Journal of Southeast Asian Orthopaedics

Short Metaphyseal Femoral Stem Total Hip Arthroplasty in Poor Quality Bone Cortex Without Neck Length Sparing: A Case Report

Aekkarith Khamkhad — 2025-03-01

Purpose: The principle of short metaphyseal femoral stem total hip arthroplasty (short stem THA) required the cortical ring of the femoral neck and lateral touch of the distal stem at the proximal femur, but this case had an improper cortical ring of the femoral neck and lateral touch.
Methods: A case report of a 39-year-old male who underwent short stem THA surgery owing to a failure of the femoral neck fixation and delayed union of the femoral shaft fracture.
Results: The patient reported successful 5-year clinical and radiographic outcomes for a short stem THA.
Conclusions: Short stem THA could be an alternative implant option, compared with conventional cementless stem, for young patients with good bone quality, despite lacking femoral neck anchoring, with superiority in terms of bone stock preservation and more natural loading.

Metastatic Bone Disease: A Clinical Approach

Edwin Maduakonam Dim — 2025-01-16

Background: Advances in oncological management have contributed to longer survival of patients, even in the presence of metastases. Consequently, more patients would be expected to present with symptomatic bony metastases. The major objectives of orthopaedic surgical interventions in bone metastases include stabilization of impending or actual pathological fractures, restoration of mobility and gait, with resultant reduction in the overall morbidity during the survival period of the cancer patient.
Purpose: This review was aimed at producing a synoptic material for ease of reference by students, trainees and young surgeons who come into contact with patients suffering from metastatic bone lesions.
Methods: A review of the literature on the subject of metastatic bone diseases was done. Information on epidemiology, pathophysiology and mechanisms of bone metastases, clinical problems and concept of skeletal related events (SREs), differential diagnoses, diagnostic approach, general principles and options of treatment, and prognosis was extracted and presented.
Conclusions: Metastatic lesions are the most common malignant tumours that affect the skeleton, and these malignant deposits in bones increase overall morbidity in cancer patients. Appendicular skeleton offers a large surface area for deposition of tumour cells from primary sites, including the breast, prostate, lung, kidney and thyroid, with the highest incidence coming from breast and prostate. The osseous lesions of primary malignant diseases predispose to pain, mechanical instability and fractures in the affected parts. These factors contribute to the overall morbidity and reduced survival in cancer patients.

Femoral Geometry in Bisphosphonate-related Atypical Femoral Fracture and Bisphosphonate-naïve Atypical Femoral Fracture

Wachirawit Songsantiphap — 2025-01-04

Purpose: To compare the radiographic characteristics of femoral geometry between bisphosphonate-related atypical femoral fracture (BPAFF) and bisphosphonate-naïve atypical femoral fracture (BPnAFF).
Methods: A case-control study was conducted at the Police General hospital in Bangkok, Thailand, from January 2012 to December 2023; medical records and all available radiographs of hip and femoral fractures were reviewed. Atypical femoral fractures (AFF) were defined using the American Society for Bone and Mineral Research (ASBMR) 2013 criteria. BPAFF was identified in patients with a documented history of bisphosphonate prescription. The analysis encompassed a comparative assessment of femoral geometry parameters, including femoral offset, neck shaft angle, and lateral cortical thickness index (LCTi), between individuals with BPAFF and BPnAFF.
Results: A total of 13 BPAFFs and 10 BPnAFFs were identified in 19 patients. The prevalence rate in our hospital was 1.69%. Patients with BPAFF were comparatively younger (73.46±6.30 vs. 82.6±3.71 years, p<0.001). Fractures were more prevalent in the subtrochanteric region in the BPAFF group (10 [76.92%] vs. 3 [30%], p=0.04). BPAFF group had significantly higher LCTi at both subtrochanteric region (0.258±0.050 vs 0.211±0.067, p=0.037), and the femoral shaft level (0.357±0.056 vs 0.288±0.059, p=0.005). However, no statistically significant differences were observed in other femoral geometry parameters between both groups.
Conclusions: BPAFF exhibited a higher LCTi at the subtrochanteric and femoral shaft levels than BPnAFFs. On average, patients with BPAFF were younger than those with BPnAFF. Most BPAFF cases occurred in the subtrochanteric region, whereas BPnAFF cases were more commonly located in the diaphysis.

Survivorship and Modes of Failure of Varus-Valgus Constrained Implants in Revision Knee Arthroplasty: A Study with a Median Follow-Up of 2.9 Years in an Asian Population

Paphon Hirunyachoke — 2025-02-18

Purpose: This study aims to evaluate the survival rate, primary causes of failure, and complications associated with varus-valgus-constrained (VVC) implants in revision total knee arthroplasty (TKA) at a large Asian medical institution.
Methods: We retrospectively reviewed 161 patients who underwent revision TKA with VVC implants at our institution between January 2013 and December 2021. Data on patient demographics, initial diagnosis, revision dates, causes of failure, and subsequent re-revisions were collected and analyzed. The Kaplan-Meier method was used to estimate implant survival rates.
Results: This study included 161 patients who received VVC implant revisions, with a mean age of 73 years at the time of surgery. The mean follow-up period was 2.9 years, extending up to 10.0 years. The primary reasons for revision were infection (47.8%), aseptic loosening (36%), and instability (8.1%). The overall survival rate of VVC implants was 86.3%, with aseptic revisions at 84.5% and septic revisions at 88.3%, based on a median follow-up of 2.9 years. The 2-year survival rates were 92.5% overall, 88.1% for aseptic revisions, and 97.4% for septic revisions. The re-revision rate was 13.7% (22 VVC implants), primarily due to infections (86.4%).
Conclusions: VVC implants demonstrated a high 2-year survival rate of 92.5% in revision TKA at a large Asian medical institution. The most common indications for VVC implant use in revisions were infection and aseptic loosening, with infection being the leading cause of subsequent re-revisions.

The Impact of Postoperative CT Parameters on Functional Outcomes in Joint Depression-Type Calcaneal Fractures Fixed with Sinus Tarsi Locking Plate: A Retrospective Analysis

Adisorn Chongmuenwai — 2025-03-02

Purpose: To examine the correlation between postoperative computed tomography (CT) parameters and functional outcomes in patients treated with sinus tarsi locking plates for joint depression-type calcaneal fractures.
Methods: This study retrospectively analyzed patients who underwent sinus tarsi locking plate fixation for joint depression-type calcaneal fractures at a tertiary hospital between 2019 and 2021. The patients were followed up for an average of 16 months. Collected data included demographic information and postoperative CT parameters, including Böhler’s angle and posterior facet congruity. Functional outcomes were evaluated using the Foot and Ankle Ability Measure (FAAM) score.
Results: Postoperative CT scans were used to evaluate the quality of fracture reduction in 55 patients with calcaneal fractures treated with sinus tarsi locking plates. The mean FAAM score was 79.4 (range: 42–100). Among the patients, 45 (82%) achieved good functional outcomes, while 10 (18%) had poor outcomes, with no significant demographic differences between groups. Anatomical, near-anatomical, and poor reduction of the posterior facet were observed in 49%, 31%, and 20% of cases, respectively. Böhler’s angle was >20º and <20º in 76% and 24% of cases, respectively. Anatomical reduction of the posterior facet showed a significant correlation (P=0.025) with favorable outcomes, whereas Böhler’s angle showed no significant association (P=0.685).
Conclusions: Sinus tarsi locking plate fixation is effective in achieving satisfactory posterior facet reduction and functional outcomes for joint depression-type calcaneal fractures. Postoperative CT scans can help predict functional recovery by evaluating posterior facet reduction. Achieving posterior facet anatomical reduction is essential for favorable functional recovery.

Combined Vertebral Fracture Assessment and FRAX Tool Thailand With or Without Bone Mineral Density for Diagnosis of Osteoporosis in Elderly

Supakrit Kijparkorn — 2025-03-03

Purpose: To evaluate the reliability of using vertebral fracture assessment by radiography (VFA) in combination with FRAX tool Thailand to diagnose osteoporosis in elderly patients, without the need for bone mineral density (BMD) measurement.

Methods: All elderly individuals who fulfill the criteria for osteoporosis assessment according to the 2021 CPG for osteoporosis care by the Thailand osteoporosis foundation were assessed BMD, VFA, and FRAX tool Thailand with and without BMD. Fracture risk was first evaluated using only FRAX without BMD and the presence of asymptomatic vertebral fractures (AVF). The second assessment used FRAX with BMD, the results of BMD measurements, and the presence of AVF. The results of these two assessments were compared to evaluate the reliability of the osteoporotic diagnosis.

Results: The prevalence of osteoporosis in the study was found to be 67% (95% CI: 60%–72.9%). The test exhibited high sensitivity (90.6%, 95% CI: 84.5%–94.9%) and specificity (92.9%, 95% CI: 84.1%–97.6%), indicating its strong ability to accurately identify both individuals with and without osteoporosis. The Receiver Operating Characteristic (ROC) area of 0.918 (95% CI: 0.879–0.956). For subgroup analysis, in males (n=44), the test demonstrated excellent performance with a sensitivity of 95.2%, specificity of 100%, and a sensitivity of 89.8% and specificity of 89.4% in females (n=165). In the age-based subgroup analysis, the results in those aged >80 years (n=35) had highest sensitivity at 96.8% but lower specificity at 75.0%. For participants aged 70-80 years (n=84), sensitivity was 94.7%, and specificity was 88.9%. The youngest group, aged <70 years (n=90), had the lowest sensitivity of 82.4% but a high specificity of 97.4%. The ROC area ranged from 0.85 in those >80 years, 0.89 in those <70 years, and 0.91 in the aged 70-80 years group.

Conclusions: The combined use of VFA and FRAX without BMD offers a simple, highly effective method for diagnosing osteoporosis in elderly patients, especially in all men and women aged 70-80 years at minimal cost.

Risk Factors for Fragility Hip Fracture in the Older in Northern Thailand: A Community-Based Retrospective Cohort Study

Krairoek Waiwattana — 2025-03-23

Purpose: This community-based retrospective cohort study aimed to identify risk factors for fragility hip fractures among older individuals in three districts of Nan Province, Thailand. The study addresses a knowledge gap regarding hip fracture risk factors specific to northern Thai communities.
Methods: Health data from the Nan Provincial Health Office database, covering the period January 1, 2019 to December 31, 2023, were analyzed for 36,521 older individuals aged ≥ 60 years. Participants had no prior history of hip fracture. Data on demographics, chronic diseases, use of walking aids, history of non-hip fragility fractures, and FRAX hip scores were collected. Multivariate Cox regression analysis was performed to identify significant risk factors for hip fractures.
Results: Key risk factors for hip fractures included female sex, age ≥ 70 years, body mass index (BMI) < 20 kg/m², use of walking aids, history of non-hip fragility fractures, hypertension, chronic obstructive pulmonary disease (COPD), chronic kidney disease, cerebrovascular accident, and Parkinson’s disease. In males, significant risk factors included a BMI < 20 kg/m² and COPD, whereas in females, risk factors included hypertension, use of walking aids, and a FRAX hip score > 3.3%. Diabetes mellitus, dementia, heart disease, and lack of a caregiver were not found to be significant risk factors.
Conclusions: This study identified key risk factors for fragility hip fractures among community-dwelling older individuals in Northern Thailand, highlighting sex-specific risk profiles. The findings emphasize the need for targeted prevention strategies. Additionally, certain risk factors may be influenced by regional characteristics, geographical factors, and cultural aspects, limiting their generalizability.

Single Intra-Articular Platelet-Rich Growth Factor Injection for Knee Osteoarthritis: Is It Effective in Severe Patients?

Nuttawut Wiwattanawarang — 2025-04-21

Purpose: This study evaluated the clinical outcomes of intra-articular (IA) platelet-rich growth factor (PRGF) in patients with varying severities of knee osteoarthritis (KOA) using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. It also examined whether IA PRGF could delay or prevent surgical intervention in patients with severe KOA.
Methods: In this analytical observational cohort study, 120 patients with KOA, without systemic inflammatory disease or other intra-articular lesions, were classified using the Kellgren-Lawrence (KL) grading system. PRGF, a combination of leukocyte-rich platelet-rich plasma (LR-PRP) and injectable platelet-rich fibrin (iPRF), was prepared using the PP, GF, and ALPAS systems. A single 7 mL IA PRGF injection was administered. WOMAC scores were assessed at baseline, 1 week, and 1, 3, 6, and 12 months post-injection.
Results: Ninety-six female and 21 male patients (mean age: 64.9±8.3 years) were included. Based on KL grading, 38 patients were classified as mild (grade I-II), 44 as moderate (grade III), and 35 as severe (grade IV). All groups showed a decline in WOMAC scores after PRGF injection. Although baseline scores were highest in the severe group, the pattern of score reduction was similar across all severities. WOMAC scores at 3 months were lower in the mild and moderate groups than in the severe group. At 12 months, all groups maintained significantly reduced scores compared to baseline.
Conclusions: A single IA PRGF injection effectively improves pain, stiffness, and function in patients with severe KOA, with outcomes comparable to those in mild and moderate cases over 12 months of follow-up.

Comparative Effectiveness of Different Osteoporosis Medications in Enhancing Bone Mass

Sitti Phapasawad — 2025-06-20

Purpose: To compare the spine and non-dominant hip bone mineral density before and after treatment with different categories of osteoporosis medications.

Methods: In this retrospective cohort study, we analyzed the medical records of patients with osteoporosis who were prescribed anti-resorptive agents (bisphosphonates, alendronate, risedronate, intravenous ibandronate, and denosumab) or bone-forming agents (teriparatide). Patients were selected using purposive sampling. Descriptive statistical analysis was performed, including calculations of percentages, means, and standard deviations, along with hypothesis testing using Wilcoxon signed-rank and t-tests.

Results: Among the 80 participants treated with these medications and monitored over 3–5 years, with at least 2 years of continuous treatment, none had hip or spine fractures. In the bisphosphonate group (n = 59), both the spine and non-dominant hip bone mineral density showed significant improvements. The denosumab group (n = 17) demonstrated a significant increase in spine bone mineral density, whereas the increase in nondominant hip bone mineral density was not significant. The teriparatide group (n = 4) showed improvements in both the spine and non-dominant hip bone mineral density, although not significant, possibly because of the small sample size.

Conclusions: All medication categories had positive effects on bone mineral density. Antiresorptive agents, particularly bisphosphonates, showed significant improvements in both spine and hip bone mineral density, whereas denosumab showed significant improvement, specifically in spine bone mineral density. The bone-forming agent teriparatide showed a positive trend, although not significant, likely because of the limited sample size.

Long-term Outcomes of Short-Stem Total Hip Arthroplasty in Patients Aged Forty Years or Younger with Osteonecrosis of the Femoral Head

Thanut Tippimanchai — 2025-06-18

Purpose: This study aimed to analyze the clinical and radiographic results with a minimum 10-year follow-up of short-stem total hip arthroplasty (THA) in patients aged 40 years or younger with osteonecrosis of the femoral head (ONFH).

Methods: A retrospective analysis was conducted on 45 of 55 eligible patients with ONFH who underwent Metha® short-stem THA, with a minimum 10-year follow-up (82% follow-up rate). The clinical outcomes were measured using the Harris Hip Score (HHS) and Forgotten Joint Score (FJS). Radiography was used to assess osteointegration, stem subsidence, and stress shielding. Patient satisfaction was recorded.

Results: The mean HHS significantly improved from 43.2 preoperatively to 97.4 at the final follow-up (p<0.0001), and the mean FJS score was 93.4. Radiography revealed osteointegration mainly in zones 1 (95.6%), 2 (88.9%), 6 (100%), and 7 (91.1%). The patient satisfaction was ‘very satisfied’ in 43 (95.6%) and ‘satisfied’ in 2 (4.4%) patients. The Kaplan-Meier survivorship for the overall implant system was 93.3% at 10 years, with revisions required in 3 cases (acetabular component or liner only). At 10 years, stem survivorship was 100% for any reason and 100% for aseptic loosening.

Conclusions: Short-stem THA provides promising long-term clinical outcomes for patients aged 40 years or younger with ONFH. Radiographic results demonstrated physiological proximal load transfer with minimal stress shielding.

Hip Fracture Surgery Between 24–48 Hours Is a Risk Factor for One-Year Mortality in Elderly Patients

Pumsak Thamviriyarak — 2025-06-20

Purpose: This study compared one-year survival rates between elderly patients who underwent hip fracture surgery within 24 hours versus those between 24–48 hours, and assessed factors influencing survival.

Methods: This retrospective cohort study included elderly patients who underwent hip fracture surgery at Yasothon Hospital between June 1, 2019, and January 31, 2023. Patients were followed up until their final life status, as determined on January 31, 2024. In total, 212 patients were included, with 106 each undergoing surgery within 24 hours and between 24–48 hours. Statistical analyses were performed using the log-rank test and Cox regression.

Results: A total of 36 patients (16.98%) died during the one-year follow-up period, with most deaths occurring in the 24–48-hour surgery group (27 patients, 25.47%). The mortality rates at 3 months, 6 months, and 1 year were 5.19%, 3.30%, and 8.49%, respectively. Significant mortality predictors included: age (adjusted HR = 1.06, 95% CI = 1.01–1.12); ASA class 3 (adjusted HR = 8.17, 95% CI = 1.03–64.79); general anesthesia (adjusted HR = 3.10, 95% CI = 1.46–6.57); complications (adjusted HR = 2.16, 95% CI = 1.02–4.56); and surgery performed after 24 hours (adjusted HR = 3.88, 95% CI = 1.67–9.02).

Conclusions: Hip fracture surgery performed after 24 hours significantly increases the mortality risk in elderly patients. General anesthesia and postoperative complications are the key factors affecting survival. These findings emphasize the importance of surgery within 24 hours to reduce both mortality and complications in elderly patients.