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< Back Dr. Savas CAMUR Periprosthetic Hip Fractures Vancouver B2 fractures—those with a loose stem but adequate bone stock—remain the most debated subtype in terms of optimal management, with recent meta-analyses redefining treatment algorithms.Periprosthetic femoral fractures (PPF) represent one of the most challenging complications after total hip arthroplasty (THA). Their incidence is rising sharply worldwide, driven by increasing THA volumes, aging populations, and poor bone health, particularly osteoporosis. Periprosthetic Hip Fractures Epidemiology & Trends Incidence: PPFs occur in 0.1–3.5% of all THAs and are among the leading causes of revision surgerys Rising burden: U.S. data (2010–2019) demonstrate a +7% annual growth in 2-year PPF incidence, nearly doubling since 2010 At-risk populations: Age < 50 years Osteoporosis Vitamin D deficiency Medicaid recipients These findings emphasize socioeconomic disparities and bone-quality-related vulnerability. Pathophysiology & Biomechanics Osteoporosis contributes directly to the pathogenesis of PPFs by altering both bone mineral density (BMD) and microarchitecture : Trabecular perforation and cortical thinning reduce load transfer capacity. Weakened osseointegration diminishes stem anchorage, increasing micromotion and loosening. This fragile biomechanical environment sets the stage for PPF even under low-energy trauma or routine postoperative stress.Animal and human models confirm that osteoporotic bone shows reduced periprosthetic bone formation and inferior implant fixation. Risk Factors CategorySpecific FactorsPatient Older age, female sex, low BMI, vitamin D deficiency, chronic corticosteroid use, smoking, alcohol, rheumatoid arthritisImplant/Bone Osteoporotic bone, cementless stems (especially in Dorr C femurs), poor osseointegrationSurgical Undersized stem, eccentric reaming, improper alignment, absence of cement in poor bone qualitySystemic Chronic kidney disease, endocrine disorders (thyroid/parathyroid), malnutrition Classification The Vancouver Classification remains the standard: Type B1: Stable stem Type B2: Loose stem, adequate bone stock Type B3: Loose stem, poor bone stock The Unified Classification System (UCS) expands this to periprosthetic fractures beyond the femur. Treatment Options 1. Osteosynthesis (ORIF) Indications: Low-demand, frail patients (ASA ≥ 3), multiple comorbidities, acceptable bone stock. Advantages: Shorter operative time (≈120 min vs 173 min for revision) Lower blood transfusion rate (44% vs 53%) Fewer complications and reoperations Similar 1-year mortality (~13%)s00198-025-07583-1 Techniques: Locking plate ± cables or cerclage Biological fixation with bridging constructs Avoid excessive stripping of periosteum Goal: achieve relative stability rather than perfect anatomic reduction 2. Revision Arthroplasty Indications: Younger, active patients; poor implant stability; severe osteolysis or bone loss. Approach: Long, diaphyseal-engaging revision stem (cementless or cemented) Extended trochanteric osteotomy if necessary Address offset, version, and limb length Drawbacks: Longer surgery, higher bleeding and infection risk, increased dislocation rates 3. Role of Cemented Fixation Hybrid THA (cemented stem + press-fit cup) yields significantly lower PPF rates in osteoporotic patients (hazard ratio 7.7 for uncemented vs cemented stems) Cemented constructs are particularly advantageous in elderly (> 65 years) and Dorr C femurs. Clinical Decision Pearls Always confirm stem stability intraoperatively before deciding against revision. In osteoporotic bone, avoid under-reaming ; consider cemented fixation. ORIF is viable for low-demand elderly or comorbid patients with adequate bone stock. Preoperative bone health optimization (vitamin D, calcium, bisphosphonates, denosumab) can reduce postoperative PPF risk. Functional outcomes (Parker Mobility, Harris Hip Score) show no significant difference between ORIF and revision. Future Directions Pre-THA bone health screening using DXA or FRAX is underutilized and should be standardized. Augmented reality navigation and AI-assisted risk scoring may improve preoperative planning. Novel biologic bone enhancers (anabolic agents, PTH analogs, sclerostin inhibitors) show promise in reducing fragility-related complications. Registry-based big data analysis will continue refining patient-specific algorithms for PPF management. Decision-Making Flowchart: Management of Vancouver B2 Periprosthetic Hip Fractures Step 1: Confirm Diagnosis Imaging: X-ray + CT (for stem stability, bone stock, osteolysis) Exclude infection: ESR, CRP, joint aspiration → If infection positive → Two-stage revision (exclude from this algorithm) Step 2: Assess Stem Stability Stable stem → → Vancouver B1 → Fixation (ORIF) Loose stem → → Vancouver B2 → Proceed below Step 3: Evaluate Patient Factors Table 1 💡 Rule of thumb: “Fix frail, revise fit.” If patient unlikely to tolerate prolonged surgery or blood loss → choose osteosynthesis . Step 4: Evaluate Bone and Implant Conditions Table 2 Step 5: Select Surgical Strategy If ORIF selected: Use locking plate ± cerclage ; avoid excessive stripping. Achieve relative stability → biological fixation concept. Allow partial weight bearing at 6–8 weeks. Post-op early geriatric rehab essential. If Revision selected: Long diaphyseal-engaging stem (cementless or cemented) Consider Extended Trochanteric Osteotomy (ETO) if necessary. Restore offset, limb length, and version. Consider dual-mobility or constrained liner for instability risk. Step 6: Postoperative Protocol ORIF group: Gradual weight bearing; follow radiographs every 6–8 weeks. Revision group: Early protected mobilization; DVT prophylaxis mandatory. All patients: Evaluate bone health (vitamin D, calcium, antiresorptives). Step 7: Expected Outcomes Table 3 References: González-Martín D et al. Eur J Trauma Emerg Surg. 2023. .Zhao A Y et al. Osteoporosis Int. 2025;36:1371–77s00198-025-07583-1 .Bauer J et al. Curr Osteoporos Rep. 2025;23:29s11914-025-00922-5 Stoffel K et al. Arch Orthop Trauma Surg. 2020. Lewis DP et al. J Orthop Trauma. 2021. 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Deformity Correction & Limb Lengthening General Principles Deformity Evaluation Deformity Analysis Gait Analysis Principles of Osteotomy Fixation Methods Lower Limb Reconstruction Femoral Osteotomies Tibial Osteotomies High Tibial Osteotomy (HTO) Distal Femoral Osteotomy (DFO) Ankle & Foot Realignment Procedures Upper Limb Reconstruction Humeral Osteotomies Forearm Malunion & Osteotomy Radial & Ulnar Lengthening/Shortening Elbow Deformity Correction Special Considerations Growth Modulation & Guided Growth Limb Lengthening Bone Transport Techniques Nonunion & Malunion Management Infection in Reconstruction Surgery

< Back Scaphoid Scaphoid fractures are the most commonly missed carpal fractures. Prompt diagnosis and appropriate treatment are essential to avoid avascular necrosis and nonunion. Scaphoid fractures usually result from a fall on an outstretched hand (FOOSH) and are common in young adults. Tenderness in the anatomical snuffbox is a key clinical sign. Plain radiographs may initially appear normal—MRI or CT can aid early diagnosis. Fractures are classified by location (waist, proximal pole, distal pole) and displacement. Non-displaced fractures can often be managed with cast immobilization; displaced or proximal fractures frequently require surgical fixation. Delayed diagnosis increases the risk of complications such as nonunion and avascular necrosis (AVN). scaphoid Previous Next

< Back Dr. Ozcan KAYA Degenerative Spondylolisthesis Degenerative spondylolisthesis is the forward or backward slip of one vertebra over another due to facet and disc degeneration, most commonly affecting the L4–L5 level in elderly women. It presents with mechanical back pain, neurogenic claudication, or radiculopathy secondary to spinal stenosis. Standing lateral radiographs confirm diagnosis and grading, while MRI assesses canal and neural compression. Conservative treatment—including physiotherapy, anti-inflammatories, and injections—is first-line for low-grade, stable cases. Surgical decompression with or without fusion is reserved for patients with persistent pain, neurological deficits, or instability, providing superior outcomes compared with nonoperative care. Overview Degenerative spondylolisthesis is defined as anterior or posterior translation of one vertebral body over another with an intact pars interarticularis, caused by progressive degenerative changes of the intervertebral disc and facet joints. It is one of the most common causes of low back pain and lumbar spinal stenosis. Prevalence increases with age (peak 70–75 years), affecting 19–43% of individuals, with a strong female predominance (F/M ratio ≈ 6:1). The most frequently involved level is L4–L5 , whereas isthmic spondylolisthesis typically occurs at L5–S1 . Degenerative changes—disc height loss, osteophyte formation, facet arthropathy, and ligamentum flavum thickening—contribute to segmental instability and neural compression. Clinical Presentation Symptoms arise from both mechanical instability and neural compression: Mechanical back pain: Due to segmental degeneration and abnormal motion. Neurogenic claudication: Caused by canal narrowing and dynamic stenosis. Radicular pain: From foraminal narrowing or nerve root compression. Imaging Radiographs: Standing lateral radiographs confirm vertebral translation and allow grading (Meyerding Classification). Bilateral oblique views help differentiate degenerative from isthmic listhesis (“Scotty dog collar sign”). Typical findings include disc space narrowing, endplate sclerosis, facet hypertrophy , and osteophyte formation . CT Scan: Defines cortical integrity, facet hypertrophy, canal compromise, and bony overgrowth in detail. MRI: Demonstrates canal stenosis, neural compression, pseudobulging, and ligamentous hypertrophy; essential for preoperative planning. Treatment Conservative management is the first-line approach for low-grade, neurologically intact patients: Activity modification and physiotherapy Analgesics and anti-inflammatory medication Epidural steroid injections or bracing as adjuncts Surgical Indications Surgery is indicated for patients with: Persistent symptoms (>3–6 months) despite conservative therapy Radiculopathy or neurogenic claudication Progressive neurologic deficit or cauda equina syndrome (urgent decompression required) Procedures: Decompression alone (laminotomy/laminectomy) may suffice in elderly or stable cases with minimal instability. Decompression with fusion provides superior long-term stability, lower reoperation rates, and improved outcomes compared with decompression alone. The SPORT trial demonstrated better functional recovery in surgical groups, particularly in patients <65 years and those >80 years compared to conservative care. Differential Diagnosis Hip pathology Vascular claudication Sacroiliac joint dysfunction Peripheral nerve entrapments can mimic symptoms. References Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis: Four-Year Results from the SPORT Trial. J Bone Joint Surg Am. 2009;91(6):1295–1304. Bydon M, Alvi MA, Goyal A, et al. Degenerative Lumbar Spondylolisthesis: Definition, Natural History, Conservative Management, and Surgical Treatment. Neurosurg Clin N Am. 2019;30(3):299–304. Inose H, Kato T, Yuasa M, et al. Comparison of Decompression, Decompression plus Fusion, and Decompression plus Stabilization for Degenerative Spondylolisthesis: A Prospective, Randomized Study. Clin Spine Surg. 2018;31(7):E347–E352. Martin CR, Gruszczynski AT, Braunsfurth HA, et al. The Surgical Management of Degenerative Lumbar Spondylolisthesis: A Systematic Review. Spine (Phila Pa 1976). 2007;32(16):1791–1798. Previous Next