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Prosthetic Neck Fracture in Exeter V40 Stems: A Report of Two Cases and Review of Literature.

ABSTRACT: This report contains 2 acute fractures of the Exeter V40 stem with 2 different types of neck fracture, one at the subcapital level and another at the base of the neck. A review of relevant literature provides an insight into a similar pattern of failures reported in a certain subset of cases. We hypothesize that for high-BMI cases, attention to proper preoperative templating is mandatory. The operating surgeon should try to restore offset without having to use a long head in this subgroup of patients. We feel that trying to compensate for the offset with a long head may lead to high-stress concentration in the neck. This, in turn, may be responsible for the failure of the stem, as seen in the reported cases. We advocate, based on the literature, the need to recreate the offset carefully with as big a stem as possible to avoid these unique and rare complications. Reducing such failures may further improve the overall survivorship of the V40 Exeter stem.

SUBMITTER: Balakumar B

PROVIDER: S-EPMC7818608 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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Prosthetic Neck Fracture in Exeter V40 Stems: A Report of Two Cases and Review of Literature.

Balakumar Balasubramanian B Raju Sivashanmugam S Chinnakkannu Karthikeyan K Mehra Akshay A

Arthroplasty today 20210112

This report contains 2 acute fractures of the Exeter V40 stem with 2 different types of neck fracture, one at the subcapital level and another at the base of the neck. A review of relevant literature provides an insight into a similar pattern of failures reported in a certain subset of cases. We hypothesize that for high-BMI cases, attention to proper preoperative templating is mandatory. The operating surgeon should try to restore offset without having to use a long head in this subgroup of pat ...[more]

PMID: 33521205

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Project description:PurposeIsolated trapezoid fractures are rare injuries, particularly among adolescents, constituting only 0.4% of all carpal bone fractures. This study aims to present two cases of isolated trapezoid fracture in adolescent goalkeepers and a scoping review of the literature to provide guidelines for the management of this injury.MethodsFollowing PRISMA-ScR guidelines, a scoping review of reported cases was conducted. Two hundred and twenty articles were found using PubMed and Google Scholar. After full-text review, a total of 30 cases from 22 articles along with our 2 cases were analyzed based on demographics, injury mechanism, method/timing of diagnosis, prognosis, and time to recovery.ResultsThirty-two reported cases of trapezoid fractures with a mean age of 26.7 years (75% male) were found, with pain as the most common presenting symptom. A majority (78%) had initial negative findings on radiography, and the diagnosis was primarily established through computed tomography (59%; n = 19) or magnetic resonance imaging (50%; n = 16). There was a substantial delay in diagnosis (mean 26 days), primarily because computed tomography/magnetic resonance imaging was frequently ordered late. The majority of cases (78%) were managed conservatively, with immobilization periods ranging from 4 to 12 weeks. The average duration for full recovery was 4.5 months, with operative management taking 7.3 months and conservative management taking 3.5 months.ConclusionTrapezoid fractures, though rare, are often not promptly diagnosed on initial plain radiographs, leading to a potential underreporting of cases. Because of the risk of complications associated with this type of injury, clinicians should maintain a high level of vigilance and consider trapezoid fracture as a possible differential diagnosis when presented with carpal pain, swelling, or limited movement, particularly after axial load incidents. Further research and guidelines are needed to enhance our understanding and management of this uncommon injury in the future.Type of study/level of evidenceDifferential diagnosis/symptom prevalence IIIb.

Project description:BackgroundPrimary hepatic neuroendocrine carcinoma (PHNEC) is extremely rare. The diagnosis of PHNEC remains challenging-partly due to its rarity, and partly due to its lack of unique clinical features. Available treatment options for PHNEC include surgical resection of the liver tumor(s), radiotherapy, liver transplant, transcatheter arterial chemoembolization (TACE), and administration of somatostatin analogues.Case presentationWe report two male PHNEC cases and discuss the diagnosis and treatment options. Both cases presented with abdominal pain; case two also presented with symptoms of jaundice. The initial diagnosis for both cases was poorly differentiated grade 3 small-cell neuroendocrine carcinoma, based on imaging characteristics and the pathology of liver biopsies. Final diagnoses of PHNEC were arrived at by ruling out non-hepatic origins. Case one presented with a large tumor in the right liver lobe, and the patient was treated with TACE. Case two presented with tumors in both liver lobes, invasions into the left branch of hepatic portal vein, and metastasis in the hepatic hilar lymph node. This patient was ineligible for TACE and was allergic to the somatostatin analogue octreotide. This limited treatment options to supportive therapies such as albumin supplementation for liver protection. Patient one and two died at 61 and 109 days, respectively, following initial hospital admission.ConclusionsWe diagnosed both cases with poorly differentiated grade 3 small-cell PHNEC through imaging characteristics, immunohistochemical staining of liver biopsies, and examinations to eliminate non-hepatic origins. Neither TACE nor liver protection appeared to significantly extend survival time of the two patients, suggesting these treatments may be inadequate to improve survival of patients with poorly differentiated grade 3 small-cell PHNEC. The prognosis of poorly differentiated grade 3 small-cell PHNEC is poor due to limited and ineffective treatment options.

Project description:BackgroundMycetoma is a chronic granulomatous infection involving cutaneous and subcutaneous tissues. It is endemic in tropical and subtropical areas, but sporadic cases have been reported also in countries of temperate climate. The purpose of this paper is to review the cases of mycetoma in European subjects (and presumably acquired in Europe), to give an insight in the main factors associated with this condition, and to describe two previously unpublished cases observed at our Centre.Methods and findingsPubMed was systematically searched for case reports and case series of mycetoma in Europeans reported between 1980 and 2014, using specific search strategies. Two further cases diagnosed by the authors are described. Forty-two cases were collected. Eleven cases were caused by Scedosporium apiospermium, mainly in immunosuppressed patients from Bulgaria, Germany, the Netherlands, Portugal, Slovenia, Spain and the United Kingdom. Excluding all patients with immunosuppression, 29 cases remain. Most of them were reported from Bulgaria and in Albanian patients (all diagnosed outside Albania). In the Bulgarian case series many different micro-organisms, both bacteria and fungi, were isolated, while all the 5 cases from Albania were caused by Actinomadura spp. Other countries reporting cases were Greece, Italy and Turkey. In general, Actinomadura spp is the most frequent causative agent isolated, followed by Nocardia spp and Madurella mycetomatis. The foot was the most reported site involved. Most patients were medically treated, but unfortunately a long-term follow up (at least one year) was available only in a few cases.ConclusionsOur review and our own cases suggest that Europeans without travel history can be affected by Madura foot. The lack of a surveillance system is likely to cause an underreporting of cases. Moreover, the unfamiliarity of Western doctors with this peculiar infection may cause a mismanagement, including unnecessary amputations.

Project description:AimsThe Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.MethodsIn this case-control study, 25 patients (22 female) at mean age of 78 years (70 to 89) received cemented Exeter short stem (case group). Cases were selected based on Dorr type A femora and matched first by Dorr type A and then age to a control cohort of 21 patients (11 female) at mean age of 74 years (70 to 89) who received with cemented Exeter standard stems (control group). Preoperatively, all patients had primary hip osteoarthritis and no osteoporosis as confirmed by dual X-ray absorptiometry scanning. Patients were followed with radiostereometry for evaluation of stem migration (primary endpoint), evaluation of cement quality, and Oxford Hip Score. Measurements were taken preoperatively, and at three, 12, and 24 months and a minimum five-year follow-up.ResultsAt three months, subsidence of the short stem -0.87 mm (95% confidence interval (CI) -1.07 to -0.67) was lower compared to the standard stem -1.59 mm (95% CI -1.82 to -1.36; p < 0.001). Both stems continued a similar pattern of subsidence until five-year follow-up. At five-year follow-up, the short stem had subsided mean -1.67 mm (95% CI -1.98 to -1.36) compared to mean -2.67 mm (95% CI -3.03 to -2.32) for the standard stem (p < 0.001). Subsidence was not influenced by preoperative bone quality (osteopenia vs normal) or cement mantle thickness.ConclusionThe standard Exeter stem had more early subsidence compared with the short Exeter stem in patients with Dorr type A femora, but thereafter a similar migration pattern of subsidence until minimum five years follow-up. Both the standard and the short Exeter stems subside. The standard stem subsides more compared to the short stem in Dorr type A femurs. Subsidence of the Exeter stems was not affected by cement mantle thickness.

Project description:BackgroundThe standard Exeter (Stryker) cemented stem is 150 mm long with standard offsets ranging from 37.5 mm to 56 mm. Exeter short stems of 125 mm are also available in the offsets of 37.5 mm, 44 mm, and 50 mm. In addition, smaller (125 mm or shorter) Exeter cemented stems with offsets of 35.5 mm or less are available. The aim of this study was to examine the New Zealand Joint Registry (NZJR) comparing medium-term survival rates and functional outcomes of standard-length stems with Exeter short stems of various offsets in patients undergoing primary total hip replacement.MethodsUsing the NZJR, we compared the results of 3 separate groups of patients with Exeter stems. Patients with standard 150 mm length Exeter stems (Standard) were compared with patients with Exeter 125 mm stems with regular 37.5 mm, 44 mm, and 50 mm offsets (Short 37+) and Exeter 125 mm stems with offsets of 35.5 mm and below (Short 37-). Demographic data, preoperative diagnosis, patient-reported outcome measures, and reasons for revision were compared between groups. Kaplan-Meier survival analysis and Cox multivariate regression analysis were used to examine implant survival and the influence of stem group on revision rates adjusting for gender, age, diagnosis, and surgical approach.ResultsThere were 43,427 Exeter cemented stems in the NZJR between January 1, 1999 and 31, May 2018; 41,629 Standard, 657 Short 37+, and 1501 Short 37-. In all 3 groups, the posterior surgical approach was preferred (Standard, 76.1%; Short 37+, 94.6%; Short 37-, 76.6%; P < .001). In the Short 37- group, 94.1% were female, while in the other 2 groups, there was an equal gender ratio (P < .001). The Short 37- group was also significantly younger than the other 2 groups with 41.6% younger than 65 years compared with Short 37+ (37.2%) and Standard groups (36.9%) (P < .01). There was no difference in American Society of Anesthesiologists grade between groups. Body mass index (BMI) was significantly higher in both the Short 37- and Short 37 + groups compared with the Standard group (Standard BMI, 28.71; SD 5.72; Short 37+ BMI, 29.69; SD, 6.67; Short 37- BMI, 29.09; SD 7.07; P < .001). The all-cause revision rate for standard stems was 0.55/100 component years (cy) (95% CI: 0.52 to 0.58). The Short 37- group had a higher rate of revision compared with the Standard group (hazard ratio 1.6; 95% CI: 1.3 to 1.98; P < .001), while the Short 37+ group had a hazard ratio of 0.84 (95% CI: 0.38 to 1.88; P = .674) compared with the Standard group. Cox regression analysis controlling for age, gender, diagnosis of OA, and surgical approach did not affect these findings. However, no clinically meaningful difference between Oxford hip scores was observed.ConclusionsThere was a significant difference in revision rates for aseptic loosening with standard-length Exeter stems having a lower revision rate than short Exeter stems with offsets 35.5 mm or less. The Short 37+ groups, despite comprising relatively small numbers, performed similarly to the Standard stem group.

Dataset Information

Prosthetic Neck Fracture in Exeter V40 Stems: A Report of Two Cases and Review of Literature.

Publications

Prosthetic Neck Fracture in Exeter V40 Stems: A Report of Two Cases and Review of Literature.

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