Conversion of hip resurfacing to total hip arthroplasty: is the outcome closer to primary or revision total hip arthroplasty?

BACKGROUND: Along with the advent of newer bearings, hip resurfacing (HR) is gaining renewed interest as a bone sparing alternative to conventional total hip arthroplasty (THA) in young patients. However, the outcome of conversion of failed HR to THA (HRc) remains sparsely described. This study aimed to compare the outcomes and complication rates of HRc to those of primary (pTHA) and revision THA (rTHA) to find out to which group HRc is most comparable. HYPOTHESIS: The study hypothesis was that the outcomes and complications rates of HRc were closer to those of pTHA than rTHA. MATERIALS AND METHODS: Between 2001 and 2011, a continuous series of 207 HR were prospectively included in our institutional registry and retrospectively analyzed. Out of them, 17 HR (8%) were converted to THA. Propensity scores were used to match patients in the HRc group to the pTHA and the rTHA groups using a greedy 1:3 matching procedure (51 pTHA and 51 rTHA). Clinical and radiographic outcomes, perioperative data and complications were analyzed and compared between the three groups. RESULTS: No significant difference between HRc and pTHA was observed in terms of clinical and functional outcomes, duration of surgery, acetabular component diameter and length of hospital stay (p = 0.13 to 0.94). Perioperative blood loss was significantly lower for pTHA than for HRc (p = 0.01). HRc demonstrated significantly higher HHS and HOOS scores than for rTHA at one year (p = 0.03 and p < 0.01, respectively). Duration of surgery was significantly lower in HRc compared to rTHA (p = 0.02) while length of hospital stay was similar (p = 0.84). Complication rate was significantly higher in the rTHA group, compared to HRc and pTHA groups (37.3 vs. 29.4 vs. 11.8%, p = 0.01). CONCLUSION: This study demonstrated that the clinical and functional outcomes of HRc were closer to those of pTHA than those of rTHA, though complication rate was higher than for pTHA. LEVEL OF EVIDENCE: III; Retrospective comparative study.

Elevated secretion of pro-collagen I-alpha and vascular endothelial growth factor as biomarkers of acetabular labrum degeneration and calcification in hip osteoarthritis: An explant study.

Background: Hip osteoarthritis (OA) involves structural degeneration of different joint compartments, including femoral head cartilage, periarticular ligaments and the acetabular labrum. However, the molecular mechanisms underlying labrum degeneration in hip OA remain poorly understood. Aim: To assess secretion of putative biomarkers for OA from explanted human labrum tissues under basal and inflammatory conditions and to determine whether these could differentiate between OA and calcification status compared to fracture controls. Methods: Intact labrum specimens were collected from patients undergoing joint arthroplasty for primary hip OA (n â€‹= â€‹15, mean age 70) or non-OA femoral neck fracture (n â€‹= â€‹5, mean age 64). Tissues were dissected in equal-sized samples and explanted for one week. To mimic activation of inflammatory signaling by endogenous damage-associated molecular patterns (DAMP) tissue were stimulated with a toll-like receptor 4 (TLR4) agonist (1 â€‹µg/mL LPS). The involvement of transforming growth factor-beta (TGF-beta) signaling was evaluated by treatment with a TGF-beta type 1 receptor inhibitor (10 â€‹µM SB-505124). Secretion of aggrecan (ACAN), pro-collagen-I alpha (Pro-Col-Iα), cartilage oligomeric matrix protein (COMP), interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) was assessed by enzyme-linked immunosorbent assay (ELISA). Labrum calcification was evaluated by 3D whole mount fluorescent microscopy of ethyl cinnamate-based optically cleared tissues stained with Alcian blue/Alizarin red. Results: Whole mount microscopy revealed non-OA fracture controls were non-calcified, whereas six OA labra (40%) were partially calcified or ossified. Basal secretion of Pro-Col-Iα and VEGF was increased four-fold in OA versus non-OA labra. Pro-Col-Iα levels were correlated with those of VEGF (r â€‹= â€‹0.65) and COMP (r â€‹= â€‹0.54). Stimulation of DAMP signaling through TLR4 affected secretion of IL-6, VEGF, COMP and Pro-Col-Iα, with distinct responses between non-OA and OA tissues. Inhibition of TGF-beta signaling specifically reduced elevated secretion of Pro-Col- Iα and VEGF in calcified OA labrum. Conclusions: Secretion of the putative OA biomarkers Pro-Col-Iα and VEGF is elevated in degenerated human acetabular labrum and may serve as indicators of OA and calcification status. Secretion of both factors was partially regulated by TGF-beta signaling in calcified OA labrum tissues.The Translational potential of this article:Our findings suggest that a biomarker panel consisting of Pro-Col-Iα/VEGF/COMP may be valuable for assessing subradiographic labrum degeneration and calcification in hip OA. Targeting TGF-beta signaling may offer a means to reduce vascular invasion and fibrosis in acetabular labrum tissue.

The use of dual mobility cups in revision total hip arthroplasty for failed large head metal-on-metal bearings.

PURPOSE: Revision of failed large head metal-on-metal (MoM) total hip arthroplasty (THA) is a challenging procedure particularly to reconstruct acetabular bone defect due to osteolysis and to achieve hip stability due to soft tissue damages, both potentially caused by adverse reaction to metal debris (ARMD). This study aimed to evaluate the outcome of dual mobility cup (DMC) constructs in revision THA for failed large head MoM bearings with a special attention to the occurrence of dislocation or re-revision. METHODS: Between 2015 and 2019, 57 patients (64 THAs, 41 men, mean age = 65 ± 10 years) underwent revision for MoM THA with the use of DMC were prospectively included in our total joint registry. Mean time to revision was 11 ± 2.5 years. The causes for revision were adverse reaction to metal debris (ARMD) in 49 THAs (76%), painful hip with elevated blood cobalt-chromium ions in seven (11%), and acetabular aseptic loosening in eight (13%). The revision was complete in 22 THAs (34%) and acetabular only in 42 (66%). Clinical and radiographic outcomes, complications, and re-revisions were evaluated at most recent follow-up. RESULTS: At mean follow-up of six ± 1.5 years, the pre- to postoperative Harris Hip Score improved from 74 ± 19 to 92 ± 4 (p = 0.004). Complications occurred in 11 cases (17%): five dislocations (8%), three periprosthetic infections (5%), two aseptic loosening of the acetabular component (3%), and two periprosthetic fractures (3%). Re-revision was required in six cases (9%). CONCLUSION: The use of DMC is a reliable option to prevent instability and ensure a stable acetabular reconstruction in revision THA for failed large head MoM bearings. However, dislocation after revision remains a concern, particularly in cases of severe soft tissue damage related to ARMD.

Direct Cementation of Dual Mobility Cups Into the Bony Acetabulum in Primary Total Hip Arthroplasty: Clinical and Radiographic Outcomes at a Minimum 5-Year Follow-Up.

BACKGROUND: Cemented dual mobility cups (DMCs) are commonly used in combination with acetabular reinforcement devices. Indeed, according to literature, direct cementation of metal-backed acetabular components into the bony acetabulum remains controversial as this technique is potentially associated with increased rates of aseptic loosening. Therefore, this study aimed to evaluate the clinical and radiographic outcomes of DMC cemented into the bony acetabulum in primary total hip arthroplasty (THA). METHODS: A total of 49 THA (48 patients, mean age 78 years [range, 51 to 91]) performed with direct cementation of a DMC into the bony acetabulum were prospectively included in our total joint registry and retrospectively reviewed. The clinical outcome was assessed using the Harris hip score (HHS). The radiographic outcome included measurement of component positioning and occurrence and progression of demarcation around the cemented DMC. Complications were reported with a particular attention to cemented fixation failure and aseptic loosening. RESULTS: At a 7-year mean follow-up (range, 5 to 8), the pre-to postoperative HHS improved from 47 (range, 30 to 58) to 92 points (range, 80 to 98) (P < .01). Nonprogressive and focalized demarcations were observed in 7 THA (14%). Importantly, no progressive demarcation or DMC aseptic loosening was observed. CONCLUSION: Direct cementation of DMC into the bony acetabulum ensured a stable fixation with no progressive demarcation or aseptic loosening at midterm follow-up. Therefore, this technique can be selectively considered in primary THA, especially in elderly or frail patients to avoid potential mechanical failure of press-fit fixation due to altered bone quality or additional morbidity related to the use of acetabular reinforcement devices.

[Partial knee arthroplasty - Which parameters to consider for the correct indication and to achieve an optimal result?] / Prothèse unicompartimentale du genou - Quels paramètres considérer pour poser la bonne indication et obtenir un résultat optimal ?

Unicompartmental knee arthroplasty (UKA) is considered an excellent alternative to total knee arthroplasty (TKA) in the treatment of unicompartmental femoro-tibial degeneration with superior functional scores, reduced morbidity and fewer complications. However, revision rates are higher, mainly during the early postoperative period. Failures are attributed to incorrect indications, surgical technical errors and to the low threshold to revision. Several clinical and radiological parameters have to be considered for a correct indication. A high surgical volume is mandatory to assure optimal outcome and survivorship.

La prothèse unicompartimentale du genou (PUC) est considérée comme une excellente alternative à la prothèse totale du genou (PTG) dans le traitement de l'arthrose monocompartimentale avec des scores fonctionnels supérieurs, une morbidité réduite et des taux de complications plus faibles. Cependant, les taux de révision sont plus élevés et se produisent principalement durant la période postopératoire précoce. Ils sont attribués à des indications incorrectes, à des erreurs chirurgicales et au fait que le seuil de révision est plus bas que pour une PTG. Plusieurs paramètres cliniques et radiologiques doivent être pris en considération afin de poser la bonne indication. Un volume chirurgical suffisant est nécessaire pour obtenir un résultat optimal et une survie prolongée de la PUC.

The Relationship Between Postoperative Opioid Analgesia and Sleep Apnea Severity in Patients Undergoing Hip Arthroplasty: A Randomized, Controlled, Triple-Blinded Trial.

PURPOSE: Residual postoperative pain after hip arthroplasty is usually treated with oral opioids. While classic opioids are associated with respiratory depression and worsening of sleep apnea, tramadol has been reported to preserve respiratory function. However, this has not been investigated in a prospective trial using respiratory polygraphy. This randomized controlled triple-blinded trial tested the hypothesis that postoperative treatment with oral opioids such as oxycodone would increase sleep apnea severity, measured with a respiratory polygraphy, compared with oral tramadol. PATIENTS AND METHODS: Sixty patients undergoing hip arthroplasty under spinal anesthesia with 15 mg isobaric bupivacaine 0.5% were randomized to receive postoperative pain treatment with either oral oxycodone (controlled-release 10 mg every 12 hours and immediate-release 5 mg every 4 hours as needed) or oral tramadol (controlled-release 100 mg every 8 hours and immediate-release 50 mg every 4 hours as needed). Respiratory polygraphy was performed on the first postoperative night. The primary outcome was the apnea-hypopnea index in the supine position. Secondary outcomes included the oxygen desaturation index, postoperative pain scores and intravenous morphine consumption. RESULTS: Mean supine apnea-hypopnea index on postoperative night 1 was 11.3 events.h-1 (95% confidence interval, 4.8-17.7) in the oxycodone group and 10.7 (4.6-16.8) events.h-1 in the tramadol group (p=0.89). There were no significant differences between the oxycodone and tramadol groups with respect to any secondary sleep-related or pain-related outcomes. CONCLUSION: Oral oxycodone did not increase sleep apnea severity measured using respiratory polygraphy compared with oral tramadol on the first postoperative night after hip arthroplasty. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov - NCT03454217 (date of registration: 05/03/2018).

Polyethylene wear of dual mobility cups: a comparative analysis based on patient-specific finite element modeling.

PURPOSE: Concerns remain about potential increased wear with dual mobility cups related to the multiple articulations involved in this specific design of implant. This finite element analysis study aimed to compare polyethylene (PE) wear between dual mobility cup and conventional acetabular component, and between the use of conventional ultra-high molecular weight PE (UHMWPE) and highly cross-linked PE (XPLE). METHODS: Patient-specific finite element modeling was developed for 15 patients undergoing primary total hip arthroplasty (THA). Five acetabular components were 3D modeled and compared in THA constructs replicating existing implants: a dual mobility cup with a 22.2-mm-diameter femoral head against UHMWPE or XLPE (DM22PE or DM22XL), a conventional cup with a 22.2-mm-diameter femoral head against UHMWPE (SD22PE) and a conventional cup with a 32-mm-diameter femoral head against UHMWPE or XLPE (SD32PE or SD32XL). RESULTS: DM22PE produced 4.6 times and 5.1 times more volumetric wear than SD32XL and DM22XL (p < 0.0001, Cohen's d = 6.97 and 7.11; respectively). However, even if significant, the differences in volumetric wear between DM22XL and SD32XL as well as between DM22PE and SD22PE or SD32PE were small according to their effect size (p < 0.0001, Cohen's |d|= 0.48 to 0.65) and could be therefore considered as clinically negligible. CONCLUSION: When using XLPE instead of UHMWPE, dual mobility cup with a 22.2-mm-diameter femoral head produced a similar amount of volumetric wear than conventional acetabular component with a 32-mm-diameter femoral head against XLPE. Therefore, XLPE is advocated in dual mobility cup to improve its wear performance.

Comparison of the long-term cause of failure and survivorship of four hundred and twenty seven metal-on-metal hip arthroplasties: resurfacing versus large head total hip arthroplasty.

INTRODUCTION: Comparison of mid- to long-term cause of failure and survivorship of metal-on-metal (MoM) resurfacing hip arthroplasty (RHA) and large head total hip arthroplasty (THA) remains sparse. This study aimed to identify and compare the cause of failure and survivorship of MoM RHA and THA at a minimum ten year follow-up. METHODS: Four hundred twenty-seven MoM hip arthroplasties (286 THA and 141 RHA) were retrospectively analyzed at a mean follow-up of 13 ± three years. Causes of failure were reported as MoM specific (i.e., adverse reaction to metal debris (ARMD) and painful hip with ion elevation) or MoM non-specific (i.e., fracture, infection, and dislocation). Chromium (Cr) and cobalt (Co) ion levels and Co/Cr ratio were compared. Survivorship was compared according to the cause of failure with revision as the endpoint. RESULTS: The rate of ARMD was significantly higher in THA (OR = 2.9 [95%-CI: 1-7]; p = 0.02). No significant difference was detected in failure rate due to other causes between the two groups (p = 0.2-0.9). Ion levels and Co/Cr ratio were both significantly higher in THA (p < 0.01). Survivorship was significantly lower in THA compared to RHA at ten years [89% (95%-CI: 85%-91%) vs 96% (95%-CI: 91%-98%); p = 0.01] and 15 years [73% (95%-CI: 67%-78%) vs 83% (95%-CI: 73%-90%); p = 0.01]. CONCLUSION: RHA survivorship was significantly higher at any time point. Failure rate due to ARMD was significantly higher in THA while no significant difference in other causes of failure was observed between the two groups. This result emphasizes the role of fretting corrosion at the head-neck junction (i.e., trunnionosis) with significantly higher ion levels and Co/Cr ratio dissociation in THA.

Total knee arthroplasty improves the quality-adjusted life years in patients who exceeded their estimated life expectancy.

PURPOSE: Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis though its risk-benefit ratio in elderly patients remains debated. This study aimed to evaluate the functional outcome, rates of complication and mortality, and quality-adjusted life years (QALY) in patients who exceeded their estimated life expectancy. METHODS: Ninety-seven TKA implanted in 86 patients who exceeded their estimated life expectancy at the time of TKA were prospectively included in our institutional joint registry and retrospectively analyzed. At latest follow-up, the functional outcome with the Knee Society Score (KSS), rates of complication and mortality, and QALY with utility value of EuroQol-5D score were evaluated. RESULTS: At a mean follow-up of three ± one years, the pre- to post-operative KSS improved significantly (p < 0.01). The rates of surgical and major medical complications related to TKA were 3% and 10%, respectively. The re-operation rate with readmission was 3% while no TKA was revised. The 30-day and one year mortality was 1% and 3%, respectively. The pre- to one year post-operative QALY improved significantly (p < 0.01). The cumulative QALY five years after TKA was four years. Assuming that these patients did not undergo TKA, their cumulative QALY at five years would have been only two years. CONCLUSION: TKA is an effective procedure for the treatment of end-stage osteoarthritis in patients who exceeded their estimated life expectancy. TKA provided significant improvement in function and quality of life without adversely affecting overall morbidity and mortality. Therefore, TKA should not be contra-indicated in elderly patients based on their advanced age alone.

Total hip arthroplasty through the direct anterior approach with and without the use of a traction table: a matched-control, retrospective, single-surgeon study.

BACKGROUND: Hip surgeons performing total hip arthroplasty (THA) through the direct anterior approach (DAA) commonly use a traction table to facilitate exposure. Even though performing THA through DAA without a traction table could be technically more demanding, this technique offers the advantage of intraoperative leg length comparison. Therefore, this study aimed to compare clinical outcomes, complication rates, component positioning, and leg length discrepancy (LLD) after THA through the DAA performed with or without a traction table. METHODS: A single-surgeon continuous series of 75 patients who underwent DAA THA performed with a traction table was matched for gender, age, and BMI with 75 patients who underwent DAA THA performed without a traction table (male, 62; female, 88, with an average age of 68 years old). Clinical and radiological outcomes, intra- and postoperative complications, and LLD were retrospectively assessed. RESULTS: No statistically significant difference was detected in surgical time, hospital stay, Harris Hip Score (HHS), complication rates, and implant positioning between the two groups. Leg length restoration was significantly more accurate in the group performed without a traction table (2.4 ± 2 mm vs. 3.7 ± 3.1 mm; p value ≤ 0.05). No LLD > 10 mm was reported in the group performed without a traction table, whereas two cases (2.7%) were reported in those performed with a traction table. CONCLUSION: Performing THA through DAA without a traction table was associated with a significantly more accurate leg length restoration without a significant increase in the rates of intra- and postoperative complications.

Supernumerary brachioradialis - Anatomical variation with magnetic resonance imaging findings: A case report.

BACKGROUND: In this single case report study, we describe an anatomical variance of a brachioradialis muscle with two muscle bellies and two tendons with their common insertion on the suprastyloid crest of a distal radius. CASE SUMMARY: After a self-mutilating forearm injury of a borderline personality patient, we observed the anatomical variation of brachioradialis tendon. After tendon repair and aftercare the muscle function recovered completely. Five months after surgery the forearm magnetic resonance imaging was done revealing a supernumerary brachioradialis muscle. CONCLUSION: Anatomical variations of forearm muscles and tendons are not rare. The treating surgeons should be aware of their existence and anatomical relationships.

Cementation of a Dual Mobility Cup Into an Existing Well-Fixed Metal Shell: A Reliable Option to Manage Wear-Related Recurrent Dislocation in Patients With High Surgical Risk.

BACKGROUND: During revision total hip arthroplasty (THA), the "double-socket" technique has been proposed as a straightforward solution in order to reduce the overall perioperative morbidity in patients with high surgical risk. However, the option of cementing a dual mobility cup into an existing well-fixed metal shell was sparsely reported. Therefore, this study aimed to evaluate the outcome of a "double-socket" technique performed with a cemented dual mobility cup in revision THA for late instability. METHODS: Twenty-eight revision THAs (28 patients) were performed for wear-related recurrent dislocation using a "double-socket" technique with a cemented dual mobility cup and retrospectively reviewed. The age at revision averaged 82 years (range 74-93). According to the American Society of Anesthesiologists (ASA) physical status classification, 12 patients (43%) were ASA II and 16 patients (57%) were ASA III before revision. RESULTS: At a mean follow-up of 3.5 years (range 2-5), the mean preoperative to postoperative functional outcome improved significantly (P < .01). The mean operative time was 107 minutes (range 75-140). The mean intraoperative bleeding was 200 mL (range 110-420). No postoperative complication, reoperation, or re-revision was reported. Importantly, no dislocation, dissociation of the cemented dual mobility cup construct, or aseptic loosening of the retained metal shell was observed. CONCLUSION: The "double-socket" technique with a dual mobility cup cemented into an existing well-fixed and well-positioned metal shell ensured a straightforward and blood-sparing revision technique that was efficient to restore stability and provide a secure acetabular construct in frail patients with high surgical risk and/or older than their natural life expectancy.

Is revision total hip arthroplasty through the direct anterior approach feasible?

BACKGROUND: To date, only limited literature exists regarding revision of total hip arthroplasty (THA) through the direct anterior approach (DAA). However, as the popularity of the DAA for primary surgery is increasing, surgeons will be confronted with the challenge of performing revision surgery through the DAA. The aim of this study was to review the potential of the DAA in the revision setting and to report the clinical results, radiologic outcomes and complication rates of 63 patients undergoing revision THA through the DAA. METHODS: From 01/2009 to 08/2017, 63 patients underwent revision THA through the DAA. Depending on the performed procedure, patients were separated into 4 groups: liner and head exchange (21 patients), revision of the acetabular cup (26 patients), revision of the femoral stem (13 patients) or revision of both components (3 patients). Postoperative complications as well as the clinical and radiological outcome were assessed retrospectively. RESULTS: At a mean follow-up of 18 months, the overall complication and re-operation rates were 14.3% and 12.7%, respectively. Specifically, the complication and re-operation rates were 14.2% and 9.5% after liner and head exchange, 15.4% after revision of the acetabular cup, 15.3% after revision of the femoral stem and 0% after revision of both components. The mean postoperative HHS at 1 year postoperatively was 91 (range 74-100). CONCLUSION: The DAA offers appropriate exposure for exchange of mobile liners and acetabular cup revision. In selected cases with appropriate stem design, femoral stem revision through the DAA is feasible. However, surgeons should be aware of the technical difficulties related to femoral revision and be prepared to extend the approach distally or perform a trochanteric osteotomy.

Should advanced age be a contraindication to total hip arthroplasty in femoral neck fracture patients? A matched-control, retrospective study.

INTRODUCTION: Due to demographic changes, the annual incidence of femoral neck fractures (FNF) in patients reaching the 9th and 10th decade of life is increasing. Although active and cognitively intact elderly patients could benefit from total hip arthroplasty (THA) in case of a FNF, there is no clear consensus on whether THA should be performed in this particular subgroup of patients with very advanced age. The purpose of this study was to report the complication rate, mortality, clinical outcomes and quality-adjusted life year (QALY) gained in patients treated with total THA for FNF, while having exceeded the mean life expectancy at the time of surgery, compared to a younger control group. MATERIALS AND METHODS: Patients treated with THA through a direct anterior approach (DAA) for FNF and exceeding the average life expectancy in Switzerland (age ≥ 83 y, n = 45) were matched for gender, body mass index (BMI) and ASA score with patients under the age of 83 (age = 65-83, n = 45). Perioperative complications, clinical and radiologic outcomes, as well as mortality were compared between groups. RESULTS: Total complication rate did not differ significantly with 22.2% in the older group compared to 17.8% in the control group. The 30-day and 1-year mortality was slightly but not significantly higher in the older group (2.2% and 8.9% vs. 2.2% and 2.2%). The average QALY gained was 3.4 years and 4.1 years for the older group and their younger counterparts, respectively. CONCLUSION: THA through the DAA for FNF in cognitively intact and active patients might be a credible and safe option even after reaching mean life expectancy with excellent functional outcomes and similar surgery-related complications compared to patients younger than 83 years. Our results imply that an advanced age should not be considered a contraindication for THA in case of a FNF.

Early locking plate removal following open reduction and internal fixation of proximal humeral fractures could prevent secondary implant-related complications.

INTRODUCTION: Proximal humeral fracture is a common cause of morbidity in the elderly and poses a challenge for the orthopedic surgeon. Open reduction and internal fixation (ORIF) with a locking plate is associated with high rate of secondary implant-related complications (IRC). Early implant removal could potentially reduce the risk of IRC and further improve the outcome in relatively asymptomatic patients. The purpose of this study was to evaluate the clinical and radiologic outcomes following implant removal. METHODS: A total of 56 patients with an average age of 63 ±â€¯13 years and a mean follow-up of 29 months were evaluated retrospectively following removal of a locking plate in the proximal humerus. Postoperative functional outcomes were evaluated with the Constant-Score, Subjective shoulder value and Quick-DASH score. RESULTS: Early implant removal resulted in high functional outcomes with 96% of the patients reporting an improvement of their shoulder function following implant removal. No intraoperative complications were reported. Avascular necrosis (AVN) of the humeral head occurred in 12.5% of the patients, but no secondary screw cut-out was reported. CONCLUSION: Early implant removal might be a safe option to avoid secondary IRC with significant subjective functional improvement also in asymptomatic patients. Although early implant removal cannot reverse the process of AVN, it could potentially prevent secondary IRC and subsequent glenohumeral cartilage destruction.

Could a Simple Screening Procedure Identify Patients With Early Cognitive Impairment? Implications for the Treatment of Geriatric Femoral Neck Fractures.

BACKGROUND: Current evidence suggests that cognitive capacities in patients who sustain a femoral neck fracture (FNF) correlate to patient outcome. We hypothesized that a simple selection procedure with 2 questions: "Can you perform your groceries independently?" and "Can you prepare your daily medications unassisted?", which imply a certain level of physical and cognitive function, could identify patients with early cognitive impairment and as a result influence the outcome of hip arthroplasty following an FNF. METHODS: At our clinic, the selection procedure was introduced in 2012 to simplify decision-making in geriatric FNF. At the time of surgery, patients received a total hip arthroplasty (THA) when able to perform their grocery shopping and prepare their daily medications unassisted (n = 100); otherwise, a hemiarthroplasty (HA) was performed (n = 100). Postoperative complications and mortality were assessed retrospectively. Second, we prospectively investigated whether patients' inability to perform groceries or prepare medications was associated with the presence of early cognitive impairment, tested with the Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery. RESULTS: The screening questions showed almost perfect agreement (k = 0.8; sensitivity/specificity: 82%/95%) to early cognitive impairment. The 30-day mortality for THA and HA patients was 2% and 4%, respectively. The 1-year and 5-year survivorship for the THA group was 95% and 87% and for the HA group 63% and 8%, respectively. Complication rates were comparable. CONCLUSION: The results might suggest that 2 simple screening questions could help in the decision-making of the appropriate surgical treatment in elderly patients suffering from a displaced FNF.

Migration analysis of a metaphyseal-anchored short femoral stem in cementless THA and factors affecting the stem subsidence.

BACKGROUND: Early femoral stem subsidence following a cementless THA is correlated with aseptic loosening of the femoral component. The short femoral stems allow bone sparing and implantation through a minimally invasive approach; however, due to their metaphyseal anchoring, they might demonstrate different subsidence pattern than the conventional stems. METHODS: In this prospective single-center study, a total of 68 consecutive patients with an average age of 63 years, and a minimum follow-up of 5 years following a cementless THA with a metaphyseal-anchored short femoral stem were included. The femoral stem subsidence was evaluated using "Ein Bild Roentgen Analyse" (EBRA). RESULTS: Average stem migration was 0.96 +/- 0.76 mm at 3 months, 1.71 +/- 1.26 mm at 24 months, and 2.04+/- 1.42 mm at last follow-up 60 months postoperative. The only factor that affected migration was a stem size of 6 or more (r2 = 5.74; p = 0.039). Subdivision analysis revealed, that only in females migration appeared to be affected by stem size irrespective of weight but not in men (female stem size of 6 or more vs. less (Difference = - 1.48 mm, R2 = 37.5; p = 0.001). Migration did not have an impact on clinical outcome measures. CONCLUSIONS: The examined metaphyseal-anchored short femoral stem showed the highest subsidence within the first 3 months postoperative, the implant began to stabilize at about 24 months but continued to slowly migrate with average total subsidence of 2.04 mm at 5 years following the THA. The amount of stem subsidence was not associated with worse clinical outcomes such as HHS, patient satisfaction, or pain.

Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty.

BACKGROUND: The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited. AIM: To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint. METHODS: We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage. RESULTS: Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively. CONCLUSION: Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

[The irreducible ankle dislocation: beware of the Bosworth injury]. / Irreponible Luxation des oberen Sprunggelenks: die Bosworth-Verletzung.

A luxation fracture of the ankle characterized by a dislocation of the fibula posterior to the tibial tubercle is defined as a Bosworth injury. The Bosworth fracture is a frequently overlooked complex injury of the ankle joint. Associated injuries such as a pilon fracture and posterior malleolus fracture have rarely been reported. In the case of a closed irreducible ankle fracture dislocation, Bosworth injuries should be considered as a potential cause. This article reports the course, treatment and clinical outcome 12 months after trauma of a Bosworth fracture with associated impaction of the posteromedial pilon and fracture of the posterior malleolus. To date, there are only few reports of comparable injuries in the German language literature.

Midterm clinical and radiographic outcomes of 115 consecutive patient-specific unicompartmental knee arthroplasties.

BACKGROUND: Poor implant positioning has been identified as a factor in early failure of unicompartmental knee arthroplasty. The aim of this study was to report the accuracy of component positioning, and midterm clinical, functional and radiological outcomes following patient-specific instrumented (PSI) unicompartmental knee arthroplasty (UKA). METHODS: A total of 115 PSI-UKA were included. The primary outcomes were UKA survival, complication, and failure rates. Tibial implant positioning was determined using plain radiographs. Functional assessment included Oxford Knee Score (OKS), Forgotten Joint Score (FJS), patient satisfaction, and range of motion (ROM). RESULTS: The survival rate of PSI-UKA was 92% after a mean follow-up of 55 months. The complication and failure rate was 13% and eight percent, respectively. The tibial component was accurately implanted in the desired frontal and sagittal alignment with a minor deviation of 0.3° (SD 1.9°) and 0.4° (SD 2.6°) to the preoperative planning. OKS increased from 24 (SD eight) points to 44 (SD six). FJS was 87 (SD 23) and 89.6% of all patients reported to be satisfied at the final follow-up. Patient satisfaction was negatively correlated with patients' age (p < 0.05). CONCLUSION: Excellent accuracy regarding component placement in UKA can be achieved with PSI. However, despite excellent survivorship and clinical outcomes, these data indicate that the PSI system is not superior to conventional UKA implantation methods.