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Shim BJ, Won H, Kim SY, Baek SH. Surgical strategy of the treatment of atypical femoral fractures. World J Orthop 2023; 14:302-311. [PMID: 37304202 PMCID: PMC10251271 DOI: 10.5312/wjo.v14.i5.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/16/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
The atypical femoral fracture (AFF) has been attracting significant attention because of its increasing incidence; additionally, its treatment is challenging from biological and mechanical aspects. Although surgery is often required to manage complete AFFs, clear guidelines for the surgical treatment of AFFs are currently sparse. We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur. For complete AFFs, cephalomedullary intramedullary nailing spanning the entire length of the femur can be used. Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point, external rotation of the nail, and the use of a nail with a small radius of curvature, or a contralateral nail. In the case of a narrow medullary canal, severe femoral bowing, or pre-existing implants, plate fixation may be considered as an alternative. For incomplete AFFs, prophylactic fixation depends on several risk factors, such as a subtrochanteric location, presence of a radiolucent line, functional pain, and condition of the contralateral femur; the same surgical principles as those in complete AFFs can be applied. Finally, once AFF is diagnosed, clinicians should recognize the increased risk of contralateral AFFs, and close surveillance of the contralateral femur is recommended.
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Affiliation(s)
- Bum-Jin Shim
- Department of Orthopedic Surgery, Kyungpook National University Chilgok Hospital, Daegu 41404, South Korea
- Department of Orthopedic Surgery, Kyungpook National University, College of Medincine, Daegu 41944, South Korea
| | - Heejae Won
- Department of Orthopedic Surgery, Kyungpook National University Chilgok Hospital, Daegu 41404, South Korea
| | - Shin-Yoon Kim
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Kyungpook National University, College of Medincine, Daegu 41944, South Korea
| | - Seung-Hoon Baek
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Kyungpook National University, College of Medincine, Daegu 41944, South Korea
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Kaku N, Hosoyama T, Shibuta Y, Kimura M, Tsumura H. Influence of femoral bowing on stress distribution of the proximal femur: a three-dimensional finite element analysis. J Orthop Surg Res 2023; 18:82. [PMID: 36721221 PMCID: PMC9890711 DOI: 10.1186/s13018-023-03559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Whether femoral bowing or its direction has a mechanical effect on the proximal femur is unclear. This study aimed to define the changes in stress distribution in the proximal femur associated with femoral bowing using finite element analysis. METHODS We created four femoral models: original, entire lateral bowing, entire anterior bowing, and the middle of both (50% anterolateral bowing) from computed tomography data of women with standard bowing. Each model's stress distribution was compared by two-layering the stress distribution under loading conditions during walking. We also evaluated displacement vectors. RESULTS In all directions of femoral bowing, the stress increased in the femoral neck and the femoral trochanter in the 50% anterolateral bowing. The direction of deformation of the vector for the femoral head increased anteroinferiorly in the 50% anterolateral bowing. CONCLUSIONS This study showed that the stress distribution at the proximal femur shifted laterally. The high-stress area increased at the femoral neck or trochanter due to increasing femoral bowing. Femoral bowing also increases the anteroinferior vector in the femoral head. This study provides valuable insights into the mechanism of proximal femoral fractures in older adults.
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Affiliation(s)
- Nobuhiro Kaku
- grid.412334.30000 0001 0665 3553Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka Hazama-Machi, Yufu City, Oita 879-5593 Japan
| | - Tsuguaki Hosoyama
- grid.412334.30000 0001 0665 3553Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka Hazama-Machi, Yufu City, Oita 879-5593 Japan
| | - Yutaro Shibuta
- grid.412334.30000 0001 0665 3553Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka Hazama-Machi, Yufu City, Oita 879-5593 Japan
| | - Makoto Kimura
- grid.412334.30000 0001 0665 3553Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka Hazama-Machi, Yufu City, Oita 879-5593 Japan
| | - Hiroshi Tsumura
- grid.412334.30000 0001 0665 3553Department of Orthopaedic Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka Hazama-Machi, Yufu City, Oita 879-5593 Japan
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Wang Q, Zhang X, Shi T, Bao Z, Wang B, Yao Y, Wu D, Liu Z, Cai H, Chen D, Dai J, Jiang Q, Xu Z. The accuracy of an extramedullary femoral cutting system in total knee arthroplasty in patients with severe coronal femoral bowing: a radiographic study. J Orthop Surg Res 2022; 17:257. [PMID: 35526040 PMCID: PMC9077963 DOI: 10.1186/s13018-022-03140-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intramedullary (IM) femoral alignment instrument is imprecise for the coronal alignment in total knee arthroplasty (TKA) in patients with severe lateral bowing of the femur, while the extramedullary (EM) alignment system does not depend on the structure of the femoral medullary cavity. The aim of this retrospective study was to compare the accuracy of postoperative limb alignment with the two femoral alignment techniques for patients with severe coronal femoral bowing. METHODS From January 2017 to December 2019, patients with end-stage knee osteoarthritis and coronal femoral bowing angle (cFBA) ≥ 5° who underwent total knee arthroplasty TKA at our institution were enrolled in the study. The postoperative hip-knee-ankle (HKA) alignment, femoral and tibial component alignment between the IM group and the EM group were compared on 5° ≤ cFBA < 10° and cFBA ≥ 10°. RESULTS In patients with 5° ≤ cFBA < 10°, no significant differences were observed in the EM group and IM group, including preoperative and postoperative parameters. However, when analyzing the patients with cFBA ≥ 10°, we found a significant difference in postoperative HKA (4.51° in the IM group vs. 2.23°in the EM group, p < 0.001), femoral component alignment angle (86.84° in the IM group vs. 88.46° in the EM group, p = 0.001) and tibial component alignment angle (88.69° in the IM group vs. 89.81° in the EM group, p = 0.003) between the two groups. Compared to the EM group, the IM group presents a higher rate of outliers for the postoperative HKA and femoral components. CONCLUSIONS The study showed that severe lateral bowing of the femur has an important influence on the postoperative alignment with the IM femoral cutting system. In this case, the application of EM cutting system in TKA will perform accurate distal femoral resection and optimize the alignment of lower limb and the femoral component.
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Affiliation(s)
- Qianjin Wang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Xiaofeng Zhang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China.,Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Tianshu Shi
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Zhengyuan Bao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Bin Wang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Yao Yao
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Dengxian Wu
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Zheng Liu
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Honggang Cai
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Dongyang Chen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Jin Dai
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China.,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China.
| | - Zhihong Xu
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, People's Republic of China. .,Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, People's Republic of China.
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Byun SE, Cho YH, Lee YK, Park JW, Kim S, Koo KH, Byun YS. Straight nail insertion through a laterally shifted entry for diaphyseal atypical femoral fractures with bowing: good indications and limitations of this technique. Int Orthop 2021; 45:3223-32. [PMID: 34522993 DOI: 10.1007/s00264-021-05212-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Inserting a straight (piriformis fossa entry) nail through the tip of the greater trochanter has been used for treating atypical femoral fractures (AFFs) with bowing. This study aimed to determine what degree of bowing can be successfully treated using a laterally shifted entry technique. METHODS Twenty-three complete and six incomplete diaphyseal AFFs treated using the shifted entry technique were retrospectively analysed. Radiologic parameters and complications were evaluated. The complete AFFs were divided into two groups based on the severity of preoperative bowing: grade 0-II bowing and < 20° lateral bowing (minimal/moderate) and grade III bowing or ≥ 20° lateral bowing (severe). Comparison according to postoperative malalignment, a change of lateral or anterior bowing ≥ 5° was also performed. RESULTS Three complete AFFs in the minimal/moderate group showed malalignment, as did all in the severe group (p < 0.001). The change of bowing was greater for the severe group in lateral and anterior bowing (p = 0.004 and 0.001, respectively). A greater fracture gap was found on AP and lateral radiographs in the severe group (p = 0.044 and 0.026, respectively). In the comparison according to postoperative malalignment, a significant difference was found for the percentage of severe deformity (p < 0.001). All incomplete AFFs were united without complication. CONCLUSION Diaphyseal AFFs with grade 0-II bowing and < 20° anterior bowing were treated successfully by the shifted entry technique. However, postoperative malalignment was found in all cases of AFFs with severe bowing. Therefore, other techniques should be considered for AFFs with grade III bowing or ≥ 20° anterior bowing.
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Shon OJ, Yoon JY, Kim JW. Clinical outcomes of using contralateral-side laterally bent intramedullary nails in atypical femur fractures with femoral bowing. Arch Orthop Trauma Surg 2021; 141:1291-6. [PMID: 32710344 DOI: 10.1007/s00402-020-03524-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION This study aimed to evaluate the clinical outcomes of using contralateral-side laterally bent intramedullary nails (IMNs) in bowed atypical femur fractures (AFFs). MATERIALS AND METHODS We retrospectively reviewed bowed AFFs treated with contralateral-side laterally bent IMNs. In total, 20 patients with 25 cases of AFFs were included. Surgical outcomes including bone union time, complications, femoral bowing, and leg length discrepancy (LLD) were evaluated. We evaluated the surgical safety of performing contralateral-side intramedullary nailing with its intraoperative and postoperative complications and compared the LLD. RESULTS The average age was 76.8 years (range 67-86 years), and all of patients were female. There were 10 cases of complete AFFs and 15 cases of incomplete AFFs. Fourteen patients (70%) had a history of bisphosphonate (BP) use with an average of 74.5 months of its use. In the complete AFF cases, reduction of the fractures was tried to restore the patients' normal anatomical geometry. The average lateral gap was 0.6 mm (0-1 mm), and the average medial gap was 1.6 mm (1-3 mm). All cases achieved bone union without secondary intervention. There were no intraoperative fractures or postoperative complications. The average bone union time was 22.0 weeks and 9.2 weeks in complete and incomplete AFFs, respectively. The average preoperative femoral bowing seen in the coronal and sagittal planes was 10.1° and 16.1°, respectively, while the average postoperative bowing was 6.6° and 11.3°, respectively. The average change of angle was 3.5° in the coronal plane and 4.8° in the sagittal plane. The mean change of LLD was 5.7 mm. CONCLUSION The use of contralateral-side laterally bent IMNs in treating bowed femurs showed excellent clinical outcomes without complications. In severely bowed femurs, this technique can be safe and useful.
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ALShammari SA, Choi KY, Koh IJ, Kim MS, In Y. Total knee arthroplasty in femoral bowing: does patient specific instrumentation have something to add? A randomized controlled trial. BMC Musculoskelet Disord 2021; 22:321. [PMID: 33794854 PMCID: PMC8017876 DOI: 10.1186/s12891-021-04198-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient-specific instrumentation (PSI) proponents have suggested the benefits of improved component alignment and reduced outliers. In this randomized controlled trial, we attempted to assess the advantage of using PSI over conventional intermedullary (IM) guides for primary total knee arthroplasty (TKA) with bilateral severe femoral bowing (> 5°). A parallel trial design was used with 1:1 allocation. We hypothesize that PSI would support more accurate alignment of components and the lower-limb axis during TKA with severe femoral bowing in comparison with conventional IM guides. METHODS Among 336 patients undergoing bilateral TKAs due to knee osteoarthritis, 29 patients with bilateral lateral femoral bowing of more than 5° were included in this study. Every patient was assigned randomly to PSI on one side and to conventional instrumentation lateralization of the entry point of the femoral IM guide was applied on the other with a goal of neutral mechanical alignment. The assessment of coronal alignment was completed by measuring the hip-knee-ankle (HKA) angle on preoperative and postoperative long film standing radiographs. Coronal and sagittal orientations of femoral and tibial components were assessed on weight-bearing radiographs. The rotational alignment of the femoral component was evaluated using computed tomography. RESULTS The postoperative mean ± standard deviation (SD) HKA angle was varus 4.0° (± 2.7°) for conventional technique and varus 4.1° (± 3.1°) for PSI, with no differences between the two groups (p = 0.459). The component orientation showed no significant differences except with respect to the sagittal alignment of the femoral component (p = 0.001), with a PSI mean ± SD flexion of 5.8° (± 3.7°) and a conventional method mean ± SD flexion of 3.2° (± 2.5°), due to the intentional 3° flexion incorporated in the sagittal plane to prevent femoral notching in PSI planning. Computed tomography assessment for rotational alignment of the femoral components showed no difference between the two groups concerning the transepicondylar axis (p = 0.485) with a PSI mean ± SD external rotation of 1.5° (± 1.3°) and conventional mean ± SD external rotation of 1.5° (± 1.6°). CONCLUSION PSI showed no advantage over lateralization of the femoral entry for IM guidance. LEVEL OF EVIDENCE 1 TRIAL REGISTRATION: Registered on US national library of medicine ClinicalTrials.gov ( NCT02993016 ) on December 12th 2016.
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Affiliation(s)
- Sammy Abdullah ALShammari
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea
| | - Keun Young Choi
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea
| | - In Jun Koh
- Department of Orthopaedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Man Soo Kim
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea
| | - Yong In
- Department of Orthopaedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea.
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Bénard MR, van Doremalen RFM, Wymenga AB, Heesterbeek PJC. Flexible versus standard intramedullary rod in posterior stabilized primary total knee arthroplasty: protocol for a randomized controlled trial. J Orthop Surg Res 2020; 15:472. [PMID: 33054780 DOI: 10.1186/s13018-020-01989-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background In total knee arthroplasty (TKA) a flexible intramedullary rod can be used to account for sagittal bowing of the distal femur. Although patients report better post-operative functional outcome when the flexible rod was used, it is unknown how the use of the flexible rod affects the placement of the femoral TKA component, and how this relates to activities of daily living. It is expected that the use of the flexible rod will result in a more flexed femoral component, a larger patellar tendon moment arm, and consequently in better functional outcome. The goal of this study is to compare the flexible rod to the standard intramedullary rod in primary TKA in terms of fit of the TKA, functional outcome, and sizing of the femoral component. Methods A single-blind randomized controlled trial with two groups (flexible vs standard rod), with patients blinded for group allocation, and 2 years post-operative follow-up. The fit of the TKA is quantified by two parameters: (1) the flexion angle of the TKA in the sagittal plane and (2) the sagittal profile of the distal femur compared between the pre-operative bone and the TKA. Both parameters are calculated in 3D volume images obtained using fluoroscopy. Functional outcome will be measured using (1) the timed Get-up and Go test (2), the stair climbing test (3), knee power output, and (4) patient and clinician reported outcomes. Different parameters will be measured during the TKA procedure to account for the invisibility of cartilage in the 3D volumes and to study if the amount of bone removed during the procedure is affected by group allocation. Discussion The sagittal fit of TKA is not a standardized outcome measure. We discuss our choice of parameters to define the sagittal fit (i.e., flexion angle and sagittal profile), our choice for the parameters we measure during the TKA procedure to account for the lack of cartilage thickness in fluoroscopy, and our choice for the parameters to study if the amount of bone removed during the procedure is affected by group allocation. Lastly, we discuss the merits of this planned trial. Trial registration Netherlands Trial Register, 4888, registered 30 March 2015. https://www.trialregister.nl/trial/4888
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Abstract
PURPOSEOF REVIEW The etiology of atypical femoral fracture (AFF) is likely multifactorial. In this review, we examined the recent literature investigating the role of lower-limb geometry in the pathophysiology of AFF. RECENT FINDINGS Increased femoral bowing was associated with prevalent AFF and a greater likelihood of a diaphyseal versus a subtrochanteric AFF location. Femoral neck geometry or hip alignment may also be related to AFF, but findings remain equivocal. Differences in femoral geometry may, in part, be responsible for the high rate of AFF in Asian compared with Caucasian populations. Finally, simulation studies suggest that lower-limb geometry influences AFF risk via its effects on mechanical strain of the lateral femoral cortex. Femoral geometry, and bowing in particular, is related to prevalent AFF, but more prospective investigation is needed to determine whether measurements of geometry can be used for clinical risk stratification.
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Affiliation(s)
- Ifaz T Haider
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, KNB 418, 2500 University Dr. NW, Calgary, Alberta, T2N 1N4, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, HRIC 3A08, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Prism S Schneider
- McCaig Institute for Bone and Joint Health, University of Calgary, HRIC 3A08, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
- Department of Surgery; Department of Community Health Sciences, Cumming School of Medicine, Foothills Campus, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - W Brent Edwards
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, KNB 418, 2500 University Dr. NW, Calgary, Alberta, T2N 1N4, Canada.
- McCaig Institute for Bone and Joint Health, University of Calgary, HRIC 3A08, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.
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Abstract
Atypical femoral fractures differ from ordinary femoral diaphyseal or subtrochanteric fractures in several aspects. Although several authors have reported the results of surgical treatment for atypical femoral fractures, the rate of complications (e.g., delayed union, nonunion, fixation failure, and reoperation) is still high. Therefore, we reviewed principles of surgical treatment and describe useful methods for overcoming femoral bowing in these high-risk patients.
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Affiliation(s)
- Kyung-Jae Lee
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Byung-Woo Min
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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Cho YJ, Kang KC, Chun YS, Rhyu KH, Kim SJ, Jang TS. Critical differences between subtrochanteric and diaphyseal atypical femoral fractures: analyses of 51 cases at a single institution in Korean population. Arch Osteoporos 2018; 13:53. [PMID: 29725835 DOI: 10.1007/s11657-018-0457-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED There still remains controversy on the pathomechanism of atypical femoral fracture (AFF). The angle of lateral bowing and bone mineral density showed significant differences between subtrochanteric and diaphyseal atypical fracture groups. In addition to the use of bisphosphonate, mechanical factors might play important roles in the occurrence of AFFs. INTRODUCTION Although AFF could be divided into subtrochanteric and diaphyseal fracture according to the location of fractures, there is a lack of evidence regarding differences between two fractures and etiology of the occurrence. The aim of study is to determine differences between atypical subtrochanteric and diaphyseal fracture in Korean population. METHODS Between February 2010 and March 2015, 51 AFFs in 40 patients were included in this study. Their medical records were retrospectively reviewed. The AFF patients satisfied all the diagnostic criteria of the 2014 revised edition of the ASMBR. To analyze the differences according to the location of fracture, the AFFs were divided into subtrochanteric (n = 16) and diaphyseal (n = 35) fracture groups. The following factors were compared between two groups: patients' demographics, underlying diseases, laboratory findings (serum-25(OH) VitD3, osteocalcin, c-telopeptide, ALP, Ca, and P), bone mineral density (BMD), duration of bisphosphonate (BP) usage, and lateral bowing of the femur at time of the fracture. RESULTS All AFFs happened in female patients (mean age, 73.8 years) who have received bisphosphonate treatments except three patients. The mean duration of bisphosphonate usage was 95.3 months. Between the two groups, demographic data (age, height, weight, and BMI), underlying diseases, laboratory findings, hip BMD, and duration of BP treatment were comparable to each other (p > 0.05). However, the subtrochanteric fracture group showed higher FNSBA (femoral neck shaft bowing angle, p < 0.001) and spine BMD (p = 0.014) compared to the diaphyseal fracture group. CONCLUSIONS Angle of lateral bowing (FNSBA) and spine BMD showed significant differences between subtrochanteric and diaphyseal atypical fracture groups. According to our results, femoral bowing and spine BMD may play important roles in the AFF locations.
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Affiliation(s)
- Yoon-Je Cho
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kyung-Chung Kang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea.
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
| | - Young-Soo Chun
- Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, Dongnamro, Gangdong-gu, 05278, Seoul, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kee Hyung Rhyu
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang-Jun Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Tae-Su Jang
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23 Kyungheedaero, Dongdaemun-gu, Seoul, 02447, Republic of Korea
- College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Akiyama K, Shibuya T. Influence of femoral bowing on range of motion after total hip arthroplasty. Int Orthop 2017; 42:1795-1802. [PMID: 29275431 DOI: 10.1007/s00264-017-3732-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/10/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The influence of physiologic femoral bowing on range of motion (ROM) after total hip arthroplasty (THA) remains unknown. The purpose of this study was to investigate the morphology of the femur in patients who underwent THA, and to analyze the influence of femoral bowing on ROM due to implant impingement after THA. METHODS The ROM was calculated from 100 hips in 90 patients who underwent THA using computed tomography data with a 3D dynamic analysis software. Lateral and anterior bowing angles of the femur were measured. A modular implant (Modulus system, Lima Corporate, Villanova di San Daniele del Friuli, Italy) was used for simulation. In all subjects, cup inclination, anteversion, and stem anteversion were set to 40°, 15°, and 30°, respectively. Multiple linear regression analyses were performed to assess the relationship between the morphology of the femur and ROM. RESULTS Lateral bowing of the femur was demonstrated to be significantly correlated with age (r = 0.361, p < 0.001) and female sex (r = 0.315, p = 0.001). Lateral bowing of the femur was significantly positively correlated with flexion and internal rotation (Int-R) with 90° flexion. Anterior bowing was significantly associated with decreasing flexion, decreasing Int-R with 90° flexion and increasing Int-R with 45° flexion and 15° adduction. CONCLUSIONS A ROM-optimized cup position cannot be calculated from femoral stem anteversion values alone; therefore, when surgeons position the cup in relation to the femoral stem anteversion, the influence of femoral bowing may also require consideration.
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Affiliation(s)
- Keisuke Akiyama
- Department of Orthopaedic Surgery, National Hospital Organization, Osaka Minami Medical Center, 2-1 Kidohigashi, Kawachinagano City, Osaka, 586-0008, Japan.
| | - Takaaki Shibuya
- Department of Orthopaedic Surgery, Sumitomo Hospital, 5-3-20, Nakanoshima, Kita-ku, Osaka City, 530-0005, Japan
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Kim JW, Kim H, Oh CW, Kim JW, Shon OJ, Byun YS, Kim JJ, Oh HK, Minehara H, Hwang KT, Park KC. Surgical outcomes of intramedullary nailing for diaphyseal atypical femur fractures: is it safe to modify a nail entry in bowed femur? Arch Orthop Trauma Surg 2017; 137:1515-22. [PMID: 28770350 DOI: 10.1007/s00402-017-2764-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The purpose of the study was to determine the surgical outcomes of intramedullary nailing in diaphyseal atypical femoral fractures (AFFs) and to evaluate the clinical outcomes of nail entry modification technique. MATERIALS AND METHODS We retrospectively reviewed diaphyseal AFFs treated with IMN at nine institutions. In total, 82 patients were included. Surgical outcomes such as complication, union time, and femoral bowing were evaluated. We modified the nail entry of the straight nail from piriformis fossa to the tip of the greater trochanter in the bowed femur and compared the surgical outcomes between the original group and the modification group. RESULTS The average union time was 20.1 weeks, and the union rate was 89.0%. The average union time was 13.1 weeks and 21 weeks in incomplete and complete AFFs, respectively. There was no nonunion in incomplete AFFs, but 13.8% in complete AFFs. Complete AFFs had 86.2% of union rate. There were 46 cases of group 1 with original entry point and 19 cases of group 2 with modified entry. In group 2, the union rate was similar to group 1 and union time was shorter. CONCLUSION Changing the entry point laterally allowed the nail to be accommodated in bowed femurs, decreasing the risk of deformity and improving healing time. In severely varus femur, the lateral entry of the straight nail can be a useful technique.
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Abstract
Introduction: Differences in the magnitude of bowing between races are well-known characteristics of the femur. Asian races have an increased magnitude of femoral bowing but most of the orthopedic implants designed for the femur do not match this exaggerated bowing. We calculated the sagittal and coronal femoral bowing in the Japanese population at different levels of the femur and addressed its surgical significance. Material and methods: We calculated the sagittal and coronal bowing of 132 Japanese femora using CT scan of the femur. A mathematical calculation of the radius of curvature at proximal, middle, and distal regions of the femur was used to determine the degree of femoral bowing. Results: Mean sagittal bowing of the femur was 581, 188, and 161 mm for the proximal, middle, and distal thirds of the femur and mean lateral bowing was 528, 5092, and 876 mm, respectively. Mean sagittal and coronal bowing for the whole femur was 175 and 2640 mm, respectively. No correlation was found between age, gender, length of femur, and the degree of bowing. Conclusion: Our study reveals that femoral bowing in the Japanese population is 175 mm in the sagittal plane and 2640 mm in the coronal plane; these values are greater than the femoral bowing in other ethnic groups studied in the literature. This may result in varying degrees of mismatch between the western-manufactured femoral intramedullary implants and the Japanese femur. We recommend that orthopedic surgeons to accurately perform preoperative evaluation of the femoral bowing to avoid potential malalignment, rotation, and abnormal stresses between the femur and implant.
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Affiliation(s)
- Ahmed Hamed Kassem Abdelaal
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan ; Department of Orthopedic Surgery, Faculty of Medicine, Sohag University Sohag 82524 Egypt
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
| | - Katsuhiro Hayashi
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
| | - Akihiko Takeuchi
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
| | - Ahmad Fawaz Morsy
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan ; Department of Orthopedic Surgery, Faculty of Medicine, Sohag University Sohag 82524 Egypt
| | - Shinji Miwa
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
| | - Yoshitomo Kajino
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
| | - Donnel A Rubio
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan ; Department of Orthopedics, Philippine General Hospital, University of the Philippines-Manila Ermita Brgy 670 Zone 72, Manila 1000 Metro Manila Philippines
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Science, Kanazawa University Kanazawa 9208641 Japan
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