follow – up was performed on the Birmingham Mid Head Resection (BMHR) .. good surgical technique and a well proven resurfacing implant is vital for success . The novel Birmingham Mid-Head Resection (BMHR) device offers the option. We have illustrated the surgical technique to manage this rare. Surgery was conducted via a standard posterior approach to the hip joint using a 58 mm BHR acetabular component, a 52 mm BMHR femoral head implant and.
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Total hip arthroplasty in the young leads to difficult choices in implant selection. Until recently bone conserving options were not available for younger patients with deficient femoral head bone stock. Femoral neck fracture is a known complication of standard resurfacing arthroplasty and is the most common reason for revision. It is unknown whether this remains to be the case for the BMHR neck preserving implants. We report a case of a year-old male, who sustained a periprosthetic fracture following surgery with a BMHR arthroplasty.
This paper illustrates the first reported case of a BMHR periprosthetic fracture. The fracture pattern is spiral in nature and reaches to the subtrochanteric area. This fracture pattern is different from published cadaveric studies, and clinicians using this implant should be aware of this as revision is likely to require a distally fitting, rather than a metaphyseal fitting stem.
We have illustrated the surgical technique to manage this rare complication. Hip arthroplasty in the young has remained a challenging subject for the orthopaedic surgeon. The need for greater implant longevity and tolerance to more active lifestyles provide the bulk of the challenges when selecting prostheses. The realisation that early primary surgery increases the probability of the requirement for revision has led to the development of bone preserving resurfacing arthroplasty instead of conventional total hip replacement.
However, resurfacing relies on the bone quality of the proximal femur. Poor femoral head bone quality vmhr a relative contraindication to resurfacing arthroplasty. Hence, one must be selective when surglcal patients undergoing conventional resurfacing arthroplasty. Patients who would normally be considered for resurfacing but have been otherwise excluded due to poor femoral head quality now have an option other than total hip replacement.
When using the BMHR, the deficient femoral head is excised at its base rather than being resurfaced so that little of the head but all of the neck remains.
© The McMinn Centre – Mr Derek McMinn MD FRCS Hip Resurfacing Birmingham UK
The femoral neck is prepared to receive the proximal load-bearing cone of the BMHR stem. This is different to when conventional resurfacing hechnique performed, when most of the femoral head is preserved and a resurfacing ‘cap’ is placed over the top.
This implant is a novel solution to addressing this challenging group of patients. Currently, there is very little clinical literature on this implant in press. So far, only 1. Hence, this report is important as it gives an insight as to what to expect with if this complication occurs and how it can be managed successfully. We report a case of periprosthetic fracture of a year-old male patient with BMHR. The patient, having previously had a left total hip replacement for osteoarthritis, subsequently underwent right hip BMHR for osteoarthritis Fig.
The surgery was uneventful and notching had not been noted at the time of surgery. The patient recovered successfully and was discharged home. Postoperative radiographs had shown a small notch in the superior femoral neck.
This has been highlighted with an arrow in Fig. This patient, who was a techniqur delivery driver, was walking pain free and unaided postoperatively. Twelve months later, he presented to surgixal via ambulance surgiical a clear history of a mechanical trip, right hip pain and inability to weight bear. This was not a high-energy mechanism and simply involved a fall from standing height with the patient landing directly onto the right hip.
Subsequent radiographs revealed an unusual periprosthetic fracture pattern around his right BMHR Fig. The fracture started high on the superior lateral side of the femoral neck and spiralled distally to the subtrochanteric region. The implant had bonded well to the stem but the fracture rendered the stem not sufficiently ‘well-fixed’ to be retained. He subsequently underwent revision surgery with a long uncemented stem. Cables were used to support the proximal fracture Fig.
A long stem, which was distally fitting, was used so as not to rely on the fractured proximal metaphysis. We describe a case of periprosthetic fracture in a patient with a BMHR implant.
This has never been described in the literature previously.
In our case, the fracture was complex, spiralling from the femoral neck to the subtrochanteric region. This is unlike the usual fracture pattern seen in conventional hip resurfacing arthroplasty and that seen in cadaveric BMHR studies.
Birmingham Mid-Head Resection Periprosthetic Fracture
Cadaveric studies have suggested that standard resurfacing arthroplasty fracture rates are reduced with slight valgus placement of the femoral component compared to anatomic position.
Again, until recently there was no corroborating evidence to suggest that this was also the case. A recent cadaveric study using the BMHR has actually found that valgus placement does not strengthen and varus placement does not weaken femora.
This is important as aiming to place the implant in valgus may result in placing it too valgus, which may result in notching and fracture as in our reported case. This latest cadaveric study seems to imply that the BMHR may be a more forgiving implant to use in terms of its positioning compared to its resurfacing cousins. However, this evidence needs to be strengthened with other such trials. The shape of the BMHR femoral stem is conical and is said to allow for improved physiologic loading similar to that of the intact femur.
Femoral neck notching has been shown to be surgiccal significant contributor to subsequent fracture of resurfacing implants. Thus, both implants have similar failure points when there are no deficiencies in the techniquue neck cortex. However, when 2 mm notches were tested in BMHR femora, there was not a significant reduction in the load failure point compared with “no notched femora.
In fact load failure rates were comparable 4, N vs. This correlates with our case where our patient also had a notched neck of femur.
Birmingham Mid Head Resection
Our patient walked well for many months before developing a fracture and this was due to a fall on to the affected side. Olsen also describes two distinct fracture patterns: The fracture patterns in our case seem to be unusual compared with what has been documented in the literature.
In the case we present, the fracture appears to have emanated from the notched superior neck cortex and spiralled distally to the subtrochanteric level. The valgus placement of the implant and radiographs suggest that reaming had thinned the medial calcar, potentially weakening the femur further.
The fracture, however, has not spread in the usual transcervical or subcapital pattern.
tehcnique This difference may represent the difference between laboratory tested axially loaded cadaveric femora and real life when a fall is more likely to result in rotation forces caused by the femoral head-neck anteversion.
Time will tell when further case reports, biomechanical and follow-up studies emerge if spiral subtrochanteric fractures are more common than suggested by current biomechanical studies. This will be shrgical great clinical significance as revision surgery will be more technically challenging and may result in longer operating times, greater blood loss, longer hospital stays and poorer patient satisfaction outcomes although it should be emphasised that it is still too early to tell.
No potential conflict of interest relevant to this article was reported. National Center for Biotechnology InformationU. Journal List Clin Orthop Surg v. Published online Aug Find articles by Adeel Aqil. Find articles sugrical Hassaan Q. Find articles by Milad Masjedi. Find articles by Jonathan Jeffers.
Find articles by Justin Cobb. Author information Article notes Copyright and License information Disclaimer. Received Jan 11; Accepted May Abstract Total hip arthroplasty in the young leads to difficult choices in implant selection.
Hip Resurfacing Specialist, BMHR, Hip and Knee Replacement Surgery – Derek McMinn
Open in a separate window. Anteroposterior radiograph showing valgus placement of the Birmingham Mid-Head Resection in the right hip and notching of the superior lateral cortex arrow. Anteroposterior radiograph of the right hip showing periprosthetic fracture spiralling to the infratrochanteric region. Anteroposterior radiograph of the right tecgnique after revision surgery. A clinicoradiologic study of the Birmingham Mid-Head Resection device.
Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: J Bone Joint Surg Br. Risk of periprosthetic bmgr neck fracture after hip resurfacing arthroplasty: J Bone Joint Surg Am. Femoral neck fracture following hip resurfacing: A biomechanical investigation of implant alignment and femoral neck notching with the Birmingham Mid-Head Resection.