Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study.

BACKGROUND: The objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome. METHODS: Eighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed. RESULTS: At the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2-0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6-3.2; p = 0.012) were significant predictor of patient satisfaction. CONCLUSION: At two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.

Successful mid- to long-term outcome after reconstruction of the extensor apparatus using proximal tibia-patellar tendon composite allograft.

PURPOSE: The purpose of the study was to assess the outcomes of extensor mechanism reconstruction with proximal tibia-patellar tendon composite allograft. METHODS: 24 consecutive patients treated with allograft-prosthetic composite for proximal tibia tumour resection and a conventional total knee arthroplasty were included. Extensor mechanism reconstruction was performed with a proximal tibia-patellar tendon composite allograft and the suture of the donor tendon to the remnant native patellar tendon. Function was evaluated by the Musculoskeletal Tumor Society score (MSTS) and range of motion. Western Ontario and MacMaster University (WOMAC) and visual analogue scale for pain also were used. RESULTS: After a mean follow-up of 11.7 (range 3-15) years, mean MSTS score was 22.4 (range 20-30), mean flexion was 94.0° (range 84°-110°), and mean extension lag was 7.2° (range 0°-18°). The mean VAS-pain was 4.3 (range 2-6), and WOMAC score was 72.4 (range 58-100). There was no failure of the reconstructed extensor mechanism. CONCLUSION: Patellar tendon reconstruction with allogeneic tissue from the proximal tibia allograft sutured to the recipient's remnant patellar tendon provides the mechanical support needed for healing of the reconstructed extensor mechanism with a substantial functional benefit to stabilize active knee extension and successful reconstruction survival at long-term. LEVEL OF EVIDENCE: III.

Better clinical outcomes and overall higher survival with hybrid versus cemented primary total knee arthroplasty: a minimum 15 years follow-up.

PURPOSE: To compare the clinical outcomes and survival at long-term between hybrid and cemented primary total knee arthroplasty (TKA). A better clinical outcome and survival following a follow-up as long as 15 years with the use of hybrid fixation as compared with cemented fixation was hypothesized. METHODS: Case-control study of 126 patients with a mean age of 62.4 years who underwent hybrid TKA matched with 126 patients underwent cemented TKA. Clinical outcome was assessed by the Knee Society scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Radiological assessment was made by the Knee Society method. RESULTS: The mean follow-up was 15.7 (range 15-17) years. At the final follow-up, clinical scores were significantly better in the hybrid group, although the differences were not clinically relevant. Revisions for all reasons were performed in five knees in the hybrid group and 15 knees in the cemented group (p = 0.033). In the hybrid group, there was one aseptic femoral loosening and no aseptic tibial loosening. In the cemented group, the main reasons for aseptic revisions were polyethylene wear (six knees) and tibial loosening (four knees). Cemented fixation was a significant risk factor for aseptic revision (hazard ratio 2.3; 95% CI 1.3-3.7%; p = 0.004). Survival at 15 years for aseptic reasons was 96.5% (95% CI 93.4-98.7%) in hybrid groups and 90.3% (95% CI 88.7-93.9%) in cemented group (p = 0.020). CONCLUSION: After a minimum follow-up of 15 years, hybrid fixation of primary TKA for osteoarthritis provide significantly higher clinical benefits compared with cemented fixation, but the differences were not clinically relevant. Hybrid fixation provides longer overall survival, although the femoral component survival was similar between groups. LEVEL OF EVIDENCE: III.

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up.

PURPOSE: To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of five years. METHODS: Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed. RESULTS: The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection. CONCLUSIONS: The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.

Minimal clinically important differences and substantial clinical benefits for Knee Society Scores.

PURPOSE: There is a paucity of literature defining the minimal clinically important difference (MCID) for the Knee Society Scores (KSS) after total knee arthroplasty (TKA), and no data on the substantial clinical benefit (SCB) for KSS have been reported. The purpose of this study was to determine MCID and SCB for the KSS in patients with primary TKA. METHODS: The median age of patients was 71.6 (range 50-88) years, and 60.3% were females 507 patients with TKA were prospectively enrolled. Patients completed the KSS before surgery and at second postoperative year. The MCID values of the KSS were estimated using anchor-based method, distribution-based method and receiver operating characteristic (ROC) curve analysis with calculation of the area under curve (AUC). SCB was estimated using ROC. RESULTS: The MCID for KSS-knee score was 7.2 points by the anchor-based method, 7.2 by the distribution-based method, and using a ROC analysis the cutoff point was 8.9 points with an AUC of 0.75. For KSS-function score, the MCID values were 9.7, 6.3, and 10.3 (AUC 0.71), respectively. SCB values were 39.7 points (AUC 0.74) for the KSS-knee score, and 38.6 (AUC 0.76) for the KSS-function score. Logistic regression showed age and Charlson index to negatively affect the changes in KSS. CONCLUSION: Different methods for MCID calculation lead to different results. With the use of ROC curve analysis, patients with an improvement of at least 9 points for KSS-knee and 10 points for KSS-function scores experience a clinically important change, whereas those who have at least an improvement of 40 points for KSS-knee and 39 points for KSS-function scores experience a substantial clinical benefit. These findings can ensure clinical improvement from the patient's perspective and also aid in interpreting results from clinical studies. LEVEL OF EVIDENCE: III.

Prior unilateral total hip arthroplasty does not influence the outcome of ipsilateral total knee arthroplasty.

PURPOSE: To assess the influence of a prior well-functioning unilateral primary total hip arthroplasty (THA) on the functional outcome of a subsequent ipsilateral primary total knee arthroplasty (TKA). METHODS: A retrospective case-control study of 92 patients older than 60 years underwent unilateral primary TKA after a prior ipsilateral THA (THA-TKA group) and 92 matched patients underwent only TKA (TKA group). Clinical assessments were performed using the Knee Society Scores (KSS) and Harris Hip Score (HSS), quality of life by the Reduced Western Ontario and MacMaster Universities (WOMAC) and Short-Form 12 (SF-12) questionnaires. Radiological evaluation was also performed. RESULTS: Median follow-up after TKA was 7.2 (range 5-9) years. There were no significant differences between groups in baseline data at the TKA time. The mean gains in KSS were similar in both groups. At the last follow-up, there were no significant differences in WOMAC-pain or SF12-physical scores, but the WOMAC-function (p = 0.003) and SF12-mental (p = 0.018) scores were significantly better in the isolated TKA group. At the last follow-up, there were no significant differences in the radiological knee alignment or component positions. For aseptic reasons, the TKA survival at 8 years in the TKA group was 95.8 (95% CI 87.8-100%), and 96.6% (95% CI 91.8-100%) in the THA-TKA group (ns). CONCLUSION: A well-functioning unilateral THA does not influence on the functional outcome of a subsequent ipsilateral TKA. This finding can help clinicians when counseling patients with hip and knee osteoarthritis. LEVEL OF EVIDENCE: III.

Is Pseudo-Patella Baja Really a Serious Complication of Total Knee Arthroplasty?

BACKGROUND: The available evidence on pseudo-patella baja (PPB) is limited. The purpose of this study is to investigate prospectively the occurrence of PPB after primary total knee arthroplasty and its clinical consequences in a large series of patients with a minimum follow-up of 2 years. PPB was defined as a patella distally displaced in relationship to the femoral trochlea with absence of patellar tendon shortening (Grelsamer RP. J Arthroplasty 2002;17:66-69) due to elevation of the joint line. METHODS: This study is a prospective case series of 354 patients with a mean age of 71.7 (range 52-87) years. Clinical evaluation was performed by the Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form 12-item (SF12), and range of motion. Patellar height was assessed by the Insall-Salvati and Blackburne-Peel ratios. RESULTS: The mean follow-up was 3.6 (range 2.0-6.6) years. Postoperatively, 286 (80.7%) patients had a normal patellar height, 17 (4.8%) had true patella baja (TPB), and 51 (14.4%) had PPB. There were no significant differences between the 3 groups in mean KSS-function (P = .107), range of motion (P = .408), WOMAC-pain (P = .095), WOMAC-stiffness (P = .279), or SF12-mental (P = .363). Between normal and PPB groups, there were no significant differences in mean KSS-knee (P = .903), WOMAC-function (P = .294), or SF12-physical (P = .940). However, the TPB group had significantly lower mean KSS-knee (P = .031), WOMAC-function (P = .018), and SF12-physical (P = .005) as compared with either 2 other groups. CONCLUSION: PPB was a relatively common finding, but no significant differences in terms of clinical outcomes were found as compared to patients with postoperative normal patellar height. TPB was infrequent, but these patients had significantly worse clinical outcomes than those with PPB or normal patellar height.

Outcomes of Total Hip Arthroplasty for Healed Intertrochanteric Hip Fractures. A Matched Retrospective Cohort Study.

BACKGROUND: Many studies have analyzed the outcomes of total hip arthroplasty (THA) after failed intertrochanteric fracture fixation, but not after healed fracture. The objective is to investigate the influence of a prior healed intertrochanteric fracture fixation on the outcomes of a subsequent THA for osteoarthritis. METHODS: This is a matched retrospective cohort study of THA between 43 patients who suffered a prior intertrochanteric fracture successfully managed with internal fixation and 43 patients without prior hip fracture. Mean age was 73.6 vs 74.2 years. A conventional cementless THA was used in both groups. Functional outcome was assessed by the Harris hip score (HHS) and reduced Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Radiological assessment was also performed. RESULTS: Mean follow-up was 6.6 (range, 5-8) years. The mean operative time and blood transfusion rate were significantly higher in the fracture group (P = .001), but there was no significant difference in the length of stay. HHS significantly improved in both groups. At final follow-up, HHS was significantly higher in nonfracture group (P = .008), but the rate of patients with excellent and good outcomes was similar (P = .616). Western Ontario and McMaster Universities Osteoarthritis Index score at the final follow-up was not different between groups (P = .058). Complication rate was similar between groups. There were no revisions, dislocations, or loose implants in the study group. CONCLUSION: Cementless THA provided successful functional outcomes and implant durability at medium term in patients treated for osteoarthritis following healed intertrochanteric fracture fixation, comparable to those without prior fracture who underwent primary THA. Surgical complexity and complication rate were low.

Mid- to long-term results of allograft-prosthesis composite reconstruction after removal of a distal femoral malignant tumor are comparable to those of the proximal tibia.

PURPOSE: To compare the outcomes of allograft-prosthesis composite for reconstruction after malignant tumors at the distal femur and proximal tibia. METHODS: Case-control study of 24 patients with distal femur tumor and 21 with proximal tibia tumor. Union of the allograft-host interface was assessed by the International Society of Limb Salvage criteria, and complications according Henderson. Functional outcome was evaluated by the Musculoskeletal Tumor Society (MSTS) score, Western Ontario and McMaster Universities (WOMAC) score, and pain by a visual analog scale. RESULTS: The median follow-up in the femoral group was 11.4 (range 2.3-25.0) years, and 10.1 (range 2.2-25.0) in tibial group. Incorporation of the allograft was successful in more than 90% in both groups. Tumor location was not significant predictor for allograft failure in multivariate analysis. Aseptic prosthesis loosening occurred in two patients in either group, and another patient in the tibial group had a breakage of the tibial insert. Excluding local recurrences and amputations, the prosthesis survival at 10 years was 94.1% in the femoral group, and 83.3% in the tibial group (n.s.). For the patients with preserved limb, the median MSTS score was 23.6 in the femoral group and 22.8 in tibial group (n.s.). Likewise, there were no significant differences in median WOMAC score (n.s.) or VAS pain (n.s.). CONCLUSIONS: Allograft-prosthesis composite is an effective procedure for distal femur tumors related to the graft, prosthesis survival, and functional outcomes. The results are comparable to those for proximal tibial tumors. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Negative impact of prior debridement on functional outcome of subsequent two-stage revision for early knee periprosthetic infection.

PURPOSE: To compare the functional outcome of two-stage revision (2SR) in patients without a prior debridement, antibiotics and implant retention with those patients who underwent 2SR after a failed debridement, antibiotics and implant retention for early periprosthetic joint infection following total knee arthroplasty (TKA). Negative impact of prior failed debridement, antibiotics and implant retention on the functional outcome of subsequent 2SR was hypothesized. METHODS: Case-control study of 49 patients initially treated with 2SR (group A) and 43 treated with 2SR after a prior failed debridement, antibiotics and implant retention (group B). Functional outcome was assessed by the Knee Society Scores (KSS) and Western Ontario and McMaster Universities (WOMAC) questionnaire. Range of motion (ROM) of the knee was also measured. RESULTS: The median follow-up was 4.1 (range 3-7) years. At final follow-up, KSS-knee (p = 0.001), KSS-function (p = 0.002), WOMAC-function (p = 0.022) and ROM (p = 0.002) were significantly better in the group A as compared to the group B. There was no significant difference between groups in the WOMAC-pain score (p = 0.597). In multivariate analysis, BMI < 30 (OR 3.1, 95% CI 1.7-4.9, p = 0.026), non- Staphylococcus causative microorganism (OR 2.7, 95% CI 1.6-5.9, p = 0.037), and 2SR procedure (OR 2.4, 95% CI 1.7-5.2, p = 0.018) were significant predictors of successful functional outcome. CONCLUSIONS: A prior debridement, antibiotics and implant retention has been shown to have a negative impact on the functional outcome of a subsequent 2SR. These findings suggest that treatment with debridement, antibiotics and implant retention for early periprosthetic infection should only be used in selected patients, and the first option in those patients with Staphylococcus organisms should be 2SR. LEVEL OF EVIDENCE: IV.

Cementless, Fluted, Long-Stem Hemiarthroplasty for Vancouver B2 and B3 Periprosthetic Fractures Around Hip Hemiarthroplasty.

BACKGROUND: The purpose of this study was to assess the effectiveness of a cementless, modular, fluted, long-stem hemiarthroplasty for the treatment of Vancouver type B2 and B3 periprosthetic femoral fracture around hip hemiarthroplasty. METHODS: This was a retrospective case-control study comparing 46 patients revised to hemiarthroplasty (HA group) and 31 revised to total hip arthroplasty (THA group). Functional outcome was evaluated by the Merle d'Aubigné score, and the Katz scale based on activities of daily living. Comorbidity was assessed by the Charlson index, and cognitive function by a mini-mental test score. Radiological evaluation was also performed. RESULTS: Mean postoperative follow-up was 3.3 (range, 2-4) years in the HA group and 3.9 (range, 2-5) in the THA group. The need for transfusion and hospital stay were significantly higher in the THA group. Postoperatively, both groups had a significant decrease in mean hip function (P = .001) although the mean Merle (P = .121) and Katz (P = .214) scores were similar at final follow-up. Likewise, there were no significant differences between groups in pain or loss of life independence. All fractures were united but one in the HA group. There were no dislocations in the HA group, and 3 in the THA group. CONCLUSION: The management of Vancouver B2 and B3 periprosthetic femoral fracture around hemiarthroplasties with a long-stem revision cementless bipolar hemiarthroplasty, supplemented with wire cerclages and cancellous allograft, was an effective option in terms of fracture healing and stability of the implant with a low rate of complications. Nevertheless, a significant functional impairment was also observed in either group.

A Comparison Study of the Outcomes of Ceramic-on-Ceramic Total Hip Arthroplasty in Young vs Older Patients: A Minimum 10-Year Follow-Up Prospective Matched Study.

BACKGROUND: The purpose of this study is to analyze the outcome and prosthesis survival in patients aged between 20 and 40 years who received a cementless total hip arthroplasty (THA) with a minimum follow-up of 10 years compared to older patients. METHODS: Prospective matched comparative study was conducted between 94 young patients with mean age of 37.2 (range 22-40) years and 90 older patients with mean age of 64.7 (range 60-70) years treated with ceramic-on-ceramic THA. Clinical outcomes were assessed by the Harris Hip Score, reduced Western Ontario and MacMaster University (WOMAC), and Short-Form-12 (SF12) questionnaires. Radiological evaluation was also performed. The primary outcome was the THA survival rate. RESULTS: Mean follow-up of 13.6 (range, 10-15) years. At the final follow-up, there was no significant difference between groups in Harris Hip Score (P = .356), WOMAC-pain (P = .461), SF12-physical (P = .305), or SF12-mental (P = .511), but younger group had significantly higher WOMAC-function score (P = .013). There were 7 revisions in the younger group and 4 in the older group (P = .197). The 14-year prosthesis survival for any reason was 93.2% (95% confidence interval [CI] 86.7-99.7) in the younger group and 98.3% (95% CI 95.1-100) in the older group (P = .189). For aseptic reason, the 14-year survival was 94.7% (95% CI 88.9-100) in the younger group and 98.3% (95% CI 95.1-100) in the older group (P = .332). CONCLUSION: At minimum follow-up of 10 years, THA with cementless stem and ceramic-on-ceramic bearing provides successful survival and functional outcomes in young patients between 20 and 40 years old.

Altered seric levels of albumin, sodium and parathyroid hormone may predict early mortality following hip fracture surgery in elderly.

PURPOSE: To analyse a wide set of routine laboratory parameters at admission to predict mortality within 30 post-operative days in elderly patients with hip fracture, as well as calculate the critical values of those biomarkers. METHOD: Data of 994 patients older than 65 years with hip fracture were analysed of which 89 (8.2%) died within 30 post-operative days. Variables described in the literature with potential influence on early mortality were collected, including demographics, fracture type, American Society of Anesthesiologists score, Charlson's comorbidity index and pre-operative Hodkinson's mental test and the Katz index for activities of daily living. In addition, an exhaustive collection of biomarkers from routine blood testing at admission was performed. Critical levels of biomarkers were calculated by the method of area under ROC curve. RESULTS: At admission, early mortality group had significantly higher Charlson's index (p = 0.001) and lower the Katz index (p = 0.001). The surgical delay also was significantly longer in that group (p = 0.001). In univariate analyses, serum concentration at admission of total protein (p = 0.004), albumin (p = 0.001), sodium (p = 0.001), and parathyroid hormone (PTH) (p = 0.001) were significantly different between both groups. In multivariate analysis, serum albumin < 2.9 g/dL (p = 0.013), sodium < 127 mEq/L (p = 0.035) and PTH > 65 pg/mL (p = 0.005) were predictors of early mortality. The three biomarkers together accounted for 67% of the variability in early mortality. CONCLUSION: The association of altered levels at admission of serum concentration of albumin, sodium and PTH was predictor of early mortality following hip fracture surgery in elderly patients.

Reasons for delaying surgery following hip fractures and its impact on one year mortality.

PURPOSE: The purposes of this study were to identify the reasons for delayed surgery following hip fractures and analyze the impact of these reasons on 1-year mortality. METHODS: A prospective cohort study of 1234 patients with mean age of 83.1 (range 65-92, SD 8.0) who underwent hip fracture surgery compared three subgroups: (1) surgery within two days from admission (609 patients); (2) delayed surgery for medical reasons (286); and (3) delayed surgery for organizational causes (339). Medical reason was defined as the need of medical optimization of the patient prior to surgery. Pre-operative assessment was performed by the American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), Hodkinson mental status, Katz index for activities of daily living, and Short-Form (SF-12) questionnaire. Univariate analyses were used (chi-square and Fisher exact or Mantel-Haenszel tests for categorical data, and variance analysis, Student t test, or Mann-Whitney U test for continuous data). Logistic regression models were used for influence of variables on complications and one year mortality. RESULTS: There were no significant differences in complications or one year mortality rates between patients with surgery within two days and those with delayed surgery for medical reasons. However, the patients with delayed surgery for organizational causes had significant higher rates of both complications and one year mortality compared to the other two groups (p = 0.001). CONCLUSIONS: This study suggests that waiting time for hip fracture surgery more than two days was not associated with higher complication or mortality rate if waiting was to stabilize patients with active comorbidities at admission, compared to stable patients at admission with early surgery. Although early surgery within two days from admission is desirable for stable patients at admission, in patients with complex comorbidities, the surgery should be performed once they are optimized. However, the patients with delayed surgery for organizational reasons had a significant higher rate of post-operative complications and one year mortality compared to the other two groups.

Comparison of Functional Outcomes Between the First and Second Knee in Staged Bilateral Total Knee Arthroplasty With Diverse Intervals Between Stages.

BACKGROUND: The objective of the study was to analyze if the length of interval time between stages influenced functional and quality of life outcomes in patients with staged bilateral primary total knee arthroplasty (TKA). METHODS: This is a retrospective comparative study between 93 patients with an interval between stages of 6-8 months (6-month group), 112 of 12-14 months (1-year group), and 108 of 24-26 months (2-year group). Outcome variables were Knee Society scores, Western Ontario and McMaster Universities, Short Form, and patient satisfaction. RESULTS: Overall, the mean follow-up for the first TKA was 8.2 (range, 7-10) years, and for the second TKA, 6.7 (range, 5-10) years. At last follow-up, functional and patient-related outcomes were similar for both knees, regardless of the interval. However, mental score and patient satisfaction were significantly better for the second than for the first TKA in the 2-year group. Age did not correlate significantly with the functional scores but was significantly correlated with the mental score. CONCLUSION: The performing staged bilateral TKA with a wide interval between surgeries provided equivalent functional outcomes and quality of life for both knees. Postoperative outcomes were not affected by the length of the time interval between procedures or age. Our results can help the surgeon to inform the patients reliably about what they can expect in the delay of a second knee replaced. Thus, patients could make an informed decision.

Total Knee Arthroplasty in Patients With Prior Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Few studies have analyzed the outcomes of total knee arthroplasty (TKA) in patients with prior anterior cruciate ligament (ACL) reconstruction, and the reported outcomes are controversial. The purpose of this study is to assess if prior ACL reconstruction had any impact on the outcome of subsequent TKA. METHODS: A matched case-control study was conducted in patients who underwent TKA, including 37 with prior ACL reconstruction and 37 patients without ACL reconstruction. Preoperative and postoperative clinical and radiological data were collected from a prospective arthroplasty database with a minimum follow-up of 5 years. The mean age was 69.6 years, and 59.4% were men. The Knee Society scores, Short Form-12, and Western Ontario and McMaster Universities questionnaires were used for functional evaluations. Visual analogue scale 0-10 was used for patient satisfaction. RESULTS: The mean follow-up after TKA was 6.1 (range 5-7.3) years. Two patients in the ACL group developed knee stiffness requiring manipulation under anesthesia, while 1 patient in the control group suffered superficial wound infection. At last follow-up, no significant differences in functional or radiologic outcomes were found between both groups. The performance of TKA in ACL patients had increased technical difficulty and significantly longer time of surgery, but this had no influence on the outcomes. In the ACL group, 24 knees had technical difficulty in surgery. The main difficulty in most ACL patients was due to varus deformity and increased retraction of the medial soft structures which required progressive medial release. Other 2 knees had difficult knee exposure. One was an unexpected partial patellar tendon avulsion and the other required planned quadriceps snip. CONCLUSION: TKA was an effective procedure for patients with prior ACL reconstruction. The surgeon should be warned of the possible difficulties in the knee exposure and possible need of medial release to obtain an appropriate ligament balance. However, these additional procedures had no negative effect on the outcomes of TKA.

Cruciate-Retaining vs Posterior-Stabilized Primary Total Arthroplasty. Clinical Outcome Comparison With a Minimum Follow-Up of 10 Years.

BACKGROUND: Controversy continues regarding whether the posterior cruciate ligament should be retained or removed during total knee arthroplasty (TKA) procedure. The objective was to compare the clinical outcomes with a minimum follow-up of 10 years between patients who received contemporary cruciate-retaining or posterior-stabilized primary TKA. METHODS: Case-control study of 268 patients who underwent cruciate-retaining TKA vs 211 to posterior-stabilized design, with the same arthroplasty system, and a minimum follow-up of 10 years. Clinical assessment was performed by Knee Society scores, Western Ontario and MacMasters Universities and Short-Form 12 questionnaires, range of motion, and patient satisfaction. RESULTS: Successful outcomes were found for both designs. No significant differences in functional scores, range of motion, patient-related scores, or patient satisfaction. Between the 5-year and last postoperative follow-up, there were a significant decrease of all clinical scores in both groups. In addition, complication rate and implant survival were similar between groups. CONCLUSION: The superiority of one design over the other was not found. Both designs can be used expecting long-term successful outcomes and high survival. The choice of the design depended on the status of the posterior cruciate ligament and surgeon preference.

Adjacent Single-level Combined Fixation Using Kyphoplasty and Percutaneous Pedicle Screws in Type A3 Unstable Vertebral Fractures in Elderly Patients.

We present a series of cases of type A3.1.2 unstable fractures of the thoracolumbar hinge treated percutaneously with third-generation kyphoplasty and only one next level percutaneous screws. Four women aged 75 to 85 years with thoracolumbar vertebral fractures, classified as type A.3.1.2, were treated with Precept® monosegmental percutaneous fixation and the third-generation SpineJack® augmentation system. The traditional treatment of type A3 unstable vertebral wedging fractures is performed with transpedicular fixation of two or more levels adjacent to the fracture causing great rigidity. Recently, the concept of bridge fixation combining one segment intrapedicular fixation with kyphoplasty has emerged as a more stable and less invasive system that allows greater mobility in this type of fractures. The combination of third-generation kyphoplasty and monosegmental bridge fixation may improve results to other fixation systems in type A3 vertebral fractures.

Comparable outcomes after total knee arthroplasty in patients under 55 years than in older patients: a matched prospective study with minimum follow-up of 10 years.

PURPOSE: To compare outcomes after TKA for osteoarthritis between patients younger than 55 years and older patients. METHODS: A cohort of 61 patients aged 55 years or younger was prospectively matched for gender, body mass index and knee function with patients with median age of 66 (range 60-70) years. Clinical evaluation was performed by the Knee Society scores (KSS), reduced Western Ontario and McMasters Universities (WOMAC) and Short-Form 12 (SF12) questionnaires. Radiological evaluation was also performed. RESULTS: The median follow-up was 12 (range 10-14) years. Survival at 14 years was 96.7% (95% CI 92-100%) in the younger group and 98.2% (95% CI 95-100%) in the older group (n.s.). There was no deep infection or loosening of femoral or patellar component in either group. In the younger group, 2 patients required revision (aseptic tibial loosening at 8 years, and polyethylene wear at 10 years). In the older group, there was 1 revision (aseptic tibial loosening). Revision rate was not significantly different (n.s.). Multivariate analysis showed no significant relationship between revision and age, gender or BMI. At 5-year follow-up, there were no significant differences between groups in KSS knee or function, WOMAC pain or function, or SF12 physical or mental, but in the last evaluation there were better results in younger patients for KSS-function (p = 0.018), WOMAC-function (p = 0.028), SF12-physical (p = 0.001) and SF12-mental (p = 0.035), although these differences were not clinically relevant. A significant decline was noted for KSS-function in either group from 5-year to at last follow-up. CONCLUSIONS: The TKA survival in younger patients was comparable to older active patients, without increased complications or revisions at a minimum follow-up of 10 years. Primary hybrid TKA can provide successful pain relief, function and quality of life in younger patients than 55 years with osteoarthritis. TKA is a suitable option for these young patients with appropriate surgical indications. LEVEL OF EVIDENCE: II.

Better functional outcome after single-radius TKA compared with multi-radius TKA.

PURPOSE: To determine whether the design of the femoral component influenced patient outcomes. METHODS: Two hundred and thirty-seven patients were randomized to compare functional outcomes between single-radius TKA (SR, 118 patients) and multi-radius TKA (MR, 119 patients) with a minimum follow-up of 5 years. Prospective pre- and postoperative assessments were performed by the clinical and radiological criteria of the Knee Society Score (KSS), WOMAC and Short-Form 12 (SF12) questionnaires. The extension mechanism was assessed based on the quadriceps strength and chair test. Patient satisfaction was also assessed. RESULTS: The median follow-up was 5.7 (range 5-7) years. At last follow-up, significant better KSSs (p = 0.001), range of motion (p = 0.001), extension lag (p = 0.020), quadriceps strength (p = 0.004), chair test (p = 0.032) and WOMAC pain (p = 0.002) were found in the SR group. Moreover, the improvements of these variables were early in the SR group (from 6 postoperative months). There were no significant differences in WOMAC function or SF12 physical and mental components. The revision rate and implant survival were similar in both groups. Satisfaction rate was significantly higher in SR group (p = 0.032). CONCLUSION: This study shows better results with SR cruciate-retaining femoral component than MR component. The use of SR system is recommended because, although the clinically relevant differences were moderate, the functional improvement was earlier and the patient satisfaction higher with this design. LEVEL OF EVIDENCE: Therapeutic study, Level I.