Indication for total knee arthroplasty based on preoperative functional score: Are we operating earlier?

BACKGROUND: The number of total knee arthroplasty (TKA) procedures performed annually is increasing for reasons not fully explained by population growth and increasing rates of obesity. The purpose of this study was to determine the role of patient functional status as an indication for surgery and to determine if patients are undergoing surgery with a higher level of preoperative function than in the past. METHODS: A systematic review and meta-analysis of the MEDLINE, Embase and Cochrane databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Functional status was assessed using the 36-Item Short Form Health Survey's physical component summary (PCS) score. Only primary procedures were included. Articles were screened by 2 independent reviewers, with conflicts resolved with a third reviewer. Meta-regression analysis was performed to determine the effect of time, age and sex on preoperative PCS score. Subgroup analysis was performed to compare results for the United States with those for the rest of the world. RESULTS: A total of 1502 articles were identified, of which 149 were included in the study. Data from 257 independent groups including 57 844 patients recruited from 1991 to 2015 were analyzed. The mean preoperative PCS score was 31.1 (95% confidence interval 30.6-31.7) with a 95% prediction interval of 22.8-39.5. The variance across studies was found to be significant (p < 0.001) with 99.01% true variance. Year of enrolment, age, the percentage of female patients and geographic region did not have any significant effect on preoperative PCS score. CONCLUSION: Patients are undergoing TKA with a level of preoperative function similar to their level of function in the past. Patient age, sex and location did not influence the functional status at which patients were considered to be candidates for surgery.

Open Versus Arthroscopic Mosaicplasty of the Knee: A Cadaveric Assessment of Accuracy of Graft Placement Using Navigation.

PURPOSE: The purpose of this study was to compare an open freehand mosaicplasty technique with an arthroscopic technique for the treatment of osteochondral lesions by measuring the instrument deviation, quantifying this deviation, and providing numerical information on the difference in the outcomes of these techniques. METHODS: Four cadaveric knees were used. Reference markers were attached to the femur, tibia, and donor/recipient site guides. A total of 10 osteochondral grafts were harvested and inserted into recipient sites arthroscopically and 10 similar grafts were inserted freehand. The angles of graft removal and placement were calculated for each of the surgical groups compared. Ostensibly, a navigation system was used as an aid, to measure the graft placement parameters. RESULTS: Statistical analysis revealed that there was no statistically significant difference between the arthroscopic method and the freehand method regarding the angle of graft removal at the donor site (P = .162), recipient site plug removal angle (P = .731), and recipient site graft placement angle (P = .630). In the freehand group, the mean angle of graft removal at the donor site was 12°, the mean angle of recipient site plug removal was 10.7°, and the mean angle of recipient site plug placement was 10.6°. Using the arthroscopic technique, the mean angle of graft removal at the donor site was 17.14°, the mean angle of recipient site plug removal was 12.0°, and the mean angle of recipient site graft placement was 10.14°. CONCLUSIONS: Our study revealed there was no statistically significant difference regarding precision and accuracy during harvesting, recipient site preparation, and plug placement between the 2 techniques. CLINICAL RELEVANCE: Controversy exists whether an open or arthroscopic osteoarticular transfer system (OATS) technique provides superior accuracy. According to our results, there is no statistically significant difference regarding better visualization, precision, and accuracy between the freehand and arthroscopic techniques. However, larger number of specimens are required for study.

Two-Stage Revision Protocol in Multidrug Resistant Periprosthetic Infection Following Total Hip Arthroplasty Using a Long Interval Between Stages.

We retrospectively reviewed the medical records of 31 patients with periprosthetic hip infections attempting to evaluate the outcome of a two-stage revision protocol characterized by prolonged interim period (mean=9.2 months, range 8-12 months) prior to the final re-implantation. In 3 cases (9.6%) the 1st stage was repeated after a mean period of 12.3 weeks due to relapse of infection. Five spacer dislocations occurred, not affecting the final clinical outcome after reimplantation, as evaluated by the Harris Hip Score. No protrusions or additional acetabular bone loss was noticed. Our proposed protocol is a simple, safe, efficient and reproducible treatment approach that may be successfully utilized predominantly when dealing with multidrug resistant pathogens.

Ultrasound-guided anterior axilla musculocutaneous nerve block.

PURPOSE: This paper presents a technique of ultrasound-guided localisation and block of the musculocutaneous nerve through the anterior wall of the axilla. MATERIALS AND METHODS: Twenty patients (7 males and 13 females; mean age, 35 years) had axillary nerve block for upper extremity trauma. With the arm adducted, the ultrasound probe was positioned on the anterior axillary wall; the axillary artery, coracobrachialis and pectoralis major muscles and lateral cord of brachial plexus were visualised in cross section. With continuous imaging of the axillary artery in cross section, the ultrasound probe was slowly moved towards the biceps muscle until the musculocutaneous nerve appeared crossing the coracobrachialis muscle. After ultrasound localisation of the musculocutaneous nerve, the arm was abducted and externally rotated, and the nerve was identified with nerve stimulation and blocked. The quality of sensory and motor nerve block, as well as of ultrasound imaging were evaluated. RESULTS: Ultrasound-guided block of the musculocutaneous nerve was excellent and complete in 18 of the 20 patients. In two patients, the musculocutaneous nerve was fused with the median nerve and the nerve block was repeated successfully with the same technique. The quality of ultrasound imaging was excellent in all patients. No patient experienced pain or tourniquet discomfort during surgery, or any other nerve block-related complication. CONCLUSION: The anterior axillary ultrasound view provides for complete nerve block and imaging of the entire course of the musculocutaneous nerve and its relations with adjacent structures with excellent quality.

When and how to operate on thoracic and lumbar spine fractures?

PURPOSE: To discuss when and how to operate on thoracic and lumbar spine fractures. PATIENTS AND METHODS: We retrospectively studied 77 consecutive patients with thoracic and lumbar spine fractures treated from 2000 to 2011; 28 patients experienced high-energy spinal trauma and 49 low-energy spinal trauma. Mean follow-up was 5 years (1-11 years). Surgical treatment was done in 15 patients with neurological deficits, and in 16 neurologically intact patients with fractures-dislocations, burst fractures and fractures with marked deformity. Non-surgical treatment was done in 46 neurologically intact patients with simple fracture configurations. Clinical and imaging examination and the Oswestry Disability Index (O.D.I.) questionnaire were obtained. RESULTS: All patients treated surgically maintained spinal alignment; patients with long fusion maintained the best alignment; however, they experienced back stiffness and moderate low back pain. Patients with combined posterior fusion and kyphoplasty experienced earlier recovery and improved sagittal correction. Mean O.D.I. was 22.4 and 14.2% at 3 and 12 months postoperatively. Thirty six (78%) patients treated non-surgically were asymptomatic, 22 (48%) experienced mild residual kyphosis, 10 (22 %) developed marked deformity during their follow-up and were finally operated; mean O.D.I. was 28.6 and 12.1% at 3 and 12 months. No difference in O.D.I. was observed between patients who had surgical and non-surgical treatment. CONCLUSIONS: Progressive neurological deficits and/or mechanical instability of the spine are absolute indications for early surgical treatment. Younger patients with high-energy spinal trauma, unstable fractures and neurological deficits should be treated surgically in order to provide optimum conditions for neurologic recovery, early mobilization and possibly ambulation. Most cases can be adequately operated through a posterior only surgical approach; an anterior or combined approach is usually indicated for burst and thoracic spine fractures. Postoperative complications, more common infection and neurological deterioration may occur. Elderly, neurologically intact patients with low-energy, stable spinal fractures without marked spinal deformity may be successfully treated conservatively. Most of these patients will do well; however, follow-up for progressive posttraumatic deformity is required.

Risk factors for and complications of distraction osteogenesis.

PURPOSE: Distraction osteogenesis is commonly used for limb deformities and reconstruction of bone defects with satisfactory outcome for the patients. However, it is associated with a risk of complications. The present study aims to assess the incidence of complications and to identify the risk factors that may predict distraction osteogenesis-related complications. MATERIALS AND METHODS: We retrospectively studied 63 patients (mean age 13.5 years; range 3-57 years) who had 74 distraction osteogenesis procedures from 2004 to 2009. A circular external fixator was used in 58 procedures, and a monolateral in 16 procedures. Fixator's time, days of treatment, lengthening percentage, bone healing index, distraction regenerate length and index, risk factors and complications were evaluated. The mean follow-up was 5 years (range 2-7 years). RESULTS: Complications occurred in 57 of the 74 procedures (77%); 70% were major complications and 30% were minor. Complications were more common in adults. Bone healing index, days of treatment and fixator's time were univariate predictors of complications. Bone healing index and adult age were the only multivariate predictors of complications. CONCLUSION: Adult age and bone healing index are the most important multivariate predictors of distraction osteogenesis-related complications. Routine follow-up after implant removal, selection of younger patients with minor risk factors and shorter fixator's time are necessary to reduce the rate of distraction osteogenesis-related complications.

Pharmacological Treatment of Degenerative Cervical Myelopathy: A Critical Review of Current Evidence.

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults, representing substantial morbidity and significant financial and resource burdens. Typically, patients with progressive DCM will eventually receive surgical treatment. Nonetheless, despite advancements in pharmacotherapeutics, evidence for pharmacological therapy remains limited. Health professionals from various fields would find interest in pharmacological agents that could benefit patients with mild DCM or enhance surgical outcomes. This review aims to consolidate all clinical and experimental evidence on the pharmacological treatment of DCM. We conducted a comprehensive narrative review that presents all pharmacological agents that have been investigated for DCM treatment in both humans and animal models. Riluzole exhibits effectiveness solely in rat models, but not in treating mild DCM in humans. Cerebrolysin emerges as a potential neuroprotective agent for myelopathy in animals but had contradictory results in clinical trials. Limaprost alfadex demonstrates motor function improvement in animal models and exhibits promising outcomes in a small clinical trial. Glucocorticoids not only fail to provide clinical benefits but may also lead to adverse events. Cilostazol, anti-Fas ligand antibody, and Jingshu Keli display promise in animal studies, while erythropoietin, granulocyte colony-stimulating factor and limaprost alfadex exhibit potential in both animal and human research. Existing evidence mainly rests on weak clinical data and animal experimentation. Current pharmacological efforts target ion channels, stem cell differentiation, inflammatory, vascular, and apoptotic pathways. The inherent nature and pathogenesis of DCM offer substantial prospects for developing neurodegenerative or neuroprotective therapies capable of altering disease progression, potentially delaying surgical intervention, and optimizing outcomes for those undergoing surgical decompression.

Sliding screw implants for extracapsular hip fractures.

Hip fractures are associated with significant mortality and morbidity for the patients, more dependent residual status, and increased socio-economic cost. Many hip-fracture patients experience severe functional impairment, and most never recover their pre-fracture level of function. Current research has sought to identify the most effective treatments to reduce the incidence of hip fractures, improve survival and quality of life, and minimize complications and disability. The treatment of these fractures in the elderly aims to return these people to their pre-fracture mobility and functional level. This article reviews the surgical treatment options for extracapsular hip fractures and discusses their associated advantages, disadvantages, and complications. Two types of implants are currently available: the dynamic hip screw (DHS), and the intramedullary hip nail with one or two sliding screws. In this review, no clear advantage of one implant over another for the treatment of extracapsular hip fractures was evident. Both the DHS and hip nails can be used successfully for the treatment of stable hip fractures; for unstable fractures and low subtrochanteric fractures, hip nails are preferred. Although hip nails are associated with limited exposure, lower blood loss and transfusion requirements, and shorter operative time, complications are more common with hip nails. Long-term survival and function are similar in the two approaches. Hip nails with two sliding screws do not seem to make the difference in clinical practice that is reported in biomechanical studies.

Median nerve entrapment and ulnar nerve palsy following elbow dislocation in a child.

This report presents a rare case of a child who presented with neglected intra-articular entrapment of the median nerve, ulnar nerve palsy, and intra-articular incarceration of the medial epicondyle following closed reduction of an elbow dislocation. In the present case, as in most other cases, the diagnosis and treatment were delayed. Careful initial and postreduction neurological examination, as well as careful interpretation of the plain radiographs, is necessary for early detection of any nerve complications and associated fractures of an elbow dislocation. The authors' opinion is that a child with an elbow dislocation, which is initially neurologically intact but advances to a median or ulnar nerve deficit after the reduction, must undergo early surgical exploration, especially when the dislocation is associated with a medial epicondyle fracture.

Discordance in spinal and thoracic correction using powerful full screw constructs in idiopathic scoliotic.

The pre and postoperative rib-vertebra angles and Cobb angles in patients with idiopathic scoliosis pre and post operatively treated with full transpedicular screw constructs were compared. Eighteen patients had right thoracic curves while only two had a left curve. 7 curves were Lenke's type 3C, 6 type 5C, 4 type 1A, 3 type 6C and one type 2A. Convex side showed larger RVAs compared to the concaved side. The rib vertebra angle decreased from T1 to T12. The rib vertebra angles pre operatively (left vs right) were significantly different in every single level apart from T1, T7, T8 and T9. Cobb angle significantly improved post - operatively (p=0.0001). The post-operative rib vertebra angle differences significantly differed at all levels (p>0.05), but not in the region spanning the thoracic apex (T6-T7-T8). The powerful full-screw instrumentation corrects the Cobb angle very satisfactorily, but only partially corrects the rib cage asymmetry as this is expressed by the rib vertebra angle differences pre and post operatively. The small or no effect on the stiff apical ribs (T6-T8) and the possible role of the related musculature need to be further evaluated and analyzed.

Megaprosthesis anti-bacterial coatings: A comprehensive translational review.

Periprosthetic joint infections (PJI) are catastrophic complications for patients with implanted megaprostheses and pose significant challenges in the management of orthopaedic oncology patients. Despite various preventative strategies, with the increasing rate of implanted orthopaedic prostheses, the number of PJIs may be increasing. PJIs are associated with a high rate of amputation. Therefore, novel strategies to combat bacterial colonization and biofilm formation are required. A promising strategy is the utilization of anti-bacterial coatings on megaprosthetic implants. In this translational review, a brief overview of the mechanism of bacterial colonization of implants and biofilm formation will be provided, followed by a discussion and classification of major anti-bacterial coatings currently in use and development. In addition, current in vitro outcomes, clinical significance, economic importance, evolutionary perspectives, and future directions of anti-bacterial coatings will also be discussed. Megaprosthetic anti-bacterial coating strategies will help reduce infection rates following the implantation of megaprostheses and would positively impact sarcoma care. STATEMENT OF SIGNIFICANCE: This review highlights the clinical challenges and a multitude of potential solutions to combating peri-prosthetic join infections in megaprotheses using anti-bacterial coatings. Reducing infection rates following the implantation of megaprostheses would have a major impact on sarcoma care and major trauma surgeries that require reconstruction of large skeletal defects.

Late compartment syndrome of the hand due to wasp sting in a child.

We report a 6-year-old girl, with no history of previous anaphylactic reaction, who sustained a wasp sting to the volar aspect of her left hand. The child did not present any symptoms at the beginning. She was first examined at the emergency department with developed compartment syndrome, after more than 24 hours later and she was urgently taken to the operating theatre. The midpalmar, thenar, and hypothenar spaces were decompressed, and the transverse carpal ligament was released. At the 11-month followup, she presented with normal function of the hand and normal 2-point discrimination in all fingers. Although the accurate mechanism of the development of compartment syndrome after a wasp sting in children is not thoroughly clear, the treatment seems to be the same as in all other cases of compartment syndrome; urgent fasciotomy. It is very important to keep in mind the possibility, even if it is extremely low, of compartment syndrome after a wasp sting in children; even of those with no history of anaphylactic reaction.

Intramedullary Nailing Versus Plate Osteosynthesis for Humeral Shaft Metastatic Lesions.

In the event of surgical management of metastases to the humeral shaft, intramedullary nailing (IMN) is often preferred to plate osteosynthesis (PO) fixation despite a lack of consensus. In this study, we hypothesized that plate osteosynthesis will be associated with better functional and pain outcomes, thus better quality of life. Eighteen patients with the diagnosis of humeral shaft metastatic fracture or impending fracture were extracted from a prospective database of 140 metastatic patients collected across three hospitals over a five-year period. Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), Quality of Life (QOL) and Brief Pain Inventory (BPI) score were gathered during the year following the surgery. Statistical analysis was performed to compare the mean score differences between the two surgical options at baseline and five follow-up visits. Both treatment options were associated with an increase in functional outcomes based on both MSTS and TESS, and a decrease in pain level. However, no significant difference was found in quality of life and between the two treatment modalities. Thus, based on our results, a similar improvement in functional status and pain level can be achieved surgically by either intramedullary nailing or plating osteosynthesis.

Systematic review of primary total hip arthroplasty using titanium-titanium modular-neck prostheses: the true risk of revision.

AIMS: Modular-neck femoral implants are used to enable more variability in femoral neck version, offset and length. It has been reported that these implants carry a higher rate of revision. The aim of this review was to assess the overall and cause-specific revision rate of titanium-titanium alloy modular-neck implants in primary total hip arthroplasty (THA). METHODS: A systematic review was conducted following PRISMA guidelines and utilising multiple databases. All results were screened for eligibility. Studies published from 2000 onwards, using a current-generation, titanium-titanium, modular-neck implant were included. Overall and cause-specific revision rates were analysed, comparing to fixed-neck prostheses where applicable. RESULTS: 920 studies were screened. After applying exclusion criteria, 23 were assessed in full and 14 included. These consisted of 12 case series and 2 joint registry analyses. 21,841 patients underwent a modular-neck implant with a weighted mean follow-up of 5.7 years, mean age of 62.4 years, and average body mass index (BMI) of 28.4kg/m2. The overall revision rate was 3.95% and 2.98% for modular and fixed-neck prostheses, respectively. For studies with >5 years follow-up the mean revision rate was 3.08%. There was no difference in cause-specific revision rates by implant design. Mean improvement in Harris Hip Score was 41.9. CONCLUSIONS: At medium-term, revision rates for titanium-titanium primary modular-neck THA are acceptable. These prostheses are a sensible management option in patients with considerable anatomical hip deformity not amenable to correction with standard fixed-neck implants. Patients of male gender, high BMI and requiring prostheses with a larger neck, offset or head are at higher risk of implant failure.

Benign peripheral nerve tumors.

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach.

Delayed presentation of bilateral central hip protrusio acetabuli: evidence-based management.

This is a case of a previously healthy 51-year-old man who sustained bilateral central hip dislocations following a sudden presentation of epileptic seizures. The patient was initially treated conservatively for a period of 9 months. On presentation, he had gross disability due to stiffness in both hips and left peroneal nerve paresis. Through minimally invasive direct anterior approaches, bilateral total hip arthroplasties were performed using tripolar head articulations. These were cemented into a biologic acetabular buttress constructed out of autologous bone graft. The femoral heads and necks were used as plugs and pressed into the acetabular defects, putting the medial acetabular walls under tension. At 24 months' follow-up, there was a good clinical outcome, and the acetabular walls remodelled bilaterally. In conclusion, in traumatic protrusio acetabuli, a functional, biologic reconstruction of the acetabular wall can be facilitated with the application of distraction osteogenesis (tension-stress) principles while using minimally invasive surgical techniques.

Multiple Soft Tissue Sarcomas in a Single Patient: An International Multicentre Review.

Developing multiple soft tissue sarcomas (STSs) is a rare process, sparsely reported in the literature to date. Little is known about the pattern of disease development or outcomes in these patients. Patients were identified from three tertiary orthopaedic oncology centres in Canada and the UK. Patients who developed multiple extremity STSs were collated retrospectively from prospective oncology databases. A literature review using MEDLINE was also performed. Six patients were identified in the case series from these three institutions, and five studies were identified from the literature review. Overall, 17 patients were identified with a median age of 51 years (range: 19 to 77). The prevalence of this manifestation in STS patients is 1 in 1225. The median disease-free interval between diagnoses was 2.3 years (range: 0 to 19 years). Most patients developed the secondary STS in a metachronous pattern, the remaining, synchronously. The median survival after the first sarcoma was 6 years, and it was 1.6 years after the second sarcoma. The 5-year overall survival rate was 83.3% and 50% following the first and second STS diagnoses, respectively. A diagnosis of two STSs does not confer a worse prognosis than the diagnosis of a single STS. Developing a second STS is a rare event with no identifiable histological pattern of occurrence. Presentation in a metachronous pattern is more common. A high degree of vigilance is required in patients with a previous STS both to detect both local recurrence and to identify new masses remote from the previous STS site. Acquiring an early histological diagnosis should be attempted.

Unusual Complete Isolated Scaphoid Dislocation, Report of a Case.

Isolated scaphoid dislocations are extremely rare injuries and are commonly associated with significant ligamentous disruptions. A dorsiflexion-supination force upon the hand is considered as the most common mechanism of injury. Different treatment options have been proposed for the management of this uncommon entity, ranging from conservative treatment with closed reduction and casting to a wide range of open or percutaneous surgical techniques. In this article, we reported ona case of this rare injury managed with open reduction and pinning along with ligamentous reconstruction.