Archives of Orthopaedic and Trauma Surgery

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Consort flow diagram. MOWHTO medial open wedge high tibia osteotomy, ACLR anterior cruciate ligament reconstruction, DFO distal femur osteotomy
Case demonstration about the additional supplemental screw in MOWHTO without hinge fracture
Introduction Our earlier studies reported that an additional lag screw placed from the opposite side increases the stability of the fixation construct in medial open wedge high tibia osteotomy (MOWHTO). The aim of the study was to evaluate the clinical relevance of the use of a supplemental screw with immediate post-operative full weight-bearing and its benefits in terms of functional outcome, radiographic outcome and complications. Materials and methods A retrospective study was performed comparing the historical cohort (MOWHTO without opposite screw) (group A) with the current cohort (MOWHTO with opposite screw) (group B). The patients underwent clinical and radiological assessments. We evaluated the WOMAC (The Western Ontario and McMaster Universities) score, IKDC (International Knee Documentation Committee) scores, and Lysholm knee score. Patients’ return to sports and work were also recorded. Results We included 123 knees receiving MOWHTO alone (group A) with 114 knees (group B) receiving MOWHTO with an opposite screw. A shorter bone union time (18.3 ± 2.1 weeks v.s. 11.5 ± 2.6 weeks, p < 0.001), earlier return to sports (6.1 months vs. 4.6 months, p < 0.001) and return to works (3.2 months vs. 2.3 months, p < 0.001) and better 6-month functional outcomes were found in group B (p < 0.001). The complications were similar in both groups. One patient experienced irritation at the site of the screw entrance and the screw was removed after union. Conclusion The current study evaluated the clinical efficacy of a supplemental lag screw placed from the opposite side in MOWHTO. Comparing to the plate alone, the additional opposite screw improved the implant and fixation stability under immediate weight-bearing without causing complications. A shorter time for returning to sports and work was noted, and a better functional outcome at 6-month follow-up was registered.
Background A reliable predictive tool to predict unplanned readmissions has the potential to lower readmission rates through targeted pre-operative counseling and intervention with respect to modifiable risk factors. This study aimed to develop and internally validate machine learning models for the prediction of 90-day unplanned readmissions following total knee arthroplasty. Methods A total of 10,021 consecutive patients underwent total knee arthroplasty. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with 90-day unplanned hospital readmissions. Four machine learning algorithms (artificial neural networks, support vector machine, k-nearest neighbor, and elastic-net penalized logistic regression) were developed to predict 90-day unplanned readmissions following total knee arthroplasty and these models were evaluated using ROC AUC statistics as well as calibration and decision curve analysis. Results Within the study cohort, 644 patients (6.4%) were readmitted within 90 days. The factors most significantly associated with 90-day unplanned hospital readmissions included drug abuse, surgical operative time, and American Society of Anaesthesiologist Physical Status (ASA) score. The machine learning models all achieved excellent performance across discrimination (AUC > 0.82), calibration, and decision curve analysis. Conclusion This study developed four machine learning models for the prediction of 90-day unplanned hospital readmissions in patients following total knee arthroplasty. The strongest predictors for unplanned hospital readmissions were drug abuse, surgical operative time, and ASA score. The study findings show excellent model performance across all four models, highlighting the potential of these models for the identification of high-risk patients prior to surgery for whom coordinated care efforts may decrease the risk of subsequent hospital readmission. Level of evidence Level III, case–control retrospective analysis.
VAS scores and ODIs before and after treatment in the control and ZOL groups. Note: Data are presented as the mean ± SD. *P < 0.01 compared with the corresponding baseline values. #P < 0.01 compared with the post-1w values. ^P < 0.01 ZOL group vs. control group. &P < 0.01 ZOL group vs. control group at post-12 m. VAS visual analog scale, ODI Oswestry disability index, ZOL zoledronic acid
BMD before and after treatment in the control and ZOL groups. Note: Data are presented as the mean ± SD. *P < 0.01 compared with the baseline values. #P < 0.01 compared with the post-6 m values. ^P < 0.01 ZOL group vs. control group. BMD bone mineral density, ZOL zoledronic acid
PINP, β-CTX and NMID before and after treatment in the control and ZOL groups. Note: Data are presented as the mean ± SD. *P < 0.01 compared with the baseline values. ^P < 0.01 ZOL group vs. control group. PINP type I procollagen amino-terminal peptide, β-CTX beta type I collagen carboxy-terminal peptide, NMID N-terminal molecular fragment, ZOL zoledronic acid
Vertebral height and Cobb angle of the injured vertebrae before and after treatment in the control and ZOL groups. Note: Data are presented as the mean ± SD. *P < 0.01 compared with the baseline values. #P < 0.01 compared with the post-3 m values. ^P < 0.01 ZOL group vs. control group. &P < 0.01 ZOL group vs. control group at post-12 m values. ZOL zoledronic acid
Introduction To explore the therapeutic efficacy of percutaneous kyphoplasty (PKP) combined with zoledronic acid (ZOL) in postmenopausal women and adult men with osteoporotic vertebral compression fracture (OVCF). Materials and methods A total of 238 patients with OVCF were randomly assigned to the control or ZOL group: 119 patients were treated with only PKP (control group), and 119 were treated with ZOL infusion after PKP (ZOL group). Clinical, radiological and laboratory indices were evaluated at follow-up. Results The visual analog scale (VAS) score and Oswestry Disability Index (ODI) were significantly higher in both groups post-treatment than at baseline (all p < 0.01). The bone mineral density (BMD) of the proximal femoral neck and height of the injured vertebra were significantly increased after treatment compared with before treatment, and the Cobb angle of the injured vertebra was significantly decreased in both groups (all p < 0.01). However, the bone metabolism indices (type I procollagen amino-terminal peptide (PINP), beta type I collagen carboxy-terminal peptide (β-CTX), and osteocalcin in the N-terminal molecular fragment (NMID)) were significantly lower post-treatment than at baseline in only the ZOL group (all p < 0.01). The VAS score, ODI, BMD, PINP level, β-CTX level, NMID level, vertebral height and Cobb angle of the injured vertebra were significantly higher in the ZOL group than in the control group (all p < 0.01). There were no significant differences in the postoperative bone cement leakage rate between the two groups. At follow-up, new OVCFs were experienced by 16 patients in the control group and 2 patients in the ZOL group (p < 0.01). Conclusion The therapeutic efficacy of PKP combined with ZOL for primary OVCF is clinically beneficial and warrants further study.
Flow chart of inclusion of patients in this study
Introduction The purpose of this study was to assess if severity of radiographic changes of knee arthritis was associated with patient improvement after total knee arthroplasty (TKA). We hypothesised that patients with mild arthritis were more likely to report lower satisfaction, improvement in knee function and Oxford knee score (OKS) compared to patients with moderate or severe arthritis. Materials and methods Secondary analysis of prospectively collected data from TKA patients of two arthroplasty centres with knee radiographs available for assessment of disease severity. Patients completed the Oxford knee score (OKS) and were asked to rate the global improvement in knee condition and their satisfaction at 6 months post-TKA. Bivariable analysis and multivariable regression models were used to test the association between disease severity and each outcome. Results 2226 patients underwent primary TKA and 3.6% had mild arthritis. Mean OKS improved from 17.0 (SD 18.0) to 38.0 (SD 8.1) 6 months after TKA. Two hundred and twenty-two patients (10%) reported ‘Poor’ or ‘Fair’ satisfaction, and 173 (8%) reported knee function was ‘Much worse’, ‘A little worse’ or ‘About the same’ 6 months post-TKA. Patients with mild arthritis showed improvement in OKS [mean improvement in OKS = 19 (SD 15)], but were significantly more likely to report dissatisfaction (OR = 3.10, 95% CI 1.62 to 5.91, p = 0.006), lack of improvement (OR = 4.49, 95% CI 2.38 to 8.47, p < 0.001) and lower OKS scores (− 3 points, 95% CI − 5.39 to − 0.85, p = 0.008) compared to patients with moderate to severe arthritis. Conclusions While patients with mild radiographic arthritic changes improve after TKA, they were significantly more likely to report higher rates of dissatisfaction, less improvement in knee function and OKS compared to patients with moderate-severe grades of arthritis.
a–f Example of a removal of a femoral well-fixed cemented offset stem-extension using an osteotomy (a–d). After cerclage wiring of the OT fragment a subsequent trialing with a metaphyseal cone (e) and augments (f) was performed to reconstruct the joint
a Comparison of the revisability between well-fixed cemented conical stems vs. well-fixed cemented cylindrical stems. b A tendency to longer overall mean surgery time was observed in revisions of cylindrical stems. * Significance at the 0.05 level
Comparison of well-fixed cemented RTKA implant removals that were done without OT and with OT. The numbers above the columns represent P values. ** Significance at the 0.01 level. * Significance at the 0.05 level
Introduction While re-revision total knee arthroplasty (ReRTKA) steadily increases, the ease and bone-sparing removal of RTKA implants is gaining more and more in importance. Biomechanical data suggest that cemented conical stems can be removed significantly easier than cylindrical stems. However, no clinical evidence exists supporting this observation. Aim of this study was to compare the revisability and need for osteotomy (OT) between removals of well-fixed cemented conical vs. cylindrical RTKA stems. Materials and methods 55 removals of well-fixed full-cemented RTKA stems (29 knees) performed between 2016 and 2018 were retrospectively analyzed. Main outcome variables were: bone loss, fractures, osteotomy incidence, surgery duration, early postoperative complications (EPC), hemoglobin drop and blood transfusion. SPSS was used for the statistical analysis. Results 44.8% were conical, 48.3% cylindrical, and 6.9% combined stem designs. Causes for re-revision were PJI (75.9%), malposition (17.2%) and persistent pain (6.9%). 10 stem removals (18.2%) required an OT (four femoral, six tibial): eight stems (14.5%) had cylindrical and two (3.6%) conical designs ( P = 0.041). Fractures were noted solely in removals without OT (11.1% vs. 0%,). There was a tendency to more bone loss in cylindrical stem revisions (53.8% vs. 32%, P = 0.24). A longer overall surgery time was observed in revisions of cylindrical stems (+ 37 min, P = 0.05). There was higher hemoglobin drop and need for blood transfusion in revisions of cylindrical stems or after OT but without reaching statistical significance. The EPC rates were slightly higher in ReRTKA on cylindrical stems ( P = 0.28). Conclusion Well-fixed cemented conical stems may be revision friendlier with less demands on OT and shorter overall surgery time than cemented cylindrical stems.
Purpose The popliteomeniscal fascicles (PMFs) are a crucial part of the posterolateral corner of the knee. They provide stability to the lateral meniscus and stabilize the joint during tibial internal rotation. The clinical diagnosis of a torn PMFs is difficult, and magnetic resonance imaging (MRI) may be inconclusive as well. The aim of the present study was to report the outcomes of a continuous series of patients affected by PMF lesions and treated with an arthroscopic repair. Methods Seventeen patients (average age of 22 ± 3.6 years) with PMF lesions and lateral meniscus instability were prospectively enrolled. All patients were evaluated with clinical examination, International Knee Documentation Committee (IKDC), Lysholm and Tegner scores and 1.5 T MRI. All patients had the same arthroscopic procedure consisting of meniscal repair with an all-inside meniscal repair system (mean 2.2 ± 0.77 anchors) and followed with the same postoperative protocol. Results All patients were available at a mean follow-up of 68 ± 24 months (range 49–84 months). Mean IKDC increased from 60.2 ± 13.5 to 83.1 ± 12, mean Lysholm score improved from 56.7 ± 8.2 to 89.8 ± 3.2, and mean Tegner score improved from 2.9 ± 1.3 to 6.5 ± 2. No intraoperative or postoperative complications were reported. MRI evaluation at 6-month follow-up showed successful healing of the menisco-popliteal fascicles in all cases. Conclusions The diagnosis and treatment of tears of the PMFs is still debated. Diagnostic confirmation of tearing of the PMFs is usually determined at the time of arthroscopy. Meniscal repair with an all-inside meniscal repair system appears to be an excellent treatment option, since it yields good functional results at mid-term follow-up, no local complications, and complete radiographic healing at 6-month follow-up MRI. Further studies are needed to confirm these promising early results. Level of evidence Case series, 4.
Axial CT image of the right femur, showing internal rotation of 3.4° from the angle formed between the surgical transepicondylar axis (sTEA) and posterior condylar line (PCL)
Axial CT images of the right tibia showing internal rotation of the tibial component: a Geometric centre (GC) of the tibial plateau determined by best fit ellipse (E1). b Tibial tubercle axis (TTA) extending from the tip of tibial tubercle prominence (TT) to the GC. c Tibial component axis (TCA) determined by drawing a perpendicular to the posterior condylar axis of the tibial polyethylene. d Tibial component rotational angle is measured to be in internal rotation of 22.4°, by the angle formed between TTA and TCA
Pre- and postoperative radiographs showing combined component malrotation: a Radiographs at 16 months post-primary TKA showing component malrotation. b Radiographs post-revision TKA demonstrating correction of the malrotation
Flow chart for different indications
Graphical representation of isolated and combined component malrotation time period of presentation from the index surgery: a Scatter plot graph demonstrating the correlations of time index of failures from primary knee replacement to isolated tibial malrotation. b Scatter plot graph demonstrating the correlations of time index of failures from primary knee replacement to isolated femoral malrotation. c Scatter plot graph demonstrating the correlations of time index of failures from primary knee replacement to combined components malrotation
Purpose Achieving normal rotational alignment of both components in total knee arthroplasty (TKA) is essential for improved knee survivorship and function. However, malrotation is a known complication resulting in higher revision rates. Understanding malrotation of the components and its concomitant clinical and functional outcomes are important for early diagnosis and management. The purpose of this study was to evaluate the effect of malrotation on clinical outcomes and failure modes in both single and combined rotational malalignment. Methods From our hospital database of 364 revisions, a cohort of 76 knees with patellar maltracking, stiffness, reduced range of motion and early aseptic failure were reviewed and investigated for component malrotation using computed tomography following Berger protocol. CT findings confirmed component malrotation in 70 of these patients. Investigations included (1) measurement of femoral component malrotation using surgical transepicondylar axis, (2) measurement of tibial component malrotation using anteroposterior axis and (3) measurement of combined component rotational errors. Results The correlation of CT analysis and clinical outcomes after primary TKA revealed association of patellar maltracking with femoral internal rotation, pain and instability with tibial internal rotation and knee stiffness in patients with combined component malrotation as the commonest mode of presentation. Our study showed that patients with isolated femoral, tibial and combined malrotation presented at a mean period of 3.4 ± 1.34, 1.7 ± 0.8 and 2.3 ± 0.69 years, respectively, after the index surgery. Post-revision, the mean Knee Society Score and Oxford Knee Score improved from 29.1 to 78.7, and 10.5 to 32.8, respectively, and the mean range of motion improved from 74.9 ± 24.8 to 97.1 ± 12.7 degrees at a mean follow-up of 42 months. Conclusion Early detection of malrotation in TKA and its management with revision of both components can lead to better clinical and functional outcomes. Level of evidence: III.
BTB autograft harvesting and bone grafting preparation. A Patellar and tibial 10 × 10x25mm bone harvest site defects. B, C Remaining extra bone removal from the bone blocks via an oscillating saw or rongeur instrument. D Bone block and chips for grafting
Bone graft placement. A Bone block inserted to the patellar harvest site defect. B, C 2.5–5.0 cubic centimeters of DBM is added as augmentation to achieve complete congruency of the patella and tibial tubercle. D Suturing the patellar paratenon using Vicryl 2–0
Purpose Bone–patellar tendon–bone (BTB) autograft remains the most widely used graft source for anterior cruciate ligament reconstruction (ACLR). The drawback associated with BTB is increased donor-site morbidity, such as anterior knee pain. The purpose of this study was to evaluate and compare anterior knee pain after refilling the patella bony defect with bone substitute. Methods This is a retrospective analysis of consecutive patients who underwent BTB ACLR at a single institution between January 2015 and December 2020. The cohort was divided into two groups; one in which the patellar bony defect was refilled with bone substitute (Bone Graft group) and another in which this the bony defects were not treated (No Bone Graft group). Demographic variables, reported anterior knee pain, visual analog scale (VAS) score, complications, re-operation, and patient reported outcome measures, such as the IKDC, LYSHOLM and SF-12 scores, were compared between groups. Results A total of 286 patients who underwent BTB ACLR were included. The No Bone Graft group included 88 (30.7%) patients and the Bone Graft group included 198 (69.3%) patients. The Bone Graft group had less anterior knee pain at last clinic follow up (33.3% vs. 51.1% p = 0.004) as well as lower VAS anterior knee pain scores (2.18 vs. 3.13, p = 0.004). The Bone Graft group had lower complications rates (21.7% vs 34.1, p = 0.027). No differences were found in the LYSHOLM, IKDC, and SF-12 scores. Conclusion Bone refilling in BTB ACLR significantly reduces prevalence and severity of anterior knee pain. Larger randomized trials are needed to confirm the benefits of bone refilling in ACLR patients. Level of evidence Retrospective study—III.
OR time comparison between the two groups
KOOS pain and function distribution
Postoperative HKA distribution
Background Robotic assisted total knee arthroplasty (RTKA) has shown improved knee alignment and reduced radiographic outliers. However, there remains debate on functional outcomes and patient-reported outcomes (PROMs). This study compares the 1-year clinical outcomes of a new imageless robotically assisted technique (ROSA Knee System, Zimmer Biomet, Warsaw, IN) with an imageless navigated procedure (NTKA, iAssist Knee, Zimmer, Warsaw, IN). Methods The study is a retrospective analysis of prospectively collected data that compared the functional outcomes and PROMs of 50 imageless RTKA with 47 imageless NTKA at 1-year follow-up. Baseline characteristics, intraoperative and postoperative information were collected including complications, revisions, Knee Society Score (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS) score, and Forgotten Joint Score (FJS-12). Radiographic analysis of preoperative and postoperative images evaluating hip–knee–ankle (HKA) angle was performed. Results There was no difference regarding baseline characteristics between the groups. Mean operative time was significantly longer in the RTKA group (122 min vs. 97 min; p < 0.0001). Significant differences were reported for the “Pain” (85 [RTKA] vs 79.1 [NTKA]; p = 0.0283) subsection of the KOOS score. In addition, RTKA was associated with higher maximum range of motion (119.4° vs. 107.1°; p < 0.0001) and better mean improvement of the arc of motion by 11.67° (23.02° vs. 11.36°; p < 0.0001). No significant differences were noted for other subsections of KOOS, KSS, FJS-12, complications, or limb alignment at 1-year follow-up. Conclusions Imageless RTKA was associated with longer surgical time, better pain perception and improved ROM at 12-month follow-up compared with NTKA. No significant differences were reported on other PROMs, complication rates and radiographic outcomes. Level of evidence III.
A After resected bone at femoral shortening osteotomy divided vertically, two or three gutters were made by surgical drill. B After wrapped osteotomy cite by resected bone, they were fastened using ultra-high molecular weight polyethylene (UHMWPE) tape. C Hybrid total hip arthroplasty with femoral shortening osteotomy. The right side is the original (S-ROM) stem, and the left side is the modified (S-ROM-A) stem
Kaplan–Meier curves for the requirement of total hip arthroplasty revision (for any reason)
Longitudinal radiographic course of the Cementless group (upper panels) and Cement group (lower panels) until 10 years. White arrows mean thinning of cortical bone and enlargement of medullary cavity
Longitudinal radiographic course of Dorr type C of the Cementless group (upper panels) and Cement group (lower panels). White lines mean stem alignment
Introduction There is still little information regarding the advantages of a using a polished tapered stem for Crowe Type IV developmental dysplasia of the hip (DDH). This study aimed to investigate the mid-term clinical and radiological outcomes of primary total hip arthroplasty (THA) with femoral shortening osteotomy using modular and polished tapered stems and to compare the results between the modular and polished tapered stems. Materials and methods This retrospective review included 32 patients (37 hips) with Crowe type IV DDH who underwent primary THA with femoral shortening osteotomy using a modular stem (cementless group, 14 hips) or a polished tapered stem (cement group, 23 hips) between 1996 and 2018. Clinical data and radiographic assessments were reviewed to analyze the differences between the two groups. Results The mean duration of patient follow-up of the cementless group (134.4 months) was longer than that of the cement group (75.5 months). There were no differences in clinical results, time of bone union, and survival rate between the two groups. However, the cementless group exhibited a higher ratio of intraoperative fracture and thinning of cortical bone including stress shielding, medullary changes, stem alignment changes, and osteolysis, compared to the cement group. Conclusions The findings of this study suggest that THA with femoral shortening osteotomy using both cemented and modular stems can provide satisfactory results. However, considering the occurrence of intraoperative fracture and radiographic analysis in the current study, the cement stem may have an advantage for patients with bone fragility and deterioration in bone quality.
Radiological analysis of a patient affected by left UKA PJI. A Preoperative X-ray showing lateral left UKA. B Articulating spacer. C 3-year follow-up with optimal implant alignment and firm osseointegration of the revision prosthesis
Radiological imaging of a UKA-infected patient. A Preoperative X-ray showing a right medial UKA. B Articulating spacer. C 4-year follow-up with a PS prosthesis implantation
Introduction Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1–0.8%. Despite the wide amount of literature about septic total knee arthroplasty management, few data are available for UKA infection treatment. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two-stage exchange. Methods We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single bone infection unit. The main demographic and surgical data were recorded. Clinical scores (VAS, KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow-up was 33.5 ± 6.9 months. Results Mean age at surgery was 68.5 ± 9.1. All but two were medial UKA. The mean number of previous surgeries was 2.9 ± 1.9. The mean ROM, VAS, KSS and OKS of the entire population improved significantly (p < 0.01). Radiological analysis did not show any migration or implant loosening. Ten constrained condylar and six posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy and good final outcome. The implant survivorship free from infection was 100% at the final follow-up. The overall survival rate for any reason of revision was 100% Conclusion According to our results, staged revision represents a reliable ad effective option in delayed and late UKA infections. This technique provides optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two-stage exchange.
Introduction In the reconstruction of distal radioulnar ligaments (DRULs), interference screws can be used for antegrade or retrograde fixation of grafts to the ulna. However, the biomechanics of interference screw fixation are currently unknown. This study aimed to determine the biomechanical effects of these two fixations on the distal radioulnar joint (DRUJ) in a cadaveric model and to investigate the appropriate initial tension. Materials and methods A total of 30 human cadaver upper extremities were used, and the DRULs were reconstructed according to Adams’ procedure. First, eight specimens were randomly divided into two groups: antegrade and retrograde, followed by translational testing and load testing. Then, the other eight specimens were divided into the two groups above, and the contact mechanics, including forces, areas, and pressures, were measured. Finally, to investigate the appropriate initial tension, the remaining 14 specimens were fixed with interference screws under different tensions in an antegrade way, and the translational testing was repeated as before. Results In the neutral position, antegrade fixation exhibited less translation than retrograde fixation (7.21 ± 0.17 mm versus 10.77 ± 1.68 mm, respectively). The maximum failure load was 70.45 ± 6.20 N in antegrade fixation, while that in retrograde fixation was 35.17 ± 2.95 N (P < 0.0001). Antegrade fixation exhibited a larger increase in contact force than retrograde fixation (99.72% ± 23.88% versus 28.18% ± 10.43%) (P = 0.001). The relationship between tension and displacement was nonlinear (Y = − 1.877 ln(x) + 7.94, R² = 0.868, P < 0.0001). Conclusions Compared with retrograde fixation, the antegrade fixation of interference screws may be a more reliable surgical technique, as it shows a higher failure load and stability. In addition, to avoid the risk of potential arthritis caused by anterograde fixation, we propose an equation to determine the appropriate initial tension in DRUL reconstruction.
Surgical analysis and the plan using osteotomy guides. The osteotomy wedge (red) was planned as 20° dorsal extending and 5° ulnar adducting osteotomy. The patient-specific instrument guide (blue) was used to perform the planned osteotomy and to position the Kirschner wires. The holes of the Kirschner wires were later used to place the screws for plate fixation
Shows thumb number 3 with basilar thumb arthritis assessed as Eaton and Littler stage I preoperatively A and postoperatively B and thumb number 7 with Eaton and Littler stage II preoperatively C and postoperatively D
Introduction Arthritis of the basal thumb is a relatively common condition also affecting younger patients. Wilson et al. described a 20°–30° closing wedge osteotomy of the first metacarpal bone to unload the trapeziometacarpal joint. It was the purpose of this study to analyze the clinical and radiographic outcome of patients who underwent proximal extension osteotomy of the first metacarpal bone using patient-specific planning and instruments (PSI). Methods All patients who underwent proximal metacarpal osteotomy for basal thumb arthritis at our tertiary referral center were retrospectively included. The patients underwent preoperative planning using computed tomography and 3D segmentation to build patient-specific guides and instruments for the operative treatment. Stable fixation of the osteotomy was achieved by internal plating. The inclusion criterion was a minimum follow-up of 1 year with clinical examination, including the Michigan Hand Outcomes Questionnaire (MHQ), and computed tomography to validate the correction. Complications and reinterventions were recorded. Results A total of eight Wilson osteotomies in six patients could be included at a mean follow-up duration of 33±16 months (range, 12 to 55 months). The patients were 49±8 years (range, 36 to 58 years) at the surgery and 88% were female. The postoperative MHQ for general hand function was 77±8 (range, 45 to 100) and the MHQ for satisfaction was 77±28 (range, 17 to 100). The working status was unchanged in 7/8 hands (6/7 patients). Radiographic analysis revealed successful correction in all cases with unchanged Eaton–Littler stage in 7/8 hands. No complications were recorded. Conclusion The combined extending and ulnar adducting osteotomy using patient-specific guides and instrumentation provides an accurate treatment for early-stage thumb arthritis. Level of evidence Type IV—retrospective, therapeutic study.
Introduction Patients with femoroacetabular impingement syndrome (FAIS) experience decreased function. Consequently, earlier studies have evaluated gait biomechanics in these patients, but a larger study evaluating gait biomechanics before and after an intervention standardising gait speed is lacking. We aimed at investigating gait kinematics and kinetics in patients with FAIS compared with pain-free controls before and 1 year after hip arthroscopic surgery. Secondary, we aimed at analysing gait pattern separately for the sexes and to investigate associations between peak kinematics and kinetics and the Copenhagen Hip and Groin Outcome Score (HAGOS). Materials and methods Sixty patients with FAIS and 30 pain-free controls were tested at a standardised gait speed (1.40 m/s ± 10%). Patients were tested twice: before and 1 year after surgery. Kinematics and kinetics were recorded using infrared high-speed cameras and a force plate. Participants answered HAGOS. Results The largest difference among groups was that gait differed between males and females. Neither before nor after surgery could we demonstrate large alterations in gait pattern between patients and pain-free controls. Male patients demonstrated associations between peak kinematics and kinetics and HAGOS Sports function. Conclusions Gait pattern was only vaguely altered in patients with FAIS compared with pain-free controls before and after surgery when using at standardised gait speed. Hence, analysing gait in patients with FAIS does not seem of major importance. Nevertheless, there was an association between HAGOS Sports function and peak kinematics and kinetics in male patients, implying that there could be a clinical importance.
Surgical technique; * gracilis tendon, # sartorius fascia, + medial collateral ligament
Surgical technique; * gracilis tendon, # sartorius fascia, + medial collateral ligament
Purpose Reconstruction of the medial patellofemoral ligament (MPFL) is an established procedure to restore patellar stability. Aim of this study is to evaluate the results of a dynamic MPFL reconstruction technique in a large university hospital setting. Methods Two hundred and thirteen consecutive patients with 221 knees were surgically treated for recurrent lateral patellar dislocation. All patients obtained dynamic reconstruction of the MPFL with detachment of the gracilis tendon at the pes anserinus while maintaining the proximal origin at the gracilis muscle. Patellar fixation was performed by oblique transpatellar tunnel transfer. Follow-up data including Kujala and BANFF score, pain level as well as recurrent patella instability were collected at a minimum follow-up of 2 years. Results Follow-up could be obtained from 158 patients (71%). The mean follow-up time was 5.4 years. Mean pain level was 1.9 ± 2.0 on the VAS. Mean Kujala score was 78.4 ± 15.5. Mean BANFF score was 62.4 ± 22.3. MPFL-reconstructions that were performed by surgeons with a routine of more than ten procedures had a significantly shorter surgical time 52.3 ± 17.6 min. Male patients yielded higher satisfaction rates and better clinical scores compared to females. Complications occurred in 27.2% of procedures, 20.9% requiring revision surgery of which were 9.5% related to recurrent patellar instability. 78% of all patients indicated they would undergo the procedure again. Conclusion Dynamic MPFL reconstruction presents a reproducible procedure with increased complication rates, inferior to the results of static reconstruction described in the literature. Despite, it appears to be an efficient procedure to restore patellar stability in a large university hospital setting, without the necessity for intraoperative fluoroscopy. Trial registration The study was registered in with the registration number NCT04438109 on June 18th 2020.
a The course of QT on the oblique sagittal plane. b The measurement of QT length on oblique sagittal T1-weighted MRI
a The course of ACL on the oblique sagittal plane. b The measurement of native ACL length on oblique sagittal T1-weighted MRI
The calculation of adequate QT autograft
Calibration plot showing the predicted probabilities for adequate QT length and height
ROC curve for height. State variable: inadequate QT
Objective This prospective study aimed to predict the adequacy of free quadriceps tendon (QT) autograft length using simple anthropometric measures. Materials and methods One hundred and eighty-four consecutive patients who underwent knee high-resolution MRI were enrolled in this study. The QT and native anterior cruciate ligament (ACL) length were measured using the oblique sagittal section. The adequate free QT length was calculated using the native ACL length and 30 mm for femoral and tibial tunnels in each patient. A QT shorter than the calculated length was considered inadequate. Age, sex, height, weight, body mass index, thigh circumference, and activity score were used to predict the adequacy of QT length with regression analysis. Results There were 92 men and 92 women with a mean age of 34.1 ± 8.0 years (range 18–45). The mean QT and ACL lengths were 69.0 ± 8.8 mm (range 48.1–90.3 mm) and 35.6 ± 2.5 mm (range 29.2–42.6 mm), respectively. The QT and the ACL lengths were longer in men (p < 0.001 for both). Twenty-three men and 39 women (total: 62, 33.7%) had inadequate QT length for a free QT autograft, and 6 patients (3 males, 3 females, 3.3%) had inadequate QT length with the bone block technique. There was a weak positive correlation between QT length and height (p < 0.001), weight (p < 0.001), and activity score (p = 0.007). Height was the only independent variable that predicted the QT length adequacy (r² = 0.051, p = 0.009) but ROC analysis showed that height did not have an ability to detect a subject with an inadequate QT length (AUC: 0.384, 95% CI 0.300–0.468). Conclusions Free QT autografts may be inadequate in one-third of the patients, while a QT autograft with a bone block is almost always sufficient. Inadequate free QT autograft is more common in women. Although QT length correlated with height, it cannot be used as an accurate diagnostic tool to identify patients with an inadequate QT autograft. Preoperative measurement of the ACL and QT lengths by MRI might be beneficial to decide whether QT is usable, especially when harvesting without a bone block. Level of evidence Level II, diagnostic, prospective cohort study.
Skin incision for the harvest of the BT graft
Double knife for harvest of the BT graft
The position of the passive markers fixed to the patient’s leg
Introduction The aim of this prospective randomised study was to evaluate clinical results and rotational stability at least 2 years after single-bundle anatomic anterior cruciate ligament reconstruction using a quadriceps tendon graft with bone block (BT) and bone–patellar tendon–bone graft (BTB). Materials and methods In both groups (BT and BTB), 40 patients selected prospectively at random were evaluated. The mean follow-up after the surgery was 28 months (range 24–33 months). A navigation system was used to measure rotational stability of the knee joint. Cincinnati, Lysholm, and IKDC scores and visual analog score (VAS) were used to evaluate clinical results and the non-parametric Wilcoxon test was used for the statistical analysis. Results After the BT reconstruction, the mean internal rotation of the tibia (IR) was 9.5°. In the contralateral healthy knee joint, IR was 8.6° at average. After the BTB reconstruction, the mean IR was 9.9°. In the contralateral healthy knee joint, IR was 8.7° at average. We did not find any statistically significant difference in IR stability between BT and BTB reconstruction. In terms of clinical results, regarding the VAS, patients perceive significantly more pain after the BTB reconstruction (p < 0.05). Kneeling was reported more difficult and painful after BTB reconstruction. Conclusions The BT reconstruction of the ACL provides similar clinical results, less pain, better flexion and the same rotational stability of the knee in comparison with the BTB reconstruction.
Computed tomography (CT) motion simulation using Articulis software (Clinical Graphics, Den Haag, The Netherlands). The software automatically converts CT scans to 3D models of the femur and pelvis. In this figure the hip joint is presented in an anterior–posterior projection with a the hip joint in neutral b the hip joint in 90 degrees’ flexion and 26 degrees’ internal rotation when the impingement occurs. The software identifies the impinging area by 0.1 mm
Maximum passive range of internal rotation with the hip in 90 degrees’ flexion measured using computed tomography (CT) motion simulation and three-dimensional (3D) motion analysis a prior to and b at mean 7 months after arthroscopic surgery. For participants with no orange bar, the CT simulation yielded 0 degrees of internal rotation with the hip in 90 degrees’ flexion
Maximum passive range of internal rotation and adduction with the hip in 90 degrees’ flexion measured using computed tomography (CT) motion simulation and three-dimensional (3D) motion analysis a prior to and b at mean 7 months after arthroscopic surgery. For participants with no orange bar, the CT simulation yielded 0 degrees of internal rotation with the hip in 90 degrees’ flexion and adduction
Introduction Discerning whether range of motion (ROM) is restricted by morphology or other pain sources is challenging in patients with femoroacetabular impingement syndrome (FAIS). Computed tomography (CT) motion simulation provides a hypothetical ROM based on morphology. This study aimed to explore associations between ROM measured using CT motion simulation and maximum passive ROM measured clinically using three dimensional (3D) motion analysis in patients with FAIS, prior to and post arthroscopic hip surgery. Materials and methods Eight males with FAIS (in total 12 hip joints) were included in this explorative feasibility study. Participants were examined using CT according to a low-dose protocol prior to and 7-months post arthroscopic surgery. Software was used to simulate at which ROM the impingement would occur. With the hip in 90 degrees’ flexion, maximum passive range of internal hip rotation, and maximum passive internal hip rotation coupled with adduction was examined clinically using 3D motion analysis pre- and postoperatively. Spearman rank correlation coefficients and linear regressions examined associations between methods. Results Preoperatively, the correlation between maximum internal hip rotation measured using CT motion simulation and 3D motion analysis was strong (r = 0.71, p = 0.009). Linear regressions demonstrated that maximal internal rotation measured using CT motion simulation was predominantly larger than when measured using 3D motion analysis. Postoperatively, and when maximum internal rotation was coupled with adduction, no correlations were found between the two methods. Conclusions The hypothetical morphology restricted ROM is larger than clinically assessed pain restricted ROM, both prior to and post hip arthroscopy. These findings suggest that ROM is restricted by pain rather than mechanical, morphology-based impingement in individuals with FAIS.
Negative lever sign test
Positive lever sign test
IntroductionThe objective of this study was to assess the diagnostic value of the “lever sign test” to diagnose ACL rupture and to compare this test to the two most commonly used, the Lachman and anterior drawer test.Method This prospective study was performed in the ED of the Cliniques Universitaires Saint-Luc (Brussels, Belgium) from March 2017 to May 2019. 52 patients were included undergoing knee trauma, within 8 days, with an initial radiograph excluding a fracture (except Segond fracture or tibial spine fracture). On clinical investigation, patients showed a positive lever sign test and/or a positive Lachman test and/or a positive anterior drawer test. Exclusion criteria were a complete rupture of the knee extensor mechanism and patellar dislocation. All the physicians involved in this study were residents in training. An MRI was performed within 3 weeks for all included patients after the clinical examination. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were investigated for all three tests with MRI used as our reference standard.ResultsForty out of 52 patients suffered an ACL rupture (77%) and 12 did not (23%). The sensitivity, specificity, PPV and NPV of the lever sign test were respectively 92.5%, 25% 82% and 50%. Those of the Lachman test were 54%, 54.5%, 81% and 25%, and those of the anterior drawer test were 56%, 82%, 90.5% and 37.5%. Twelve out of 40 ACL ruptures (30%) were diagnosed exclusively with a positive lever sign test.Conclusion When investigating acute ACL ruptures (< 8 days) in the ED, the lever sign test offers a sensitivity of 92.5%, far superior to that of other well-known clinical tests. The lever sign test is relatively pain-free, easy to perform and its visual interpretation requires less experience. Positive lever sign test at the ED should lead to an MRI to combine high clinical sensitivity with high MRI specificity.
Coronal (a) and sagittal (b) MRI of a representative case of the no-shift-type of CDLM
Two positioned MRI at full extension (a) and deep flexion (b) positions. A case of anterior displacement during deep flexion is shown in (c) full extension MRI, (d) routine MRI in the 10-degree flexion position and (e) deep flexion MRI. A case of posterior displacement during full extension is shown in (f) during full extension MRI, (g) routine MRI in the 10-degree flexion position and (h) deep flexion MRI. Meniscal displacement was identified as anterior shift (e: white arrow) with suspected posterior PRI and as posterior shift (f: white arrow) with suspected anterior PRI
Intraoperative findings in anterior PRI viewed from the anteromedial port (a) and posterior PRI from the lateral gutter view through the anterolateral port (b). Meniscal detachment was observed (a; white arrow) for anterior PRI: anterior horn (black arrow in (a)) of the displaced DLM. The tibial plateau (b; white arrow) was observed to detect posterior PRI, black arrow; (b): posterior horn of the displaced DLM. White arrowhead (b): popliteal tendon
IntroductionWe evaluated the efficacy of two positioned magnetic resonance imaging (MRI) for visualizing the snapping phenomenon and detecting peripheral rim instability (PRI) in no-shift-type complete discoid lateral meniscus (CDLM).Materials and methodsThe records of 39 patients diagnosed with no-shift-type CDLM under routine MRI who underwent arthroscopic surgery were reviewed. The snapping phenomenon and meniscal shift on two positioned MRI in full extension and deep flexion were evaluated and calculated the agreement between these findings. The positive predictive value (PPV), sensitivity, and specificity of meniscal shift on two positioned MRI for predicting PRI were calculated; PRI was further investigated according to anterior and posterior location. The hypotheses of this study were asfollows: (1) Two positioned MRI can visualize the snapping phenomenon and (2) Meniscal shift on two positioned MRI is an important predictive sign of detecting the instability site in no-shift-type CDLM.ResultsThe κ values between the snapping phenomenon and meniscal shift on two positioned MRI were 0.84. The snapping and two positioned MRI findings had high PPV (1.0, 0.96), sensitivity (0.82, 0.85), and specificity (1.0, 0.91) for predicting overall PRI. For anterior PRI, the snapping and posterior shift on two positioned MRI had moderate and high PPV (0.78, 0.9), high sensitivity (0.9, 0.9), and specificity (0.8, 0.89). The anterior shift on two positioned MRI findings predicted posterior PRI with high PPV (1.0) and specificity (1.0).Conclusions Two positioned MRI visualized the snapping phenomenon. Meniscal shift on two positioned MRI was an important predictive sign of overall PRI, anterior PRI, and posterior PRI in no-shift-type CDLM.
PurposeConventional press-fit technique for anterior cruciate ligament reconstruction (ACLR) is performed with extraction drilling of the femoral bone tunnel and manual shaping of the patellar bone plug. However, the disadvantages of this technique include variation in bone plug size and, thus, the strength of the press-fit fixation, bone loss with debris distribution within the knee joint, potential heat necrosis, and metal wear debris due to abrasion of the guide wire. To overcome these disadvantages, a novel technique involving punching of the femoral bone tunnel and standardized compression of the bone plug was introduced. In this study, the fixation strength and apparent stiffness were tested and compared to that of the gold-standard interference screw fixation technique in three flexion angle configurations (0°/45°/90°) in a porcine model. We hypothesized that the newly developed standardized press fit fixation would not be inferior to the gold standard method.Methods Sixty skeletally mature porcine knees (30 pairs) were used. Full-thickness central third patellar tendon strips were harvested, including a patellar bone cylinder of 9.5 mm in diameter. The specimens were randomly assigned to 10 pairs per loading angle (0°, 45°, 90°). One side of each pair was prepared with the press-fit technique, and the contra-lateral side was prepared with interference screw fixation. Equivalent numbers of left- and right-sided samples were used for both fixation systems. A three-way multifactor ANOVA was carried out to check for the influence of (a) fixation type, (b) flexion angle, and (c) side of the bone pair.ResultsThe primary fixation strength of femoral press-fit graft fixation with punched tunnels and standardized bone plug compression did not differ significantly from that of interference screw fixation (p = 0.51), which had mean loads to failure of 422.4 ± 134.6 N and 445.4 ± 135.8 N, respectively. The flexion angle had a significant influence on the maximal load to failure (p = 0.01). Load values were highest in 45° flexion for both fixations. The anatomical side R/L was not a statistically significant factor (p = 0.79).Conclusion The primary fixation strength of femoral press-fit graft fixation with punched femoral tunnels and standardized bone plug compression is equivalent to that of interference screw fixation in a porcine model. Therefore, the procedure represents an effective method for ACL reconstruction with patellar or quadriceps tendon autografts including a patellar bone plug.
Flow diagram
Activity at ACL injury 42% of the patients at both A and B injured their ACL during soccer
Time from ACLR to re-rupture of graft. Absolute number (n) of re-ruptures indicated at each time interval
Non-revised vs revised patients
Introduction The guidelines regarding rehabilitation after pediatric anterior cruciate ligament reconstruction (ACLR) are sparse. The aim of the study was to retrospectively describe the long-term outcome regarding further surgery and with special emphasis on the revision rate after two different postoperative rehabilitation programs following pediatric ACLR. Material and methods 193 consecutive patients < 15 years of age who had undergone ACLR at two centers, A ( n = 116) and B ( n = 77), in 2006–2010 were identified. Postoperative rehabilitation protocol at A: a brace locked in 30° of flexion with partial weight bearing for 3 weeks followed by another 3 weeks in the brace with limited range of motion 10°–90° and full weight bearing; return to sports after a minimum of 9 months. B: immediate free range of motion and weight bearing as tolerated; return to sports after a minimum of 6 months. The mean follow-up time was 6.9 (range 5–9) years. The mean age at ACLR was 13.2 years (range 7–14) years. The primary outcome measurement in the statistical analysis was the occurrence of revision. Multivariable logistic regression analysis was performed to investigate five potential risk factors: surgical center, sex, age at ACLR, time from injury to ACLR and graft diameter. Results Thirty-three percent had further surgery in the operated knee including a revision rate of 12%. Twelve percent underwent ACLR in the contralateral knee. The only significant variable in the statistical analysis according to the multivariable logistic regression analysis was surgical center ( p = 0.019). Eight percent of the patients at center A and 19% of the patients at B underwent ACL revision. Conclusions Further surgery in the operated knee could be expected in one third of the cases including a revision rate of 12%. The study also disclosed a similar rate of contralateral ACLR at 12%. The revision rate following pediatric ACLR was lower in a center which applied a more restrictive rehabilitation protocol. Level of evidence Case-control study, Level III.
Flow chart demonstrating the excluded patients
A Arthroscopic image of Outerbridge grade 4 chondral lesion during ACL reconstruction; B lesion area after microfracture procedure completed; C reconstructed anterior cruciate ligament
The purposes of this study were to evaluate the clinical effects of microfracture (MFX) performed for Outerbridge grade 3 or 4 focal cartilage lesion during the same surgery with arthroscopic anterior cruciate ligament (ACL) reconstruction and to analyze the major determinants of these potential effects on the clinical outcome. The clinical and radiographic data of 119 patients were evaluated. The mean follow-up time was 32.6 ± 6 months. Isolated arthroscopic ACL reconstruction was performed in 70 patients (Group 1), whereas MFX for Outerbridge grade 3 or 4 chondral lesion during ACL surgery was performed in 49 patients (Group 2). Visual analogue scale (VAS) score, Lysholm knee score, and Tegner activity scale were the instruments used as outcome measures to evaluate the clinical status of the patients. Routine X-ray and MRI were also performed for all patients pre-operatively as well as at the latest follow-up visit. Lineer regression analysis was performed to determine major factors predicting the poorer clinical outcome. Clinical outcomes were similar between isolated ACL reconstruction and combined procedure. On the other hand, according to lineer regression analysis, cartilage lesion size > 2 cm² and > 5 degrees of varus alignment were detected as the major determinants leading to poorer outcomes in combined ACL reconstruction and MFX. Level of evidence: III – Retrospective Comparative Study.
The method of measurement of the ML dimension marked by a solid line (A) and AP dimension marked by a solid line (B). ML mediolateral, AP anteroposterior
The method to measure the overhang of the femoral implant intraoperatively
The measurement of implant’s AP and ML dimensions using a caliper (Persona TKA design). ML mediolateral, AP anteroposterior, TKA total knee arthroplasty
The ML/AP ratio of the standard implant of both TKA systems. ML mediolateral, AP anteroposterior, TKA total knee arthroplasty
The ROC curve of both TKA systems PERSONA (A) and Anthem (B). ROC using receiver operating characteristic, TKA total knee arthroplasty
Background Recently, total knee arthroplasty (TKA) designs that allow the use of narrow-version femoral implants have been introduced to avoid femoral overhang. The purpose of this study was to investigate the frequency of the use of narrow-version femoral implants and identify the difference in radiographic parameters between using a narrow-version femoral implant and a standard-version femoral implant in TKA.MethodsA retrospective study was conducted on 504 primary TKAs using a TKA system (Anthem or Persona) that allowed narrow-version femoral implants. Anteroposterior (AP) dimension, mediolateral (ML) dimension, and modified aspect percentage ratio (ML/AP dimension) of the distal femur in preoperative radiographs were compared between a standard-version group (n = 275) and a narrow-version group (n = 229). A cut-off value of a modified aspect percentage ratio indicating the need for a narrow-version femoral implant was determined using the receiver operating characteristic (ROC) curve.ResultsMean ML dimension was 80.9 ± 6.1 mm in the standard-version group and 77.3 ± 4.4 mm in the narrow-version group (p < 0.001). Mean modified aspect percentage ratio was 138.8 ± 8.1% in the standard-version group and 131.7 ± 6.3% in the narrow-version group (p < 0.001). The optimum cut-off point of the modified aspect percentage ratio for narrow-version femoral implants was 135.4% (sensitivity: 72.0%; specificity: 66.7%) for Anthem and 133.3% (sensitivity: 75.9%, specificity: 76.4%) for Persona.Conclusion In the narrow-version femoral implant group, the ML dimension and the mean modified aspect percentage ratio were smaller than in the standard-version femoral implant group. A smaller modified aspect percentage ratio of the distal femur in preoperative radiographs could predict the need for narrow-version femoral implants in TKA. It was suggested that the cut-off point could be suggested as 135.4% for Anthem TKA design and 133.3% for Persona TKA design. These radiographic parameters are cost-effective and easily applicable for planning a TKA.A smaller modified aspect percentage ratio of the distal femur in preoperative radiographs could predict the need for narrow-version femoral implants in TKA. The cut-off point was 135.4% for Anthem TKA design and 133.3% for Persona TKA design.
Differences of the femoral component between the 1st generation and the 2nd generation medial pivot total knee prostheses. Superposition of the 1st generation (orange) and the 2nd generation (blue) medial pivot total knee protheses, showing a decrease in the overhang of the posterior condyle in the new design, which could reduce the gap tension in the position of full knee flexion. TKA total knee arthroplasty
The Kaplan–Meier survival curve for the 1st generation and the 2nd generation medial pivot total knee prostheses. The survival curves are not significantly different between the two types of prostheses (log-rank test), with the endpoint of observation defined as reoperation due to any reason. Dashed lines represent the 95% confidence intervals. N.S. not significant
IntroductionThe medial pivot total knee arthroplasty (TKA) has good patients’ satisfaction; however, there is likely the restriction of postoperative knee flexion. The 2nd generation medial pivot TKA prosthesis was designed to improve postoperative knee flexion. This study aimed to compare the clinical outcomes and patient satisfaction between the 2nd generation and 1st generation medial pivot TKA prostheses.Materials and methodsWe conducted a retrospective study of 472 consecutive TKAs, performed using either the 2nd generation (EVOLUTION™), having smaller posterior femoral condyle and asymmetrical tibial tray, or 1st generation (ADVANCE™) prosthesis. The use of each system was historically determined. Patient age, sex and body mass index were matched between the two groups, with 157 cases ultimately included in each group. Measured clinical outcomes included: knee range of motion, the Knee Society Score, the rate of re-operation, and radiological parameters. Patient satisfaction was evaluated using the 12-item Forgotten Joint Score (FJS-12).ResultsThe average follow-up period was 5.0 (3.7–6.3) years for the 2nd generation group and 8.7 (6.1–12.8) years for the 1st generation group (p < 0.01). The postoperative knee flexion range was 127° (80°–140°) for the 2nd generation and 118° (90°–135°) for the 1st generation at final follow-up (p < 0.01). On multivariate regression analysis, use of the 2nd generation prosthesis predicted greater postoperative knee flexion. The average FJS-12 score was 64 (0–100) for the 2nd generation and mean 57 (0–100) for the 1st generation (p < 0.01). Other clinical outcomes were similar between the two groups.Conclusions Compared to the 1st generation, the 2nd generation medial pivot prosthesis provides greater postoperative knee flexion and patient satisfaction.
IntroductionThe influence of a previous high tibial osteotomy (HTO) on the outcome and survival of a knee arthroplasty is a debated issue. The purpose of this study is to compare subjective, radiographic, and functional outcomes of unicompartmental knee replacement (UKR) and total knee replacement (TKR) after failed open wedge HTO.Methods26 post-HTO UKRs (group A) with an average follow-up of 7.8 years (range 2–13), and 33 post-HTO TKRs (group B) with an average follow-up of 11.2 years (range 4–16) operated between 2001 and 2017, were retrospectively reviewed. Assessment included Knee Society Score (KSS), University of California at Los Angeles Activity Score (UCLA), and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Standard knee X-rays, and long-standing X-rays were performed pre-operatively and at follow-up to evaluate prosthesis survival, coronal alignment, and patellar height.ResultsImprovements regarding KSS, UCLA and WOMAC scores were noted at follow-up in both groups compared to pre-operatory status (p < 0.001). No statistically significant differences in clinical and functional postoperative scores were reported between groups (p = n.s.) at follow-up. Group B presented a more neutral mean mechanical axis of 0.5° compared to 2.7° in Group A (p < 0.001).Conclusions Performing UKR after previous failed HTO is a safe and effective procedure which leads to clinical, radiological and functional outcomes comparable to TKR after HTO.
IntroductionShort stems seem to be a good alternative for young patients as they offer promising results, rapid recovery and preservation of metaphyseal bone stock. This is one of the few studies in the literature to report medium-term clinical-radiological results for short hip stems.Materials and methodsThis prospective study evaluated 68 short femoral stems in 63 patients treated with total hip replacement. Clinical, functional and quality-of-life outcomes were measured at 6 and 12 months, and annually thereafter until the end of follow-up. The radiological analysis included measurements of potential leg length discrepancies, stem alignment and signs compatible with stress shielding.ResultsFifty-four males (59 hips) and nine females (9 hips) of an average age of 44.3 years (range, 25–68) were studied. The most common diagnosis was osteoarthritis (51.5%). Mean overall follow-up was 7.8 years (range, 5.8–9.8). The overall survival rate was 97.1% (95% CI 88.7–99.7%). Surgery resulted in an increase of 42.3 ± 1.1 points in the modified Harris Hip Score and 21.9 ± 0.6 points in the Oxford Hip Score (p < 0.001, respectively). Moreover, the pain score as measured on a numerical rating scale (NRS) improved from 95.8 to 36.3. As regards function, an improvement was observed from 3.2 ± 0.8 points to 6.8 ± 1.14 points on the University of California at Los Angeles activity score (p < 0.001, respectively). The radiological analysis showed an absence of radiolucencies or stress-shielding throughout the series. The complications rate at the end of follow-up was 5.7%.Conclusions The use of ultra-short cylindrical stems with complete anchorage in the femoral neck was shown to offer promising medium-term results. Such stems appear to be a good option for young patients, who are likely to require several revisions over their lifetime.
Bone impaction grafting surgical technique. 1: bone bank femoral head; 2: morcelized chips; 3: acetabular bone defect; 4: chips impaction to fill the defect
Acetabular defect Paprosky III B treated with BIG and Burch-Schneider revision ring. 1: preoperative X-ray; 2: FU X-ray demonstrating the stability of the APC and the integration of the bone graft
Pie chart representing the distribution of BIG resorption on control X-rays according to Gross: the left chart considers the global cohort while the two right charts differentiate Paprosky type III A and B defects
Pie chart representing the distribution of APCs stability on control X-rays according to Gill: the left chart considers the global cohort while the two right charts differentiate Paprosky type III A and B defects
PurposeReport clinical and radiological long-term follow-up (FU) outcome of bone impaction grafting (BIG) and anti-protrusio cage (APC) technique in hip revision surgery.Materials and methodsWe analysed data on complications, as well as the clinical and radiological outcome of patients treated using this technique at our institution. We evaluated the acetabular bone stock renovation, acetabular component stability and its radiological migration. The clinical parameters considered were the Visual Analogue Scale (VAS) and the modified Harris Hip Score (mHHS).ResultsForty hips, with a mean 14.3-year FU, were included. This technique showed good clinical long-term results in an elderly and low-demanding population (mean age at surgery 71.4 ± 12.1 years). The radiological results were not as good as clinical results: 67.5% of cases had a radiographic evidence of resorption of less than 1/3 of the bone graft; 27.5% had a resorption ranging from 1/3 and ½ of the graft, and 5% had more than ½ of the graft. Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC (p < 0.001). The survival rate was 95% and a 2.5% rate of septic failure was recorded.Conclusion Impaction grafting with femoral head and APC is an effective technique for treating high-grade acetabular defects. APC reconstructs the hip centre of rotation, avoiding loading forces on the underlying bone graft that can be correctly integrated. At long-term FU, satisfactory clinical results, not strictly correlated to radiological signs of integration, were observed; Paprosky type III B reported worse results in terms of graft resorption and a greater migration of the APC.
Anterior to posterior X-rays showing an Accolade II stem (A) and with EBRA-FCA references (B) a head points b stem axis c stem shoulder d major trochanter line e minor trochanter lines f tip-of-stem line g points at femoral bone contour
Mean and standard deviation (bars) of total stem subsidence for the clinical follow-up of 48 months
Mean and standard deviation (bars) of the angle between stem and femur axis for the clinical follow-up of 48 months
The X-ray series presents the procedure of the patient with the largest detected subsidence A preoperative situation showing osteoarthritis of the hip B preoperative prosthetic planning C immediate postoperative X-ray D subsidence of 5.3 mm was detected by EBRA-FCA 6 weeks after surgery E subsidence of 12 mm was detected by EBRA-FCA 12 months after surgery
Purpose Uncemented stem migration analysis by EBRA-FCA (Einzel-Bild-Roentgen Analyse, Femoral Component Analyse) has been seen to be a good predictive indicator for early implant failure. In this study, we investigated the migration behavior of a cementless metaphyseal-anchored press-fit stem after 4-year follow-up. Methods Applying a retrospective study design, we reviewed all consecutive patients who between 2012 and 2017 received a cementless Accolade II press-fit stem at our Department. We reviewed medical histories and performed radiological measurements using EBRA-FCA software. EBRA-FCA measurements and statistical investigations were performed by two independent investigators. Results A total of 102 stems in 91 patients (female 60; male 31) fulfilled our inclusion criteria. Mean age at surgery was 66.2 (range 24.3–92.6) years. EBRA migration analysis showed a mean subsidence of 1.4 mm (range 0.0–12.0) at final follow-up. The angle between stem and femur axis was 0.5° (range 0.0°–2.8°) after 48 months. No correlations between gender or Dorr types and subsidence were found (p > 0.05). A body mass index > 30 kg/m² showed a significant increase in stem subsidence within the first 6 (p = 0.0258) and 12 months (p = 0.0466) postoperative. Conclusions Migration pattern of the metaphyseal-anchored stem and a low subsidence rate at final follow-up may predict a good long-term clinical result. Trial registration Number: 20181024-1875.
IntroductionOn rare occasions, fractures of the tibial plateau may occur after uni-compartmental knee arthroplasty (UKA) and account for 2% of total UKA failures. The purpose of this narrative review is to identify and discuss potential risk factors that might lead to prevention of this invalidating complication.Materials and methodsElectronic database of Pubmed, Scopus, Cochrane and Google Scholar were searched. A total of 457 articles related to the topic were found. Of those, 86 references were included in this narrative review.ResultsUKA implantation acts as a stress riser in the medial compartment. To avoid fractures, surgeons need to balance load and bone stock. Post-operative lower limb alignment, implant positioning, level of resection and sizing of the tibial tray have a strong influence on load distribution of the tibial bone. Pain on weight-bearing signals bone-load imbalance and acts as an indicator of bone remodeling and should be a trigger for unloading. The first three months after surgery are critical because of transient post-operative osteoporosis and local biomechanical changes. Acquired osteoporosis is a growing concern in the arthroplasty population. Split fractures require internal fixation, while subsidence fractures differ in their management depending of the amount of bone impaction. Loose implants require revision knee arthroplasty.Conclusion Peri-prosthetic fracture is a rare, but troublesome event, which can lead to implant failure and revision surgery. Better knowledge of the multifactorial risk factors in association with a thorough surgical technique is key for prevention.
Initial X-ray of an 8-year old girl after a fall from a bull-riding-machine onto her left arm (a a.p. view, b sagittal view). Radiographs show a grossly dislocated supracondylar humerus fracture type Gartland III
Postoperative X-ray of the injured upper left extremity from the patient in Fig. 1. Baumann´s angle in the ap view (a) is 75° and the K-Wires cross proximal of the fracture zone. In the sagittal plane (b) Roger´s Line (AHL) centers on the capitulum. The distal humerus is reduced anatomically
Initial X-ray of a left elbow of a 3-year old girl after a fall from her bunk bed. Because of the fracture pattern an additional second plane was not obtained
Postoperative radiographs (ap, lateral) of the left upper extremity after initial treatment from the patient in Fig. 3. Baumann`s angle in the ap view (a) is 72°. In the lateral view (b) a malrotation is visible. Roger’s line (AHL) does not center on the capitulum. Revision surgery was indicated due to the not anatomically reconstructed distal humerus
Radiographs (ap, lateral) of the left upper extremity after revision surgery (3 days after trauma) from patient in Fig. 3. Baumann`s angle in the ap view (a) is 67°. In the lateral view (b) a malrotation is no longer visible. Roger’s line (AHL) centers on the capitulum. The distal humerus is sufficiently reduced
Introduction The supracondylar humerus fracture (SCHF) is one of the most common pediatric injuries. Highly displaced fractures can be very challenging. If closed reduction fails, the therapy algorithm remains controversial. Materials and methods In total, 41 patients (21 boys and 20 girls) with irreducible Gartland type III SCHF, treated with open reduction through three different approaches and cross-pin fixation, were retrospectively evaluated. The mean follow-up was 46 months (min.: 12, max.: 83, SD: 23.9). The Mayo elbow performance score (MEPS) as well as the quick disabilities of arm, shoulder and hand (qDASH) score were used to assess the functional outcome. Baumann’s angle and the anterior humeral line (AHL, Roger’s line) were obtained from follow-up radiographs. Time to surgery, postoperative nerve-palsy, rate of revision surgery, and complication rate were examined. Results Two revision surgeries were reported. One due to inadequate reduction and one due to secondary loss of reduction. In this context, the AHL was a sufficient tool to detect unsatisfactory reduction. According to the MEPS the functional outcome was excellent (> 90) in 37/41 patients and good (75–89) in 4/41 at the final visit. Fair or poor results were not documented. The qDASH score was 1.8 (min.: 0, max.: 13.6, SD: 3.4). There were no significant differences between the utilized surgical approaches. An iatrogenic injury of the ulnar nerve was not reported in any case. Overall, one heterotopic ossification without impairment of the range of motion and one preliminary affection of the radial nerve were documented. Conclusion In the rare case of an irreducible SCHF, an anatomical reduction can be achieved by open approaches with excellent functional outcome and a high grade of patient satisfaction. All described open approaches can be utilized with a high safety-level.
a Preoperative radiograph (antero-posterior view) of right leg showing compound fracture of tibial mid-shaft and segmental fracture of the fibula. b Temporary stabilization of fractures of both bones with external fixator as damage control orthopedics resulting as infected non-union of the tibial diaphysis. c Immediate postoperative radiograph of right leg antero–posterior view, showing Ilizarov fixator stabilization after radical debridement of infected bone ends and proximal metaphyseal corticotomy of tibia. d Antero-posterior radiographic view of limb at final follow up showing consolidation of regenerate at proximal metaphyseal site and union at the fracture site with the adequate alignment of the limb. e Lateral radiographic view of limb at final follow up showing consolidation of regenerate at proximal metaphyseal site and union at fracture site with adequate alignment of limb
a Antero-posterior and lateral views of radiograph showing infected non-union of tibia managed with Masquelet technique and cement spacer in situ. b Radiographs showing failure of Masquelet technique and resorption of bone graft with sequestrum formation at grafting site. c Radiographs showing revision surgery with re-debridement and proximal metaphyseal corticotomy in failed Masquelet technique. d AP and lateral radiographs showing aligned limb with union at fracture site and regenerate formation at corticotomy site stabilized with Ilizarov bone transport technique. e AP and lateral radiographs showing complete union at the fracture site and consolidation of regenerate with the adequate alignment of the limb at corticotomy site at final follow-up
AimThe present prospective randomized study compared the bone transport technique (BT) and Masquelet technique (MT) in the treatment of infected gap non-union of the tibia. Patients and methodsTotal 25 patients with infected gap non-union of the tibia with bone gap upto 6 cm were randomised into BT group (group I, 13 patients) and MT (group II, 12 patients). The mean age was 31.77 years in group I and 39.67 years in group II. The mean intra-operative bone gap was 3.92 cm in group I and 3.79 cm in group II. Monolateral fixator was applied in nine patients each in both groups, while four and three fractures were stabilized with ring fixators in group I and II, respectively. Mean follow-up was 31.62 months and 30.42 months in group I and II, respectively. Bone and functional results were compared using the association for the study and application of the method of Ilizarov (ASAMI) criteria.ResultsThe average fixator period was 9.42 and 16.33 months in group I and II, respectively (p < 0.001). Union was achieved in 12 (92%) patients and 6 (50%) patients in group I and II, respectively. The functional results were excellent (eight and two), good (four and six), fair (zero and three) and poor (one and one) in group I and II respectively, (p 0.23). The Bone results were excellent, good and poor in nine, three and one patients in group I, and three, three and six patients in group II respectively, (p 0.109).Conclusions The functional and bone results were comparable but more reliable in bone transport than the Masquelet technique. The fixator duration and incidence of non-union were higher in MT group. Ilizarov bone transport technique should be preferred in infected non-union of the tibia with bone loss upto 6 cm.
Flow chart with studies included in this review
Introduction Intramedullary locking devices (ILDs) have recently been advocated as a minimally invasive approach to manage displaced intraarticular calcaneal fractures (DIACFs), to minimise complications and improve outcomes. We reviewed clinical and biomechanical studies dealing with commercially available devices to identify their characteristics, efficacy and safety. Methods Following a PRISMA checklist, Medline, Scopus and EMBASE databases were searched to identify studies reporting the use of ILDs for treating DIACFs. Biomechanical studies were first evaluated. Cohort studies were then reviewed for demographics, surgical technique, postoperative protocol, clinical and radiographic scores, complications and reoperations. The modified Coleman Methodology Score (CMS) was used to assess the quality of studies. Results Eleven studies were identified which investigated two devices (Calcanail®, C-Nail®). Three biomechanical studies proved they offered adequate primary stability, stiffness, interfragmentary motion and load to failure. Eight clinical studies (321 feet, 308 patients) demonstrated a positive clinical and radiographic outcome at 16-months average follow-up. Metalware irritation (up to 20%) and temporary nerve entrapment symptoms (up to 30%) were the most common complications, while soft tissue issues (wound necrosis, delayed healing, infection) were reported in 3–5% of cases. Conversion to subtalar fusion was necessary in up to 6% of cases. Four (50%) out of 8 studies were authored by implant designers and in 5 (62%) relevant conflicts of interest were disclosed. Mean (± standard deviation) CMS was 59 ± 9.8, indicating moderate quality. Conclusions Treating DIAFCs with ILDs leads to satisfactory clinical outcomes at short-term follow-up, enabling restoration of calcaneal height and improved subtalar joint congruency. Metalware irritation and temporary nerve entrapment symptoms are common complications although wound complications are less frequent than after open lateral approaches. The quality of evidence provided so far is moderate and potentially biased by the conflict of interest, raising concerns about the generalisability of results. Level of evidence Level V – Review of Level III to V studies.
Different types of proximal radius fractures representative for different dimensions of stability, courses and prognosis. Stable buckle fracture of the radial neck (→ arrow) in a 4-year-old girl (a). Salter–Harris II fracture of the radial neck with the risk of further dislocation (b). Complete dislocation of a metaphyseal radial neck fracture in a 12-year-old boy with elbow dislocation, presenting the worst prognosis due to the complete disruption of the nutritive vessels possibly resulting in total or partial necrosis or pseudarthrosis (c). Intraarticular fracture of the radial head representing an adulthood fracture in a 15-year-old adolescent boy with closed physis (d)
Complete fracture of the metaphyseal radial neck and proximal ulna shaft fracture in a 5-year-old boy treated with ESIN (a). The postoperative control showed axial alignment of both fractures (b). Consolidation was documented after four weeks, but the radial implant showed evidently missing the radial head, which represents a technical complication that should not have been overlooked intraoperatively (c). Due to the consolidation process and to not further damage the blood supply, we refrained from a nail revision and the nail was removed consecutively (d). Following this, pseudarthrosis seemed to develop, but complete consolidation (e) and remodeling were observed after 11 months (f), and 2 years (g). In this age group, an enormous potential for growth-related correction exists, however, it should never be overestimated
Completely displaced proximal radial fracture in a seven-year-old girl (a, b). Open reduction and stabilization were performed using two ESIN implants to provide maximal stability to the radial head, which healed even though having been totally deperiostized (c, d)
ESIN osteosynthesis in an eight-year-old boy with a Salter–Harris II radial neck fracture (a, b). A sharpened 2.0 mm titanium nail was used for closed reduction and an additional intraarticular olecranon fracture was treated using a 4.0 mm lag screw to allow early elbow mobilization (c, d)
Introduction Pediatric radial neck and head fractures are rare, accounting for only 1% of all fractures in children. The aim of this study is to describe the management and results of the respective fracture types and different injury characteristics. Materials and methods This study performs a retrospective data analysis of 100 consecutive patients with a fracture of the proximal radius treated in a single high-volume pediatric trauma center. Results One hundred patients [mean age 7.5 years (1–15)] were documented with a fracture of the proximal radius between 3/2011 and 12/2019. The gender distribution was 62 girls and 38 boys. Twenty-seven patients had concomitant injuries. Conservative treatment was performed in 63 patients (Judet I = 27; II = 30; III = 6; Mason I = 2) using an above-the-elbow cast for 21 days (6–35). Surgical treatment was performed in 37 patients (Judet II = 3; III = 22; IV = 5; V = 7) using elastic stable intramedullary nailing (ESIN). Open reduction was necessary in five cases, and additional immobilization was performed in 32 cases. Six complications occurred: loss of implant stability ( n = 2), healing in malalignment, pseudarthrosis, radioulnar synostosis, and a persisting hypoesthesia at the thumb. As a result, two ESIN osteosynthesis were revised, and one radial head resection was performed. Loss of movement was seen in 11% of cases, overall Mayo elbow performance index (MEPI) was 99.8 (90–100), and none of the patients experienced negative impacts on activities of daily life. Conclusions Proximal radial fractures occur predominately without dislocation. Good results are obtained with conservative treatment throughout. In cases with displacement exceeding growth-related correction, ESIN is the undisputed treatment of choice. Open surgery and long immobilization periods should be avoided whenever possible.
a Shortening was measured on three-dimensional computed tomography images. A line was drawn along the longitudinal axis of the proximal fragment of the clavicle, and the distance over which the distal fragment was shortened (a) was measured; b To measure fracture displacement, the diameter of the distal end of the proximal fracture fragment (a′) was measured first. A perpendicular line was drawn from the distal end to the clavicle longitudinal axis to obtain the distance to the point of contact with the far cortex of the distal fragment (b′), and fracture displacement was evaluated as a percentage (a′/b′ × 100)
a Incisions (~ 3 cm) were made medially and laterally to the fracture site; b After fraction reduction, an intraoperative C-arm X-ray image was used to confirm lengthening and fracture displacement
Introduction Only a few previous studies have evaluated the factors related to supraclavicular nerve (SCN) injury after clavicle mid-shaft fracture surgery. We analyzed the frequency and risk factors for SCN injury after clavicle mid-shaft fracture surgery via open reduction and internal fixation (ORIF) versus minimally invasive plate osteosynthesis (MIPO) Materials and methods We retrospectively reviewed the cases from 59 patients who had undergone surgery for clavicle mid-shaft fractures between January 2018 and April 2019. Twenty-nine patients had undergone ORIF and 30 had undergone MIPO. The frequency of SCN injury in the two groups was evaluated, and preoperative patient demographics (age, sex, body mass index, smoking, alcohol, diabetes mellitus, and trauma mechanism), and radiological parameters (fracture displacement and shortening) were measured and evaluated as risk factors for SCN injury. When neurological symptoms, such as numbness, were present on the anterior chest wall or at the incision site, electromyography (EMG) was conducted. Results Neurological symptoms were present in 12 patients. Numbness in the anterior upper chest around the incision site was present in eight and four patients who underwent ORIF and MIPO, respectively (p < 0.001). Furthermore, fracture displacement evaluated on preoperative three-dimensional computed tomography was significantly associated with the occurrence of SCN injury in patients who underwent MIPO (odds ratio, 1.038; 95% confidence interval, 1.001–1.077; p = 0.047). Although EMG was conducted in all patients with SCN injury, peripheral neuropathy was not found in any cases. Conclusions SCN injury, which is a possible complication of clavicle mid-shaft fracture surgery, occurred significantly less frequently in MIPO than in ORIF. In MIPO, greater preoperative fracture displacement was associated with a higher risk of SCN injury. Additional studies are required to reach a consensus regarding accurate methods to evaluate SCN injuries. Level of evidence IV, case series, treatment study
A 69-years-old female with a left femoral neck fracture presenting with a valgus angle displacement, b the posterior tilt displacement on plain radiographs, c valgus displacement, and d posterior tilt displacement on a computerized tomographic scan
Three-dimensional computerized tomographic scan presentation of Garden Type 1 impacted valgus showing a posterior tilt on the lateral view
Postoperative reduction quality, age influence
Fracture reduction performed on a fracture table by internal rotation and traction and gentle application of anteroposterior pressure on the femoral neck if needed
The patient in Fig. 1 demonstrating some undetected features that probably led to a failed primary treatment; a a short retained femoral head and an anterior dye-punch fracture; b postoperative radiographs demonstrating good reduction and fixation; c avascular necrosis of the femoral head as well as varus collapse are observed 2 years postoperatively and treated by total hip replacement
IntroductionSub-capital femoral fractures (SCFF) are impacted or non-displaced in Garden types 1 and 2, respectively. Non-surgical treatment is protected weight-bearing combined with physiotherapy and radiographic follow-up in selected patients. Traditionally, in situ pinning is the surgical treatment of choice. The aim of this study was to estimate whether the valgus deformity in Garden types 1 and 2 (AO classification 31B1.1 and 31B1.2) SCFF is a virtual perception of a posterior tilt deformity and if addressing this deformity improves patients’ outcomes.Materials and methodsThe records of 96 patients with Garden Types 1 and 2 SCFF treated in tertiary medical center between 1/2014 and 9/2017 were retrospectively reviewed. They all had preoperative hip joint anteroposterior and lateral radiographic views. 75 patients had additional computed tomography (CT) scans. Femoral head displacement was measured on an anteroposterior and axial radiograph projections and were performed before and after surgery. Preoperative 3D reconstructions were performed for a better fracture characterization, and assessment of the imaging was performed by the first author. ResultsThe average age of the study cohort was 73 years (range 28–96, 68% females). There were 58 right-sided and 38 left-sided fractures. Ninety patients had Type 1 and six patients had Type 2 fractures. The average preoperative posterior tilt was 15 degrees and the average valgus displacement was 10 degrees on plain radiographs compared to 28 degrees and 11 degrees, respectively, on CT scans. Posterior tilt was found with a virtual perception as valgus-impacted fractures. The postoperative posterior tilt was corrected to an average of 3 degrees and the valgus displacement to 5 degrees.ConclusionCT provides an accurate modality for measuring femoral head displacement and fracture extent. The posterior tilt displacement should be addressed during surgery to lower failure risk and the need for additional procedures. IRB approvalTLV-0292-15.Level of evidenceIV.
a–c Predicted inpatient opioid consumption histogram in patients with and without RA from 0 to 72 h post-operative. Vertical bars represent mean consumption
a–c Predicted outpatient opioid prescription histogram in patients with and without RA. Vertical bars represent mean prescription
IntroductionRegional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand.Methods This study evaluated inpatient post-operative opioid consumption (0–24 h, 24–48 h, 48–72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand.ResultsAdjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE’s without RA vs 6.2 OE’s with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE’s without RA vs 6.9 OE’s with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE’s without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE’s to 6 weeks, and 85 vs 113.1 OE’s to 90 days, p < 0.05).DiscussionIn distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures.Level of evidenceLevel III, retrospective, therapeutic cohort study.
Unstable pertrochanteric fracture of the left femur (AO 31A2) in an 84-year-old patient (a). Image after intramedullary fixation with a short hip nail evaluated as favorable (b). CT analysis, however, showing excessive internal rotational error of 47° (c)
Representation of the individual types of fractures as insignificant (0–14.9°), significant (15–24.9°), and excess malrotation (> 25°). Negative rotation D values indicate external malrotation, while positive D values indicate internal malrotation of the femur
PurposeFunctional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures.Materials and methodsThe authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon’s experience as possible risk factors for limb malrotation after trochanteric fracture surgeries.ResultsThe average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error.Conclusion Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.
Osteotomy at the level of the spinoglenoid notch (A acromion, Sc.Sp scapular spine)
Plate configuration for the SP (a) and DP osteosynthesis (b)
Fixation of the suture wires for load transmission to the deltoid muscle (a), test setup (b) the red arrow indicates the direction of loading
Failure loads after DP compared to SP for specimens with osteoporotic bone (SP single plate, DP double plate)
Example of the catastrophic load to failure with plate and screw cut out
Introduction The number of atraumatic stress fractures of the scapular spine associated with reverse shoulder arthroplasty is increasing. At present, there is no consensus regarding the optimal treatment strategy. Due to the already weakened bone, fractures of the scapular spine require a high fixation stability. Higher fixation strength may be achieved by double plating. The aim of this study was to evaluate the biomechanical principles of double plating in comparison to single plating for scapular spine fractures. Methods In this study, eight pairs ( n = 16) of human shoulders were randomised pairwise into two groups. After an osteotomy at the level of the spinoglenoid notch, one side of each pair received fracture fixation with a single 3.5 LCP (Locking Compression Plate) plate. The contralateral scapular spine was fixed with a 3.5 LCP and an additional 2.7 LCP plate in 90–90 configuration. The biomechanical test protocol consisted of 700 cycles of dynamic loading and a load-to-failure test with a servohydraulic testing machine. Failure was defined as macroscopic catastrophic failure (screw cut-out, plate breakage). The focus was set on the results of specimens with osteoporotic bone quality. Results In specimens with an osteoporotic bone mineral density (BMD; n = 12), the mean failure load was significantly higher for the double plate group compared to single plating (471 N vs. 328 N; p = 0.029). Analysis of all specimens ( n = 16) including four specimens without osteoporotic BMD revealed no significant differences regarding stiffness and failure load ( p > 0.05). Conclusion Double plating may provide higher fixation strength in osteoporotic bone in comparison to a single plate alone. This finding is of particular relevance for fixation of scapular spine fractures following reverse shoulder arthroplasty. Level of evidence Controlled laboratory study.
IntroductionThe aim of this study was to present recent epidemiological data on extremity and axial skeletal fractures in German hospitals and to compare them with older data to detect time trends.Materials and methodsInpatient data from the German National Hospital Discharge Registry were used. The absolute number and age-standardized incidence of fractures in 2002 and 2018 were analysed by fracture location according to the International Classification of Disease. Data were analysed according to age group. Male: female ratios (MFRs) and incidence rate ratios (IRRs) were calculated to compare the 2018 and 2002 data.ResultsThe absolute number of fractures of the nine analysed locations was 15.2% higher in 2018 than in 2002. By fracture location, the changes were as follows (absolute change + IRR): “neck” (S12): + 172%, IRR = 2.6; “rib(s), sternum, thoracic spine” (S22): + 57%, IRR = 1.3; “lumbar spine and pelvis” (S32): + 66%, IRR = 1.3; “shoulder and upper arm” (S42): + 36%, IRR = 1.2; “forearm” (S52): + 13%, IRR = 1.0; “wrist and hand level” (S62): − 32%, IRR = 0.7; “femur” (S72): + 24%, IRR = 0.9; “lower leg, including ankle” (S82): − 24%, IRR = 0.7; “foot, except ankle” (S92): − 4%, IRR = 0.9. The overall MFR changed from 0.7 in 2002 to 0.6 in 2018. The age group of 45–54 years represented a turning point, males were more often affected than females in the younger age groups, and the opposite trend was observed in the older age groups.Conclusions The increase in the absolute fracture rates was due to increased rates of femur, shoulder, upper arm, forearm, and axial skeletal fractures, with elderly women being the main contributors. Femur fractures were found to be the most common fractures treated in German hospitals.
a X-ray of a displaced ACPHT fracture. b Ap view of the hip joint with ARRP and THA 6 months after surgery. c CT imaging confirmed bony healing and osseous incorporation of the ARRP. Uneventful healing of the iatrogenic femoral fracture
a X-ray of a periprosthetic acetabular fracture. b Postoperative X-ray of the hip joint with implantation of ARRP and THA. c After 6 months fracture healed without bone grafting due to the lack of femoral head
Introduction Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA. Materials and methods Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures. Results The mean age was 80.5 years (range 65–98 years). The average time from injury to surgery was 8.5 days (range 1–28). Mean time of surgery was 167 min (range 100–303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification. Conclusions The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.
a Preoperative anteroposterior and lateral radiographs of a 74-year-old female patient with a quadrimalleolar fracture-dislocation of her left ankle. b Preoperative axial and sagittal CT images reveal a large triangular posterior malleolar fragment (Bartoníček–Rammelt type 4) and a chip-like avulsion from the anterior tibial tubercle
Type of posterior malleolar fracture fixation with respect to the pathoanatomy (Bartoníček–Rammelt classification [20])
a Postoperative anteroposterior and lateral radiographs and b axial and sagittal CT scans after open reduction and posterior antiglide plate fixation of the distal tibia and fibula via a posterolateral approach and medial malleolar fixation via a medial approach all with the patient in prone position (same patient as in Fig. 1)
Free function (50 degrees of sagittal ankle motion on both sides) at 69-month follow-up (OMAS 100; AOFAS 100; FFI-D 1.85; SF-36 PCS 54.7 MCS 52.6) of the same patient shown in Figs. 1 and 4. Because the patient was pain free, no indication was seen for another set of radiographs at the time of follow-up
Mode of posterior malleolar fracture fixation in relation to the use of a syndesmotic positioning screw. There is a statistically significant correlation between no fixation of the posterior malleolus fracture fragment and the insertion of a syndesmotic positioning screw (p = 0.010)
Introduction The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population. Materials and methods One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček–Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern. Results Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery ( p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 ( SD: 21.5 ), the Olerud Molander Ankle Score (OMAS) averaged 80.2 ( SD: 24 ) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 ( SD: 19.1 ). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 ( SD: 12.51 ) and 50.5 ( SD: 9.36 ), respectively. Range of motion was within 3.4 ( SD: 6.63 ) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation ( p = 0.031). Conclusions With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.
Predicted probabilities and 95% confidence intervals for the model with transfusion as outcome variable and age, type of surgery, and preoperative hemoglobin concentration as predictors. Preoperative hemoglobin concentration was adapted to 13.9 g/dl (median) in the upper two panels and age was adjusted to 69 years (median) in the lower two panels
Introduction Accurate identification of patients at risk of blood transfusion can reduce complications and improve institutional resource allocation. Probabilistic models are used to detect risk factors and formulate patient blood management strategies. Whether these predictors vary among institutions is unclear. We aimed to identify risk factors among our patients who underwent total hip (THA) or knee (TKA) arthroplasty, and combine these predictors to improve our model. Materials and methods We retrospectively assessed risk factors among 531 adults who underwent elective THA or TKA from January 2016 to November 2018. Using relevant surgical and patient characteristics gathered from electronic medical records, we conducted univariable and multivariable analyses. For our logistic regression model, we measured the impact of independent variables (age, gender, operation type (THA or TKA) and preoperative hemoglobin concentration) on the need for a transfusion. Results Of the 531 patients, 321 had THA (uncemented) and 210 had TKA. For the selected period, our transfusion rate of 8.1% (10.6% THA and 4.3% TKA) was low. Univariable analyses showed that lower BMI (p < 0.001) was associated with receiving a transfusion. Important factors identified through logistic regression analyses were age (estimated effect of an interquartile range increase in age: OR 3.89 [CI 95% 1.96–7.69]), TKA (OR − 0.77 [CI 95% − 1.57–0.02]), and preoperative hemoglobin levels (estimated effect of interquartile range increase in hemoglobin: OR 0.47 [CI 95% 0.31–0.71]). Contrary to findings from previous reports, gender was not associated with transfusion. Conclusions Previously published predictors such as advanced age, low preoperative hemoglobin, and procedure type (THA) were also identified in our analysis. However, gender was not a predictor, and BMI showed the potential to influence risk. We conclude that, when feasible, the determination of site-specific transfusion rates and combined risk factors can assist practitioners to customize care according to the needs of their patient population. Level of evidence Level 3, retrospective cohort study
MRI of patients with atraumatic LUCL insufficiency (right elbow): a partial lesion of LUCL and extensor tendons (blue arrows) after multiple steroid injections and b complete LUCL and extensor tendon avulsion (blue arrow) following Hohmanns’ surgery
Arthroscopic instability testing with a 4 mm switching stick of a right elbow with symptomatic PLRI: a humeroulnar dorsal: grade III, b radioulnar: grade I, c humeroradial: drive through sign, grade III. TH trochlea humeri, R radial head, O olecranon, BA bare area
Postoperative X-rays a a.p. and b lateral after LUCL reconstruction using ipsilateral triceps graft: flip button fixation at the ulnar side and SwiveLock anchor (Arthrex Napels, FL, USA) fixation at the humeral condyle
Rating system of the MEPS according to Nestor and Morrey [29]
Purpose Traumatic and atraumatic insufficiency of the lateral ulnar collateral ligament (LUCL) can cause posterolateral rotatory instability (PLRI) of the elbow. The influence of the underlying pathogenesis on functional outcomes remains unknown so far. The objective of this study was to determine the impact of the initial pathogenesis of PLRI on clinical outcomes after LUCL reconstruction using an ipsilateral triceps tendon autograft. Methods Thirty-six patients were reviewed in this retrospective study. Depending on the pathogenesis patients were assigned to either group EPI (atraumatic, secondary LUCL insufficiency due to chronic epicondylopathia) or group TRAUMA (traumatic LUCL lesion). Range-of-motion (ROM) and posterolateral joint stability were evaluated preoperatively and at follow-up survey. For clinical assessment, the Mayo elbow performance (MEPS) score was used. Patient-reported outcomes (PROs) consisting of visual analogue scale (VAS) for pain, disability of arm, shoulder and hand (DASH) score, patient-rated elbow evaluation (PREE) score and subjective elbow evaluation (SEV) as well as complications were analyzed. Results Thirty-one patients (group EPI, n = 17; group TRAUMA, n = 14), 13 men and 18 women with a mean age of 42.9 ± 11.0 were available for follow-up evaluation (57.7 ± 17.5 months). In 93.5%, posterolateral elbow stability was restored ( n = 2 with re-instability, both group TRAUMA). No differences were seen between groups in relation to ROM. Even though group EPI (98.9 ± 3.7 points) showed better results than group TRAUMA (91.1 ± 12.6 points) ( p = 0.034) according to MEPS, no differences were found for evaluated PROs (group A: VAS 1 ± 1.8, PREE 9.3 ± 15.7, DASH 7.7 ± 11.9, SEV 92.9 ± 8.3 vs. group B: VAS 1.9 ± 3.2, PREE 22.4 ± 26.1, DASH 16.0 ± 19.4, SEV 87.9 ± 15.4. 12.9% of patients required revision surgery. Conclusion LUCL reconstruction using a triceps tendon autograft for the treatment of PLRI provides good to excellent clinical outcomes regardless of the underlying pathogenesis (traumatic vs. atraumatic). However, in the present case series, posterolateral re-instability tends to be higher for traumatic PLRI and patient-reported outcomes showed inferior results. Level of evidence Therapeutic study, LEVEL III.
Kaplan–Meier curve for the failure of revision THA due to recurrent dislocation
Introduction Recurrent dislocation represents the third most common cause of revision surgery after total hip arthroplasty (THA). However, there is a paucity of information on the outcome of revision total hip arthroplasty for recurrent dislocation. In this study, we investigated (1) clinical outcomes of patients that underwent revision THA for recurrent dislocation, and (2) potential risk factors associated with treatment failure in patients who underwent revision total hip arthroplasty for recurrent dislocation. Methods We retrospectively reviewed 211 consecutive cases of revision total hip arthroplasty for recurrent dislocation, 81 implanted with a constrained liner and 130 with a non-constrained liner with a large-diameter femoral head (> 32 mm). Patient- and implant-related risk factors were analyzed in multivariate regression analysis. Results At 4.6-year follow-up, 32 of 211 patients (15.1%) underwent re-revision surgery. The most common causes for re-revision included infection (14 patients) and dislocation (10 patients). Kaplan–Meier analysis demonstrates a 5-year survival probability of 77% for patients that underwent revision THA for recurrent dislocation. Osteoporosis, obesity (BMI ≥ 40), spine disease and abductor deficiency are independent risk factors for failure of revision surgery for recurrent dislocation. Liner type (constrained vs. non-constrained) was found not to be associated with failure of revision THA for recurrent dislocation (p = 0.44). Conclusion This study suggests that THA revision for recurrent dislocation is associated with a high re-revision rate of 15% at mid-term follow-up. Osteoporosis, obesity (BMI ≥ 40) spine disease and abductor deficiency were demonstrated to be independent risk factors for failure of revision THA for recurrent dislocation. Level of evidence Level III, case–control retrospective analysis.
Purpose A question still remains as to whether constrictive toe-box shoes (TBS) cause disability only due to pain on pressure points or if they can cause permanent changes in the hallux anatomy. The aim of this study is to compare the hallux morphology in 3 groups classified according to their use of constrictive or open TBS. Methods 424 patients were classified into 3 groups: group A used open TBS daily; group B used constrictive TBS daily; group C used both open and constrictive TBS. Hallux’s angles, presence of exostoses and shape of the distal phalanx (DP) were analyzed on dorsoplantar weight-bearing radiographs and compared amongst groups. Results The intermetatarsal (IMA), metatarsophalangeal (MTPA), DASA, PASA, interphalangeal (IPA), obliquity (AP1), asymmetry (AP2) and joint deviation (JDA) angles for group A were 10°, 8°, 5°, 4°, 9°, 3°, 5°, 3°; for group B were 9°, 19°, 5°, 6°, 12°, 2°, 8°, 2°; and for group C were 10°, 10°, 4°, 4°, 12°, 3°, 8°, 1°. Only the differences in the MTPA, IPA and AP2 were statistically significant (p < 0.05). The prevalence of exostoses on the tibial side of the DP was 22, 36, and 29% in groups A, B and C, respectively (p < 0.05). We found similar distributions of the different DP shapes in the three groups. Conclusions Our results suggest that the use of constrictive TBS, even if used only occasionally, could change hallux anatomy from a young age increasing MTPA, IPA and AP2. Moreover, we have found that DP exostoses are present as a “normal variation” in patients who wear an open TBS, but their prevalence is higher in those wearing constrictive toe-box shoes. This could be due to a reactive bone formation secondary to the friction caused by the inner border of the shoe. Level of clinical evidence 3.
Introduction This systematic review aimed to assess the safety and efficacy of outpatient joint arthroplasty (OJA) pathways compared to inpatient pathways. Materials and methods An electronic literature search was conducted to identify eligible studies. Studies comparing OJA with inpatient pathways—following hip and/or (partial) knee arthroplasty—were included. Included studies were assigned—based on OJA definition—to one of the following two groups: (1) outpatient surgery (OS); outpatient defined as discharge on the same day as surgery; and (2) semi-outpatient surgery (SOS); outpatient defined as discharge within 24 h after surgery with or without an overnight stay. Methodological quality was assessed. Outcomes included (serious) adverse events ((S)AEs), readmissions, successful same-day discharge rates, patient-reported outcome measures (PROMs) and costs. Meta-analyses and subgroup analyses by type of arthroplasty were performed when deemed appropriate. Results A total of 41 studies (OS = 26, SOS = 15) met the inclusion criteria. One RCT and 40 observational studies were included, with an overall risk-of-bias of moderate to high. Forty studies were included in the meta-analysis. Outpatients (both OS and SOS) were younger and had a lower BMI and ASA class compared to inpatients. Overall, no significant differences between outpatients and inpatients were found for overall complications and readmission rates, and improvement in PROMs. By type of arthroplasty, only THAs in OS pathways were associated with fewer AEs [OR = 0.55 (0.41–0.74)] compared to inpatient pathways. 92% of OS patients were discharged on the day of surgery. OJA resulted in an average cost reduction of $6.797,02. Conclusion OJA pathways are as safe and effective as inpatient pathways in selected populations, with a potential reduction of costs. Considerable risk of bias in the majority of studies emphasizes the need for further research.
Percentage of documentation of treatment escalation plan in audit cycle 1 prior to educational program
Percentage of documentation of treatment escalation plan in audit cycle 2 following educational program
Introduction The majority of neck of femur (NOF) fracture patients are frail and at a higher risk of cardiac arrest. This makes discussion of treatment escalation vital to informed care. The optimal time for these discussions is prior to admission or trauma. However, when this has not occurred, it is vital that these discussions happen early in the patient’s admission when family is often present and before further deterioration in their condition. We undertook a service evaluation to evaluate and discuss the effect of clinician education on improving rates of timely discussion amongst orthopaedic doctors. Materials and methods The first cycle included 94 patients. Their notes were reviewed for presence of a ReSPECT (Recommend Summary Plan for Emergency Care and Treatment) form prior to operation and whether this it countersigned by a consultant. Following this, clinician education was undertaken and a re-audit was carried out involving 57 patients. Results ReSPECT form completion rates rose from 23% in cycle 1–32% in cycle 2 following intervention. The proportion which consultants signed rose from 41% to 56% following intervention. Conclusion This project demonstrates how a basic education program can prove limited improvements in the rates of timely resuscitation discussions. We discuss a current lack in quality research into educational programs for discussion of treatment escalation for orthopaedic trainees. We suggest there is room to improve national best practice guidelines and training to ensure these discussions are carried out more frequently and to a better standard.
Top-cited authors
Wolf Petersen
  • Martin-Luther Hospital
Michael Raschke
  • Universitätsklinikum Münster
Carsten Perka
  • Freie Universität Berlin
Norbert P Südkamp
  • University Medical Center Freiburg
Andreas B. Imhoff
  • Technische Universität München