The outcomes of conversion of hemiarthroplasty to total hip arthroplasty, a systematic review and meta-analysis.

INTRODUCTION: Acetabular erosion is an important complication in hemiarthroplasty and may lead to total hip arthroplasty as a conversion. The results of total hip arthroplasty as a conversion remain unclear. We performed a systematic review and meta-analysis to compare the outcome of total hip arthroplasty as a conversion with primary total hip arthroplasty. MATERIALS AND METHODS: PRISMA guidelines were used and Pubmed, Embase and the Cochrane libraries were searched. Both, studies comparing the outcome of total hip arthroplasty as a conversion with the outcome of primary total hip arthroplasty and the outcome of cohort studies limited to total hip arthroplasty as a conversion, were included. Risk of bias was assessed using the Methodological Index for Non Randomized Studies checklist. Meta-analysis was performed concerning pooled annual revision, dislocation and infection rates. RESULTS: A total of 27 studies were available for analysis; four comparative studies and 23 cohort studies. Comparative studies were defined as high quality and cohort studies as medium quality. Analysis revealed a significantly higher overall revision risk (Hazard Ratio 1.72, 95% confidence interval 1.39 to 2.14) after total hip arthroplasty as a conversion compared to primary total hip arthroplasty. The annual revision rate of total hip arthroplasty as a conversion was 1.63% (95% confidence interval 1.14 to 2.33) in the comparative studies and 1.40% (95% confidence interval 1.17 to 1.66) in the cohort studies. A pooled infection rate of 4.34% (95% confidence interval 2.66 to 7.01) and dislocation rate of 4.79% (95% confidence interval 3.02 to 7.53), was found. CONCLUSIONS: Literature concerning the results of total hip arthroplasty as a conversion is limited. The risk of revision after conversion of hemiarthroplasty is higher compared to primary total hip arthroplasty.

Revision risk of salvage compared with acute total hip arthroplasty following femoral neck fracture: an analysis from the Dutch Arthroplasty Register.

BACKGROUND AND PURPOSE: There is no consensus on the treatment of patients with femoral neck fractures between internal fixation (IF) or directly treated with a total hip arthroplasty (fracture-THA) in particular for the age group 60-70 years. Failure of IF is not uncommon, resulting in salvage total hip arthroplasty (salvage-THA). The aim of our study was to compare revision rates of salvage-THA with fracture-THA and osteoarthritis (OA)-THA. PATIENTS AND METHODS: Revision rates and reasons for revision were compared. Data collected in the Dutch Arthroplasty Register (LROI) between 2007 and 2018 was used. The study included 4,310 salvage-THAs, 12,159 fracture-THAs, and 274,147 OA-THAs. We performed Kaplan-Meier survival analyses and Cox regression to evaluate THA survival. RESULTS: No statistically significant difference in revision rates between salvage-THAs and fracture-THAs was found (HR 1.0, 95% CI 0.7-1.3) whereas the revision rate was higher compared with OA-THAs (HR 1.3, CI 1.0-1.5). The 5-year revision rate was 5.0% (CI 4.4-5.8) in salvage-THAs, 4.5% (CI 4.1-5.0) in fracture-THAs, and 3.1% (CI 3.0-3.2) in OA-THAs. A higher revision rate for infection was found in salvage-THAs in comparison with fracture-THAs (HR 1.6, CI 1.0-2.3). CONCLUSION: We found no difference in revision rates for salvage-THAs compared with fracture-THAs. The risk of revision for infection was higher for salvage-THA.

Empiric antibiotic therapy in early periprosthetic joint infection: a retrospective cohort study.

PURPOSE: Periprosthetic joint infection (PJI) is a devastating complication following total knee or total hip arthroplasty (TKA/THA). Appropriate empiric antibiotic treatment, initiated directly after debridement and implant retention (DAIR), is suggested to contribute to treatment success. The aim of this study was to describe the microbiology and the antibiotic susceptibility in early PJI to guide future empiric treatment in a region with a low incidence of methicillin-resistant Staphylococcus aureus (MRSA). METHODS: Consecutive patients who underwent DAIR within 3 months after primary unilateral TKA or THA between January 2011 and December 2018 were retrospectively identified from the hospital electronic health records. Data on causative pathogens, antimicrobial susceptibility and the number of post-operative days until cultures demonstrated bacterial growth were collected. RESULTS: One hundred and eleven early PJIs were identified of which 65 (59%) were monomicrobial and 46 (41%) polymicrobial. Among all isolated pathogens, Staphylococcus aureus (n = 53; 29%) was the most commonly identified pathogen in early PJI without any involvement of MRSA. 72% of PJIs were susceptible to vancomycin which could be increased to around 90% by adding gram-negative coverage. On the 5th postoperative day, bacterial growth was observed in 98% of cases. All gram-negative bacteria demonstrated positive tissue cultures on the 4th postoperative day. CONCLUSION: Vancomycin combined with ciprofloxacin or a third generation cephalosporin provided the highest antimicrobial coverage of all responsible pathogens identified in early PJI. Empiric treatment of gram-negative treatment can be safely terminated in the absence of gram-negative pathogens after 4 days of culturing in cases without preoperative antibiotic treatment.

Increased failure rates after the introduction of the TFNA proximal femoral nail for trochanteric fractures: implant related or learning curve effect?

Background and purpose - Trochanteric fractures are often treated using intramedullary fixation. In our institution, the TFN-Advanced Proximal Femoral Nailing System (TFNA) was introduced as replacement for the Gamma Trochanteric Nail (GTN3) for the treatment of these fractures as a result of a hospital-driven change of trauma implant supplier. We compared trochanteric fracture fixation failure rate between these 2 intramedullary nails. Patients and methods - All trochanteric fractures treated surgically from 2011 to 2019 were retrospectively reviewed for fixation failure. From 2016 only the TFNA was used. Fixation failure was defined as implant cut-out, implant breakage, non-union, malpositioning of the screw/blade requiring reoperation, new fracture around the nail, or miscellaneous. Propensity score matching was used to balance distribution of covariates and to compare failure rates between TFNA and GTN3 groups. Learning curve analyses were performed. Results - After exclusion, 797 GTN3s (779 patients) and 542 (536 patients) TFNAs were available for analysis. A higher risk of fixation failure was found in the TFNA group (14%) compared with the GTN3 group (7.0%) (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.2-3.5). This was mainly attributed to a higher risk of cut-out (HR 2.2; CI 0.9-5.7), malpositioning (HR 4.7; CI 0.7-34), and new fracture around the nail (HR 4.0; CI 1.0-16). Learning curve analyses indicated no clear learning curve effect. Interpretation - Failure of fixation increased after a switch from the GTN3 to the TFNA proximal femoral nail for the treatment of trochanteric fractures. Cut-out and malpositioning of the calcar screw or blade appeared to be the most dominant failure mechanisms. Modifications in implant design may have played a role in this increased risk of failure of fixation. In our institution a new implant device was introduced without solid clinical evidence behind it. This study may help to underline the need for medical doctors with a critical and scientific background to be involved in implant choices.

The value of radiographic markers in the diagnostic work-up of rotator cuff tears, an arthroscopic correlated study.

OBJECTIVE: To evaluate the value of radiographs during the diagnostic work-up of rotator cuff tears, using arthroscopy as reference standard. MATERIALS AND METHODS: This retrospective study included 236 shoulders of 236 patients. All radiographs were evaluated for inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, greater tubercle cysts, and subacromial space calcifications. Predictive value of these radiographic signs in predicting rotator cuff tears was determined with arthroscopy as reference standard. RESULTS: According to arthroscopy, 131 shoulders were diagnosed with rotator cuff tears. Seventy-two out of 131 shoulders (55%) had inferior cortical acromial sclerosis, 37 (28%) lateral acromial spur, 21 (16%) superior migration of the humeral head, 7 (5%) greater tubercle cysts and 15 subacromial space calcifications (11%). Inferior cortical acromial sclerosis (P = 0.001), lateral spur (P = 0.001), superior migration (P = 0.002), and cysts (P = 0.03) were significantly and independently associated with rotator cuff tears, whereas subacromial calcifications (p = 0.21) was not. Inferior cortical acromial sclerosis, superior migration, lateral acromial spur, and cysts combined have a positive predictive value of 78%. CONCLUSIONS: The combination of inferior cortical acromial sclerosis, lateral acromial spur, superior migration of the humeral head, and greater tubercle cysts has a high positive predictive value for the presence of full-thickness rotator cuff tears. In patients with a high suspicion for having a rotator cuff tear based on radiographic findings, MRI can be performed directly without the delay and costs caused by an additional ultrasound exam.

Severe Hallux Valgus Angle Attended With High Incidence of Nonunion in Arthrodesis of the First Metatarsophalangeal Joint: A Follow-Up Study.

The incidence of nonunion after first metatarsophalangeal joint (MTP-1) arthrodesis was found to be high in our clinic. By raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers, and promoting solely the use of hand instruments to prepare the joint for arthrodesis, we tried to decrease the numbers of nonunion. This prospective cohort study included all patients who underwent MTP-1 fusion between January 2018 and March 2019. Patients were treated according to a standardized protocol, using hand instruments to prepare the joint for fusion. Anthropometric and therapy-related data were collected and compared with an earlier 2015-2016 cohort that was retrospectively assessed. Furthermore, the frequency of nonunion between convex-concave reamers and hand instruments was compared. A total of 53 patients underwent MTP-1 fusion surgery. The incidence of nonunion was 3.8%, significantly lower than the 24.1% in 2015 to 2016 (p = .002). Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019 (95% confidence interval [CI] 1.55 to 32.55) (p = .012). Furthermore, an increase of 10° in HVA showed a 1.52 risk of occurrence of nonunion (95% CI 1.07 to 2.17) (p = .021). The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion (95% CI 1.14 to 11.43) (p = .029); however, after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion (p = .108). Patients suffering from severe hallux valgus had nonunion in 32.1% of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation. Severe hallux valgus is prone to nonunion, and more research into this indication for MTP-1 fusion and outcome is needed.

Do we publish what we present? The publication rate of a national arthroscopy society and a review of the literature.

The publication rate (PR) of full-text articles after presentation at medical society meetings varies widely. The purpose of this study is (1) to determine the PR of abstracts presented at the Dutch Arthroscopy Society's (NVA) annual meeting from 2006 until 2016, (2) to determine the time between presentation and publication, and (3) to review the known literature on the PR of orthopaedic scientific meetings. We retrospectively reviewed the programs of the NVA annual meetings from 2006 to 2016. All podium presentations reported were included. The search for subsequent journal publication was performed using PubMed, EMBASE, and Google Scholar databases. A systematic literature search was performed in PubMed. All studies regarding the publication rates of orthopaedic scientific meetings were included. From 2006 to 2016 a total of 131 papers were presented at the NVA annual meetings, of which 83 were published as full text articles (63%). The mean time to publication was 16.5 months. The overall PR at orthopaedic scientific meetings ranges from 21% to 71%.

High incidence of early periprosthetic joint infection following total hip arthroplasty with concomitant or previous hardware removal.

INTRODUCTION: Hardware removal preceding total hip arthroplasty may increase the risk of prosthetic joint infection (PJI). Whether hardware removal and total hip arthroplasty (THA) should be performed in a single- or two-stage procedure remains controversial. In this comparative retrospective study, the incidence of PJI following either single- or two-stage THA with hardware removal was assessed in a consecutive series. PATIENTS AND METHODS: All patients that underwent THA preceded by hardware removal from January 2006 until March 2018 were retrospectively reviewed and checked for the occurrence of early PJI. Recognized risk factors for PJI at the time of surgery were evaluated and the incidence of early PJI was compared between one- and two-stage THA regarding hardware removal. RESULTS: 145 patients underwent THA and hardware removal (52 two-stage surgery and 93 single-stage surgery). There were no significant differences between both groups regarding pre-operative hemoglobulin levels, time interval between internal fixation and THA, antibiotic-loaded-cement use, BMI and ASA classification. Overall the incidence of early PJI was 6.9%. The incidence of PJI was 8.6% in the single-stage group versus 3.8% in the two-stage group (P = 0.234). CONCLUSION: Irrespective of single- or two-stage procedures, a high incidence of PJI was encountered. Despite non-significance, a trend towards a higher proportion of patients developing PJI after single-stage surgery was encountered. We recommend a two-stage surgical procedure regarding hardware removal and THA in patients that are expected to tolerate this surgical strategy. When considering a one-stage procedure, it should be preceded by a thorough pre-operative workup including joint aspiration and serum determination of inflammatory parameters. Multiple tissue samples should be obtained during hardware removal in either one- or two-stage procedures since the risk for development of PJI is relevant.

General anesthesia might be associated with early periprosthetic joint infection: an observational study of 3,909 arthroplasties.

Background and purpose - Periprosthetic joint infection (PJI) remains a devastating complication following total knee or total hip arthroplasty (TKA/THA). Nowadays, many studies focus on preventive strategies regarding PJI; however, the potential role of anesthesia in the development of PJI remains unclear.Patients and methods - All consecutive patients undergoing elective primary unilateral TKA or THA from January 2014 through December 2017 were included. Exclusion criteria included femoral fractures as the indication for surgery and previously performed osteosynthesis or hardware removal on the affected joint. Age, sex, BMI, ASA classification, type of arthroplasty surgery, type of anesthesia, duration of surgery, smoking status, and intraoperative hypothermia were recorded. Propensity score-matched univariable logistic regression analysis was used to control for allocation bias.Results - 3,909 procedures consisting of 54% THAs and 46% TKAs were available for analysis. 42% arthroplasties were performed under general anesthesia and 58% under spinal anesthesia. Early PJIs were observed in 1.7% of the general anesthesia group and in 0.8% in the spinal anesthesia group. The multivariable logistic regression model demonstrated an odds ratio for PJI of 2.0 (95% CI 1.0-3.7) after general anesthesia relative to the propensity score-matched patients who received spinal anesthesia.Interpretation - These results suggest a potential association between general anesthesia and early PJI. Future research using large-scale data is required to further elucidate this clinically relevant association.

Physical examination of the elbow, what is the evidence? A systematic literature review.

OBJECTIVE: Primary to provide an overview of diagnostic accuracy for clinical tests for common elbow (sport) injuries, secondary accompanied by reproducible instructions to perform these tests. DESIGN: A systematic literature review according to the PRISMA statement. DATA SOURCES: A comprehensive literature search was performed in MEDLINE via PubMed and EMBASE. ELIGIBILITY CRITERIA: We included studies reporting diagnostic accuracy and a description on the performance for elbow tests, targeting the following conditions: distal biceps rupture, triceps rupture, posteromedial impingement, medial collateral ligament (MCL) insufficiency, posterolateral rotatory instability (PLRI), lateral epicondylitis and medial epicondylitis. After identifying the articles, the methodological quality was assessed using the QUADAS-2 checklist. RESULTS: Our primary literature search yielded 1144 hits. After assessment 10 articles were included: six for distal biceps rupture, one for MCL insufficiency, two for PLRI and one for lateral epicondylitis. No articles were selected for triceps rupture, posteromedial impingement and medial epicondylitis. Quality assessment showed high or unclear risk of bias in nine studies. We described 24 test procedures of which 14 tests contained data on diagnostic accuracy. CONCLUSIONS: Numerous clinical tests for the elbow were described in literature, seldom accompanied with data on diagnostic accuracy. None of the described tests can provide adequate certainty to rule in or rule out a disease based on sufficient diagnostic accuracy.

Biographical background and origin of common eponymous terms in orthopedic surgery: anatomy and fractures in knee surgery.

An eponym is a person after whom an eponymous term is named. These eponymous terms are easy shorthand in communication between surgeons. Therefore, they are often used and hard to eradicate. We discuss eponymous terms that describe anatomical features and fracture types in the knee. With these terms, an overview of the historical background of the eponym and its current clinical implication is discussed. The eponymous terms discussed are Gerdy tubercle, Pellegrini-Stieda lesion, Segond fracture, Hoffa fracture and fat pad. The meaning of the eponymous term is clarified, the biography of the namegiver given and its contemporary clinical implication discussed. Since eponymous terms are used frequently in inter-collegial discussion and literature, the meaning should be clear for everyone, since otherwise it might give room for misunderstanding.

Eponymous terms in daily practice: a survey among Dutch orthopedic surgeons.

INTRODUCTION: With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues. MATERIALS AND METHODS: In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice. RESULTS: No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons. DISCUSSION: Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty. CONCLUSION: Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.

Eponymous hip joint approaches.

After the low friction arthroplasty by John Charnley was no longer confined to specialized hospitals but commonplace in the general orthopedic practice, the issue remained how to most optimally reach the hip. The names of the authors of these approaches remain in a lot of cases connected to the approach. By evaluating the original articles in which the approaches are described we ascertain the original description and technique. By various sources we obtained the (short) biography of the people whose name is connected to the approach. Our research covers the biographies of colleagues Smith-Petersen, Watson-Jones, Hardinge, Charnley, Moore and Ludloff. The eponymous approaches are shown and described after the short biography on each individual. This study shows that without the work of our colleagues we cannot proceed in our profession. An understanding and knowledge of the people who dedicated themselves to developing the orthopedic surgery to the high standard it has today is the least honour we should give them.

"Atypical" atypical femur fractures and use of bisphosphonates.

BACKGROUND: Atypical femur fractures (AFFs) present a rare but serious condition associated with use of bisphosphonates. Underlying mechanisms and clinical risk factors remain unclear. According to the diagnostic criteria formulated by the ASBMR, a lateral localization of an AFF is required. CASE HISTORY: We present a patient who developed bilateral leg pain while using an oral bisphosphonate and aromatase inhibitor in the course of adjuvant treatment for breast cancer. Initially she was diagnosed with bone metastases and received radiotherapy on the right femur. However, the bilateral periosteal reactions of the subtrochanteric femur are highly suggestive of AFFs. Our case meets all criteria for AFF except that she presented with lesions at the medial side of the femur. Therefore they could be best described as "atypical" atypical femur fractures. DISCUSSION: Since the pathogenesis of AFFs is not fully understood, we cannot rule out that AFFs also occur in the medial femur or in other weight-baring bones. Hence we propose that medial stress reactions belong to a spectrum of atypical fractures associated with use of antiresorptive drugs. The localization may depend on yet unknown biomechanical factors. CONCLUSION: We propose that these periosteal reactions of the subtrochanteric femur are in fact AFFs with uncommon medial localization and could hence be considered "atypical" AFFs. We recommend being alert of AFFs in patients with bone pain and medial subtrochanteric lesions. More epidemiological studies are needed to investigate the occurrence of both medial and lateral AFFs and to gain more insight into its frequency and pathogenesis.

Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events.

PURPOSE: In the recent clinical guideline for acute lateral ankle sprain, the current best evidence for diagnosis, treatment and prevention strategies was evaluated. Key findings for treatment included the use of ice and compression in the initial phase of treatment, in combination with rest and elevation. A short period of taking non-steroidal anti-inflammatory drugs (NSAIDs) may facilitate a rapid decrease in pain and swelling can also be helpful in the acute phase. The objective was to assess the effectiveness and safety of oral and topical NSAID in the treatment for acute ankle sprains. METHODS: Randomised controlled trials comparing oral or topic NSAID treatment with placebo or each other were included. Primary outcome measures were pain at rest or at mobilisation and adverse events. Trials were assessed using the Cochrane risk of bias tool. RESULTS: Twenty-eight studies were included, and 22 were available for meta-analysis. Superior results were reported for oral NSAIDs when compared with placebo, concerning pain on weight bearing on short term, pain at rest on the short term, and less swelling on short- and intermediate term. For topical NSAIDs, superior results compared with placebo were found for pain at rest (short term), persistent pain (intermediate term), pain on weight bearing (short- and intermediate term) and for swelling (short and intermediate term). No trials were included comparing oral with topic NSAIDs, so conclusions regarding this comparison are not realistic. CONCLUSIONS: The current evidence is limited due to the low number of studies, lack of methodological quality of the included studies as well as the small sample size of the included studies. Nevertheless, the findings from this review support the use of NSAIDs for the initial treatment for acute ankle sprains. LEVEL OF EVIDENCE: Meta-analysis of RCTs, Level I.

Quality of research and quality of reporting in elbow surgery trials.

BACKGROUND: Randomized controlled trials (RCTs) are high in the hierarchy of scientific evidence, but possible sources of bias should be identified or even excluded. This systematic review assessed the methodologic quality and the quality of reporting of the RCTs on the treatment of elbow pathology. METHODS: A systematic review of RCTs was performed on the treatment of elbow pathology. PubMed/MEDLINE, Embase, and the Cochrane Library were searched for relevant trials. Thirty-five of the initial 540 articles being an (pseudo) RCT on invasive treatment of elbow pathology in humans were included. These were scored with the use of an adapted Checklists to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). To assess quality of reporting, points were administered to the articles based on the results from CLEAR-NPT list. The highest possible score for quality is 26 points. RESULTS: The average quality score was 18.1 points (range, 10-25 points). The mean scores were 19.5 for trials published in the American Journal of Sports Medicine, 19.8 for those published in the Journal of Bone and Joint Surgery, and 20.3 for those published in the Journal of Shoulder and Elbow Surgery. CONCLUSIONS: The most important finding was that the overall quality and the quality of reporting has not improved over the years and that the overall quality of the selected studies and the quality of reporting in these trials is not related to the journal they are published in.

Eponyms in elbow fracture surgery.

Eponyms are common in medicine and in orthopaedic surgery. For future reference and historical considerations, we present common eponyms in elbow fracture surgery. We describe in short the biography of the name giver and give, where possible, the original description on which the eponym was based. Whether eponyms should continue to be used is a question that remains unanswered, but if we use them, knowledge of the original description can prevent confusion and knowledge of the historical background sheds light on the interesting roots of our profession.

Controversies around hip fracture treatment: clinical evidence versus trends from national registries.

PURPOSE: Several controversies in the optimal treatment of femoral neck fractures persist, together with large variations in clinical practice. METHODS: A narrative literature review covering 4 current controversies in the surgical management of femoral neck fractures (total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented HA, internal fixation versus arthroplasty, operative versus non-operative) was performed. Available literature was balanced against annual trends in the management of femoral neck fractures from the public domain of several national registries (Sweden, Norway, The Netherlands, Australia and New Zealand). RESULTS: For most controversies, the literature provides stronger evidence than is reflected by variations encountered in daily practice. Implementation of clinical evidence tends to lag behind and important differences exist between countries. CONCLUSIONS: Trends of clinical practice from national registries indicate that implementation of available clinical evidence needs to be improved.

Eponymous terms in acromioclavicular joint surgery.

Eponymization serves as a means of paying tribute to individuals who have made significant contributions to our culture. Each eponym is often linked with a story for everyone to discover. To aid in the retention of these stories, this review offers readers an overview of the individuals behind the eponymous terms, as well as their original descriptions, within the context of acromioclavicular joint pathology and orthopaedic surgery.