patients. Compared between a group of patients with ETO PJI and a group of patients with non-PJI ETO, there were no significant differences in postoperative complications, both septic and aseptic, and for postoperative HHS. CONCLUSION ETO proved to be a safe and effective procedure in PJI revisions. It may be a viable option in challenging femoral stem removal during the two-stage hip revision in PJI. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Giorgio Cacciola
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", Via Consolare Pompea, 98100, Messina, Italy
| | - Fortunato Giustra
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Turin, Italy
| | - Francesco Bosco
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy.
- Department of Orthopaedics and Traumatology, Ospedale San Giovanni Bosco - ASL Città di Torino, Turin, Italy.
| | - Alessandro Aprato
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Federico De Meo
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", Via Consolare Pompea, 98100, Messina, Italy
| | - Pietro Cavaliere
- Istituto Ortopedico del Mezzogiorno d'Italia "Franco Scalabrino", Via Consolare Pompea, 98100, Messina, Italy
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Matteo Giachino
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Luigi Sabatini
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
| | - Alessandro Massè
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Via Zuretti 29, 10126, Turin, Italy
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Tran J, Yu H, Paprosky WG, Sheth NP. Systematic Exposure in Revision Total Hip Arthroplasty: The Posterior Approach. J Am Acad Orthop Surg 2023; 31:e736-e745. [PMID: 37352384 DOI: 10.5435/jaaos-d-22-00724] [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: 08/09/2022] [Accepted: 05/23/2023] [Indexed: 06/25/2023] Open
Abstract
As indications for total hip arthroplasty (THA) continue to expand, and patients continue to live longer with more active lifestyles, the incidence of revision THA is expected to rise. General orthopaedic surgeons are now beginning to consider doing revision THA surgery because of the increased revision burden being experienced nationwide. While classical approaches to the hip can be used for simple revisions, extensile exposure techniques in conjunction with selective soft-tissue releases are often required for adequate visualization for more complex revision cases. This review provides a systematic approach to surgical exposure for revision THA using the posterior approach. The surgeon should follow a stepwise progression to obtain safe, adequate, and reproducible visualization of both the acetabulum and the proximal femur.
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Affiliation(s)
- Jonathan Tran
- From the Department of Orthopaedic Surgery, Rush University, Chicago, IL (Paprosky), the Department of Orthopaedic Surgery, Pennsylvania HospitalPhiladelphia, PA (Tran, Yu, and Sheth)
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Tardiani L, Goldsmid S, Lanz O. Approach to the canine coxofemoral joint using an osteotomy of the deep gluteal muscle insertion for total hip replacements. Front Vet Sci 2023; 10:1224944. [PMID: 37720477 PMCID: PMC10501306 DOI: 10.3389/fvets.2023.1224944] [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: 05/18/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Canine total hip replacements (THR) are commonly performed using a craniolateral approach to the craniodorsal aspect of the hip which traditionally involves a partial deep gluteal tendon tenotomy (DGT). Performing an osteotomy of the insertion of the deep gluteal tendon has been utilized by some surgeons. Utilizing bone healing over tendon healing aims to improve post operative hip stability. To the authors' knowledge, this is the first published description of the novel deep gluteal osteotomy (DGO) approach. It differs from a greater trochanteric osteotomy as the latter involves an osteotomy of both the deep and middle gluteal insertions. DGT and the novel DGO approach were performed in ten medium to large breed cadavers on contralateral limbs. The surface area of acetabular exposure was measured in contralateral limbs following the approaches and the iatrogenic damage to the deep gluteal, middle gluteal and vastus lateralis muscles following femoral reaming was visually graded (none, mild, moderate or severe) based on muscle proportion damaged. There was no statistically significant difference (p = 0.8223) between the surface area of acetabular cartilage exposed by each approach with the mean surface area for the DGO approach being 2.99 cm2, whilst the mean surface area for the DGT was 2.97 cm2. In 80% of cadavers, the DGO approach achieved lower muscle damage following retraction and femoral reaming compared to the DGT approach for the middle gluteal and deep gluteal muscles (p = 0.0073). In all cadavers, overall muscle damage was lower for the DGO approach compared to the DGT approach (p = <0.001). There was no difference in vastus lateralis damage between procedures. The DGO approach may be a reasonable alternative to the DGT for approaching the hip joint and femur for Zurich THR as it provides similar exposure to the acetabulum with less muscle damage. It relies on more reliable osseous healing compared to tendon healing. Reduced muscle damage may be important for postoperative hip stability following THR. Further studies are required to biomechanically assess the strength of DGO repair compared to DGT repair as well as a case series documenting clinical outcomes.
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Affiliation(s)
| | | | - Otto Lanz
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, United States
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8
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Ismailidis P, Mündermann A, Stoffel K. A Monocortical Screw for Preventing Trochanteric Escape in Extended Trochanteric Osteotomy: A Simple Solution to a Complicated Problem? J Clin Med 2023; 12:jcm12082947. [PMID: 37109281 PMCID: PMC10145078 DOI: 10.3390/jcm12082947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Extended trochanteric osteotomy (ETO) is an established method in revision total hip arthroplasty. Proximal migration of the greater trochanter fragment and the resulting non-union of the osteotomy remains a major problem, and several techniques have been developed to prevent its occurrence. This paper describes a novel modification of the original surgical technique in which a single monocortical screw is placed distally to one of the cerclages used for the fixation of the ETO. The contact between the screw and the cerclage counteracts the forces applied on the greater trochanter fragment and prevents trochanteric escape under the cerclage. The technique is simple and minimally invasive, does not require special skills or additional resources, or add to surgical trauma or operating time, and therefore represents a simple solution to a complicated problem.
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Affiliation(s)
- Petros Ismailidis
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
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9
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Pan Y, Chen Y. Greater trochanteric osteotomy and subtrochanteric osteotomy in primary/revision total hip arthroplasty. Front Surg 2023; 10:1103689. [PMID: 36843986 PMCID: PMC9947351 DOI: 10.3389/fsurg.2023.1103689] [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: 11/20/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Osteotomy of the femur is necessary in some cases of primary/revision total hip arthroplasty (THA) procedure. There are two mainly used femur osteotomy methods in THA: greater trochanteric osteotomy and subtrochanteric osteotomy. Greater trochanteric osteotomy can improve hip exposure, provide greater stability against dislocation and favorably influence the abductor moment arm. Whether in the primary or revision THA, greater trochanteric osteotomy has its unique position. Subtrochanteric osteotomy adjusts the degree of femoral de-rotation and corrects the leg length. It is widely used in hip preservation and arthroplasty surgery. All osteotomy methods have specific indications, while nonunion is the commonest complication. In this paper, we analyze the greater trochanteric osteotomy and the subtrochanteric osteotomy in primary/revision THA and summarize the characteristics of different osteotomy methods.
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Affiliation(s)
- Yuqi Pan
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Kahhaleh E, Charles T, Collard X, Jayankura M. A low dislocation rate after revision total hip arthroplasty performed through the anterior approach. ARTHROPLASTY (LONDON, ENGLAND) 2023; 5:4. [PMID: 36600292 PMCID: PMC9814313 DOI: 10.1186/s42836-022-00159-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Dislocation is a major complication in revision total hip arthroplasties. This study aimed to evaluate the dislocation rate, complications, and functional scores of revision total hip arthroplasty performed through the direct anterior approach. METHODS Between January 2014 and March 2020, 84 patients undergoing revision total hip arthroplasty were retrospectively reviewed. All operations were performed through the direct anterior approach. At the final follow-up, incidences of dislocation, reoperation, acute deep infections, periprosthetic fractures and psoas impingement were assessed. The median postoperative Oxford Hip Score was also calculated. RESULTS At revision surgery, the mean age was 66 ± 12 years (range, 28-91). During an average follow-up of 4.2 ± 1.2 years, reoperation rate for major complications in the non-infected revisions was 15% (n = 11), including five acute deep infections (7%), four periprosthetic fractures (5%), one dislocation and one psoas impingement (1%). The median postoperative Oxford Hip Score was 39 (interquartile range = 14). CONCLUSION In our series, revision total hip arthroplasty through direct anterior approach was associated with a very low dislocation rate, acceptable complication rates and good functional results. Our results suggest that this procedure is safe and reliable. TRIAL REGISTRATION Ethical approval for this study was obtained, before enrollment of the first participant, by CUB Erasme's research ethics committee (P2020/323) and C.H.U Ambroise Paré's research ethics committee.
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Affiliation(s)
- Edward Kahhaleh
- grid.412157.40000 0000 8571 829XDepartment of Orthopaedic Surgery and Traumatology, C.U.B Erasme, Route de Lennik 808, 1070 Brussels, Belgium ,grid.492608.1Department of Orthopaedic Surgery and Traumatology, C.H.U Ambroise Paré, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium
| | - Tatiana Charles
- grid.412157.40000 0000 8571 829XDepartment of Orthopaedic Surgery and Traumatology, C.U.B Erasme, Route de Lennik 808, 1070 Brussels, Belgium
| | - Xavier Collard
- grid.492608.1Department of Orthopaedic Surgery and Traumatology, C.H.U Ambroise Paré, Boulevard John Fitzgerald Kennedy 2, 7000 Mons, Belgium
| | - Marc Jayankura
- grid.412157.40000 0000 8571 829XDepartment of Orthopaedic Surgery and Traumatology, C.U.B Erasme, Route de Lennik 808, 1070 Brussels, Belgium
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11
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Charalambous LT, Wixted CM, Kim BI, Cochrane NH, Belay ES, Joseph HL, Seyler TM. Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer. J Arthroplasty 2023; 38:6-12. [PMID: 35872231 DOI: 10.1016/j.arth.2022.07.011] [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: 06/22/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. METHODS An institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. RESULTS A comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. CONCLUSION Age, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.
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Affiliation(s)
| | | | - Billy I Kim
- Duke University School of Medicine, Durham, North Carolina
| | - Niall H Cochrane
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Elshaday S Belay
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Hayden L Joseph
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
| | - Thorsten M Seyler
- Duke University Medical Center, Department of Orthopaedics, Durham, North Carolina
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12
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Mo TT, Zhu YS, Zhang JN, Zhang WK, Jiang C. The clinical effect of trochanteric slide osteotomy combined with a cementless femoral conical stem in total hip replacement for the treatment of Crowe type IV developmental dysplasia of the hip. Technol Health Care 2023; 31:553-563. [PMID: 36120798 DOI: 10.3233/thc-220147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Total hip replacement (THR) for Crowe type IV developmental dysplasia of the hip (DDH) is still challenging due to specific joint deformities and the high incidence of post-operative complications. OBJECTIVE This study aimed to evaluate the clinical effect of trochanteric slide osteotomy (TSO) combined with a cementless femoral conical stem in THR for the treatment of Crowe type IV DDH. METHODS Thirty-one total hip replacements (26 patients) with Crowe type IV DDH were performed using TSO combined with a cementless femoral conical stem. Surgical outcomes were evaluated using leg length discrepancy (LLD), Harris hip score, and post-operative complications. RESULTS The average pre-operative LLD was 51 mm (range 46-58 mm), decreasing to an average of 10 mm (range 8-12 mm) post-operatively. As a result, the post-operative incidence of the Trendelenburg sign significantly decreased compared with the pre-operative incidence (P< 0.05). Bony union was identified in 26 hips (83.9%), fibrous union in four (12.9%), and non-union in one (3.2%). No acetabular or femoral component loosening, dislocation, or deep infection around the component was found in any of the patients during the follow-up period (27 to 39 months). The average Harris hip score improved from 63.0 ± 3.0 (range 58-69) to 93.3 ± 2.0 (range 91-96). CONCLUSION TSO combined with a cementless conical stem in THR is an appropriate option for patients with high congenital hip dislocation.
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13
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[Strategies for stem revision : Surgery planning, implant removal and reimplantation]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:21-34. [PMID: 35802156 PMCID: PMC9842594 DOI: 10.1007/s00132-022-04277-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PLANNING Femoral revision represents a challenging procedure in its surgical planning and technical execution. The results are mainly dependent on the bone loss present, the quality of the implant removal and the choice of revision system. Patient-specific factors such as age, comorbidities, bone quality or even the localization of the cement have a decisive influence on the surgical strategy. Appropriate preoperative preparation, including the presence of the necessary special instruments, which are essential for gentle implant removal, is indispensable to achieve the best possible result. THERAPY A bone-sparing implant removal can be particularly challenging, especially in the case of well-fixed stems and cement residues, which may extend far beyond the isthmus. In such situations, a transfemoral approach should be considered. Cementless reimplantation using modular or non-modular titanium stems is currently the preferred treatment of choice for most revisions. In elderly, low-demand patients or with poor bone quality, cemented revision remains a good alternative treatment option.
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Kanniyan K, Manivannun K. Wedge Episiotomy for Long Cemented Femoral Stem Removal and Reconstruction. A Case Report on One-Stage Revision for Failed Bipolar for Proximal Femur Giant Cell Tumor. J Orthop Case Rep 2022; 12:61-65. [PMID: 36874881 PMCID: PMC9983381 DOI: 10.13107/jocr.2022.v12.i10.3368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/27/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Osteotomy around proximal femur provides excellent exposure and helps in revision of both cemented and uncemented femoral stem. Hereby, describing our case report on wedge episiotomy, a new surgical technique for removal of distal fitting cemented or uncemented femoral stem in conditions were extended trochanteric osteotomy (ETO) becomes inappropriate and episiotomy becomes inadequate. Case Report A 35-year-old lady presented with painful right hip and difficulty in walking. Her X-rays showed a dissociated bipolar head and long cemented femoral stem prosthesis. She gave history of proximal femur giant cell tumor operated with cemented bipolar which failed in 4 months (Figs. 1, 2, 3). There were no signs of active infection such as discharging sinus and elevated blood infection markers. Hence, she was planned for one-stage revision of the femoral stem and conversion into total hip arthroplasty. Surgical Technique A small trochanter fragment, along with the abductor and vastus lateralis continuity, was preserved and mobilized away augmenting hip exposure. The long femoral stem was found well fixed with a cement mantle all around in an unacceptable retroversion. There was metallosis with no macroscopic signs of infection. Taking in consideration of her young age and the long femoral prosthesis with cement mantle, the idea of ETO was considered inappropriate and more iatrogenic.Initially, an episiotomy was done along the lateral border of femur with an oscillating saw to interrupt the radio compressive force of the bone along the cement mantle and stem. However, the lateral episiotomy was not sufficient to loosen up the tight fit between bone and cement interface. Hence, a small wedge episiotomy was done along the full length lateral border of the femur (Figs. 5 and 6). A lateral wedge of 5 mm bone was removed increasing the exposure of bone cement interface with intact 3/4th cortical rim. This exposure allowed 2 mm K-wire, drill bit, flexible osteotome, and micro saw to go in between the bone and cement mantle to dissociate it. A 240 x 14 mm long uncemented femoral stem was fixed using bone cement extending along the entire femur length, With utmost care, all the cement mantle and implant were removed. The wound was soaked with three minutes of hydrogen peroxide and betadine solution and washed with high jet pulse lavage. A long 305 × 18 mm Wagner-SL revision uncemented stem was placed with adequate axial and rotational stability (Fig. 7). The long straight stem of 4 mm wider than the extracted was passed along the anterior femoral bowing augmenting the axial fit and the wagner fins helped in getting the much need rotational stability (Fig. 8). The acetabular socket was prepared with uncemented cup size of 46 mm with a posterior lip liner poly and 32 mm metal head was used. The wedge of bone was kept back along the lateral border and help with 5-ethibond sutures. Intraoperative histopathology sampling did not show any evidence of giant cell tumor recurrence, ALVAL score of 5 and microbiology culture grew negative. The physiotherapy protocol included non-weight-bearing walking for 3 months, later then partial loading was started and complete loading was done by end of fourth month. The patient had no complication such as tumor recurrence, periprosthetic joint infection (PJI) and implant failure at end of 2 years(Fig. 9).
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Affiliation(s)
- Kalaivanan Kanniyan
- Department of Arthroplasty and Oncology, Asian Institute of Orthopaedics, SIMS Hospitals, Chennai, Tamil Nadu, India
| | - K Manivannun
- Director, Department of Orthopaedics, Manisundaram Medical Mission, Vellore, Tamil Nadu, India
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Bhagwat AP, Ambade DR. Virtual and Augmented Surgical Skills in Total Hip Arthroplasty. Cureus 2022; 14:e28895. [PMID: 36237780 PMCID: PMC9543854 DOI: 10.7759/cureus.28895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/07/2022] [Indexed: 11/05/2022] Open
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Smith EB. Save the Greater Trochanter: A Novel Modification to the Extended Trochanteric Osteotomy. Arthroplast Today 2022; 16:107-111. [PMID: 35677941 PMCID: PMC9168376 DOI: 10.1016/j.artd.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 11/26/2022] Open
Abstract
The extended trochanteric osteotomy is the workhorse for removal of well-fixed femoral stems during total hip revision arthroplasty. Despite its reliable performance in exposing the implants for removal and accessing the femoral canal, significant complications can occur. Though these complications are rare, trochanteric nonunion, trochanteric escape, and femoral implant subsidence can have a significant negative impact on gait mechanics and patient outcome. If access to the canal was still possible and the greater trochanter could remain in place, these complications could be minimized or possibly even eliminated. This paper describes a novel technique using a lateral cortical window just distal to the greater trochanter that allows removal of a well-fixed stem and leaves the greater trochanter intact.
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Affiliation(s)
- Eric B. Smith
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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Pearce AN, Stambough JB, Mears SC, Barnes CL, Stronach BM. Diagnosis and Treatment Options of Abductor Insufficiency After Total Hip Replacement. Orthop Clin North Am 2022; 53:255-265. [PMID: 35725034 DOI: 10.1016/j.ocl.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Abductor insufficiency can cause abnormal gait, lateral hip pain, and abduction weakness in both native and prosthetic hips. In the setting of total hip arthroplasty (THA), abductor insufficiency may occur secondary to iatrogenic injury to the superior gluteal nerve or gluteus medius muscle, adverse local tissue reactions owing to metal-associated prosthetics, and osteolysis owing to bearing wear or infection. Surgical reconstruction of the abductor complex is indicated for patients with chronic tears who have pain, weakness, limp, and/or instability. This article reviews the pearls and pitfalls of surgical reconstruction options for abductor insufficiency following THA.
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Affiliation(s)
- Alexa N Pearce
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Box 531, Little Rock, AR 72205, USA
| | - Jeffrey B Stambough
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Box 531, Little Rock, AR 72205, USA
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Box 531, Little Rock, AR 72205, USA
| | - Charles Lowry Barnes
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Box 531, Little Rock, AR 72205, USA.
| | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Box 531, Little Rock, AR 72205, USA
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Başarır K, Kalem M, Şahin E, Özbek EA, Karaca MO, Küçükkarapınar İ, Tönük E. The Relationship Between Arthroplasty Surgeons' Experience Level and Optimal Cable Tensioning in the Fixation of Extended Trochanteric Osteotomy. Geriatr Orthop Surg Rehabil 2021; 12:21514593211063324. [PMID: 34925952 PMCID: PMC8671821 DOI: 10.1177/21514593211063324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/11/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction In this study, our aim was to examine the relationship between the arthroplasty surgeons’ experience level and their aptitude to adjust the cable tension to the value recommended by the manufacturer when asked to provide fixation with cables in artificial bones that underwent extended trochanteric osteotomy (ETO). Materials and Methods A custom-made cable tensioning device with a microvoltmeter was used to measure the tension values in Newtons (N). An ETO was performed on 4 artificial femur bones. Surgeons at various levels of experience attending the IXth National Arthroplasty Congress were asked to fix the osteotomized fragment using 1.7-mm cables and the tensioning device. The participants’ demographic and experience data were investigated and recorded. The surgeons with different level of experience repeated the tensioning test 3 times and the average of these measurements were recorded. Results In 19 (35.2%) of the 54 participants, the force applied to the cable was found to be greater than the 490.33 N (50 kg) value recommended by the manufacturer. No statistically significant difference was determined between the surgeon’s years of experience, the number of cases, and the number of cables used and the tension applied over the recommended maximum value (P = .475, P = .312, and P = .691, respectively). Conclusions No significant relationship was found between the arthroplasty surgeon’s level of experience and the adjustment of the cable with the correct tension level. For this reason, we believe that the use of tensioning devices with calibrated tension gauges by orthopedic surgeons would help in reducing the number of complications that may occur due to the cable.
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Affiliation(s)
- Kerem Başarır
- Department of Orthopedics and Traumatology, University of Ankara, Ankara University Medicine Faculty, Ankara, Turkey
| | - Mahmut Kalem
- Department of Orthopedics and Traumatology, University of Ankara, Ankara University Medicine Faculty, Ankara, Turkey
| | - Ercan Şahin
- Faculty of Medicine, Department of Orthopedics & Traumatology, Bülent Ecevit University, Zonguldak, Turkey
| | - Emre Anıl Özbek
- Department of Orthopedics and Traumatology, University of Ankara, Ankara University Medicine Faculty, Ankara, Turkey
| | - Mustafa Onur Karaca
- Department of Orthopedics and Traumatology, University of Ankara, Ankara University Medicine Faculty, Ankara, Turkey
| | - İbrahim Küçükkarapınar
- Department of Orthopedic Surgery and Traumatology Polatlı State Hospital, Ankara, Turkey
| | - Ergin Tönük
- Department of Mechanical Engineering, Middle East Technical University, Ankara, Turkey
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Pan Y, Li Y, Zhang X, Wang Q, Chen Y, Jiang C. [Application of sliding trochanteric osteotomy in total hip arthroplasty for Crowe type Ⅳ developmental dysplasia of the hip]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1525-1530. [PMID: 34913307 DOI: 10.7507/1002-1892.202108125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of sliding trochanteric osteotomy (STO) in total hip arthroplasty (THA) for Crowe type Ⅳ developmental dysplasia of the hip (DDH). Methods Between July 2016 and April 2021, 52 patients (57 hips) with Crowe type Ⅳ DDH who underwent primary THA were enrolled according to inclusion criteria. There were 5 males and 47 females with a median age of 51 years (range, 18-76 years). There were 47 cases of single hip and 5 cases of bilateral hips. The leg length discrepancy (LLD) was 50.50 (44.00, 55.00) mm, visual analogue scale (VAS) score was 8.0 (6.0, 9.0), and Harris score was 58.0±5.0 before operation. Trendelenburg sign was positive in 46 patients (46 hips). All patients underwent STO and THA using Wagner-cone stem. The operation time, intraoperative blood loss, blood transfusion volume, Trendelenburg sign, and related complications were observed. During follow-up, VAS and Harris scores were recorded to evaluate the hip pain and function. X-ray film was used to measure the LLD and observe the bone union situations. Results The operation time was 90-125 minutes (mean, 105 minutes). Introperative blood loss was 420-800 mL (mean, 640 mL). Ten patients underwent blood transfusion and the amount of allogeneic blood transfusion was 2-4 U (mean, 3 U). All incisions healed by first intention after operation. All patients were followed up 4-60 months (median, 24 months). At last follow-up, LLD was 6.00 (4.00, 7.75) mm, showing significant difference when compared with that before operation ( Z=-6.278, P=0.000). After operation, 51 hips (89.5%) achieved bone union at the osteotomy site, 4 hips (7.0%) had fibrous union, and 2 hips (3.5%) had nonunion. The healing time of osteotomy was 3-12 months, with an average of 6 months. At last follow-up, the VAS score was 3.0 (2.0, 5.0) and the Harris score was 85.0±6.0. The differences between pre- and post-operation were significant ( Z=-6.176, P=0.000; t=-25.285, P=0.000). Trendelenburg sign remained positive in 4 patients (4 hips) at last follow-up and the difference was significant when compared with preoperative ( χ 2=67.947, P=0.000). One patient had a medial femoral cortical fracture when Wagner-cone stem was implanted during operation, and 2 patients had early symptoms of sciatic nerve palsy after operation, and no other related complications occurred. Conclusion For Crowe type Ⅳ DDH patients, STO applied in THA can reduce the resected bone mass, provide better exposure of hip as well as improve function of hip abductor muscle. Wagner-cone stem is recommended.
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Affiliation(s)
- Yuqi Pan
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200233, P.R.China
| | - Yamin Li
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200233, P.R.China
| | - Xianlong Zhang
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200233, P.R.China
| | - Qi Wang
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200233, P.R.China
| | - Yunsu Chen
- Department of Joint Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, 200233, P.R.China
| | - Chang Jiang
- Department of Joint Surgery, the First People's Hospital of Wenling, Wenling Zhejiang, 317500, P.R.China
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