Cemented stems in healthy elderly patients result in higher hypoxia despite a paradoxical lower femoral increase of intramedullary pressure.

PURPOSE: Hypoxia is a well-known complication in cemented arthroplasty; however, it is not known whether the level of hypoxia is related to the intramedullary pressure or to the age of the patient; therefore, we studied the intramedullary pressure and level of hypoxia in patients undergoing cemented arthroplasty. METHODS: A prospective study was performed during cemented arthroplasties in 25 patients with an average age of 66.2 ± 12.1 years old. The intramedullary pressure (IMP) was measured by placing a pressure transducer within the bone while simultaneously measuring the pulse oximetry arterial oxygen saturation (SpO2), pulse, and blood pressure. These variables were obtained immediately after spinal anaesthesia, five minutes after cementation, and 15 minutes after prosthesis insertion. RESULTS: One hundred percent of patients had hypoxia at some level, but 83% of elderly patients (older than 66.5 years) had hypoxia (SpO2 <94%) as compared to only 23% of younger patients (p = 0.006). In the group of young patients, IMP was roughly increased 32 times as compared with baseline level, with as consequences a decrease of 4% of SpO2 (from 98.3 to 94.15%); in the elderly group, the IMP was only increased 20 times, but a decrease of 6% of SpO2 (from 97.25 to 91%) was observed. CONCLUSIONS: This series demonstrated higher hypoxia in elderly healthy patients despite a paradoxical lower femoral increase of intramedullary pressure as compared with younger patients. This hypoxia is probably not only related to the cement but also to the patient's age with decline of maximum oxygen uptake capacity and increase bone porosity. CLINICAL TRIALS: ClinicalTrials.gov Identifier: NCT03930537 https://clinicaltrials.gov/ct2/show/NCT03930537.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Targeting Core Decompression and Cell Therapy Injection of Hip Osteonecrosis with Computer-Assisted Navigation.

PURPOSE: Surgical treatment of hip osteonecrosis with stem cell therapy is a new procedure in which cells are injected with a trocar under fluoroscopic guidance. Proper surgical technique to obtain appropriate placement of the trocar in the center of the osteonecrosis is sometimes difficult and can require additional radiation exposure until the surgeon is satisfied with the trocar position. This study describes an improvement of this procedure using computer-assisted navigation. METHODS: A prospective, randomized study was conducted on cadavers using surgical trainees with no experience and one expert surgeon in surgical core decompression. During a training session, 3 novice surgeons underwent a test by performing the surgical task (core decompression) on a cadaver hip using fluoroscopic guidance. These trainee surgeons then placed the Kirschner wire under computer-assisted navigation. Osteonecrosis was defined as a target volume situated on the superior and anterior part of the femoral head. Performance during the tests was evaluated by radiographic analysis of trocar placement and by the measurement of radiation exposure. RESULTS: During the cadaver session, computer-assisted navigation achieved a better match to the ideal position of the trocar, with better trocar placement in terms of the tip-to-subchondral distance and the ideal center position. Computer-assisted navigation was associated with fewer attempts to position the trocar, a shorter duration of fluoroscopy, and decreased radiation exposure compared to surgery performed under conventional fluoroscopy. CONCLUSIONS: The findings suggest that computer-assisted navigation may be safely used to train surgical novices in core decompression. This technique avoids the use of both live patients and harmful radiation. For expert surgeons, computer-assisted navigation might improve precision with less radiation, which might be desirable in cell therapy.

Dual Mobility Acetabular Cup Versus Hemiarthroplasty in Treatment of Displaced Femoral Neck Fractures in Elderly Patients: Comparative Study and Results at Minimum 3-Year Follow-up.

BACKGROUND: Hip fractures are serious injuries associated with relatively high mortality rates and disabilities, commonly seen in elderly persons. There is an ongoing debate regarding the advantages of various hip arthroplasty devices. This study aimed to analyze the long-term advantages of 2 different surgical procedures and assess if the dislocation rate, Harris Hip Score (HHS), and functional independence measure (FIM) are more favorable in dual mobility (DM) than those in hemiarthroplasty (HA). HYPOTHESIS: Dual mobility procedures provide better postoperative outcomes than HA in terms of HHS, FIM, and dislocation rate. MATERIALS AND METHODS: The survey was a prospective, comparative interventional single-blinded study performed at the University Clinical Center of Kosovo, a tertiary health-care institution. A total of 94 patients underwent DM or conventional bipolar HA for repair of displaced femoral neck fractures within 2 weeks of injury. Primary outcomes were postoperative dislocation rate, FIM, and HHS. Secondary outcomes included duration of surgery, estimated intraoperative blood loss, time to first postoperative full weight-bearing, time to walking ability with and without crutches, mortality rate, and postoperative infection rate. RESULTS: There were no significant differences for most parameters between the groups. We found a significant difference in the dislocation rate between the 2 groups, wherein there were no dislocations in the DM group and 3 dislocations in the HHS group (0% vs 6.4%). In terms of postoperative HHS at 12 months and 3 years, DM provided better outcomes (<0.034 and <0.014, respectively). DISCUSSION: Dual mobility compares favorably to HA in terms of dislocation rate and HHS, while no difference was found for FIM. In order to have a more complete overview, we recommend more intense long-term studies including several heterogeneous parameters to compare the clinical outcomes between DM and HA. LEVEL OF EVIDENCE WITH STUDY DESIGN: Level II.

Primary hemiarthroplasty for treatment of unstable pertrochanteric femoral fractures (AO/OTA Type 31 A2.3) in elderly osteoporotic patients.

INTRODUCTION: The aim of this study was to prospectively analyze the role of primary hemiarthroplasty in unstable osteoporotic pertrochanteric fractures (AO/OTA Type 31 A2.3), with emphasis given to postoperative Functional Independent Measure (FIM) and Harris Hip Score (HHS). METHODS: Fifty-six consecutive patients (average age 78.25 ± 5.45), out of which 24 males (79.29 ± 4.99) and 32 females (77.47 ± 5.72), with unstable pertrochanteric femoral fractures, operated with primary hemiarthroplasty procedure from 2012 to 2014 were included in this prospective study with a follow-up of two years. Primary outcomes were FIM and HHS. Secondary outcomes included duration of surgery, estimated intraoperative blood loss, time to first postoperative full weight-bearing, time to walking ability with and without crutches, average hospital stay, postoperative complications, and mortality. RESULTS: The FIM score at 3 months was 85.9 ± 5.7. HHS at two years was excellent for 41 patients (73, 2%), good for eight (14.3%), fair for four (7.1%), and poor for three (5.4%). The mean duration of surgery was 62.6 min, estimated intraoperative blood loss 175.5 mL, time to first postoperative full weight-bearing 2.2 ± 0.4 days, ability to walk with crutches 6.3 ± 1.8 days and without crutches 44.2 ± 12.7 days, and the average hospital stay was 9.6 ± 2.7 days. CONCLUSION: This study highlighted good clinical postoperative outcome scores for primary hemiarthroplasty for the treatment of unstable pertrochanteric femoral fractures in elderly osteoporotic patients. This procedure seems to be secure and effective, and offers a good quality of life in terms of FIM and HHS.