RESUMO
BACKGROUND: We created a Multicenter Survey for Italian orthopedics surgeons on how they approach leg length discrepancy when dealing with primary total hip arthroplasty. Aim of the study was to show how surgeons manage LLD and follow literature recommendations during clinical practice. METHODS: The Survey was composed of 25 questions divided in 4 sections: surgeon's profile, preoperative and intraoperative evaluation, postoperative management. In this paper, we report the absolute and relative frequencies of answers to section on "postoperative management." Then, regarding the treatment of residual LLD, we reported whether trauma surgeons and experts in replacement surgery had higher odds ratios for providing "literature-based" answers compared to orthopedics physicians. RESULTS: Only four questions received more than 70% agreement on one of the answers. The OR for giving the "literature-based" answer, taking OP as the reference group was 1.57 for TR and 1.72 for RS for 10 mm LLD at first follow-up (FU) and 1.23 TR and 1.32 RS when 20 mm. When 10 mm LLD at 3 months FU the OR was 0.88 TR and 1.15 RS. The OR for treatment of LLD after the first examination of a new patient was 2.16 TR and 1.85 RS. CONCLUSIONS: LLD is a debated topic with no definitive recommendations. Many decisions still depend on tradition. Treatment of LLD during clinical practice often differs from literature recommendations.
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Total knee arthroplasty (TKA) alignment has recently become a hot topic in the orthopedics arthroplasty literature. Coronal plane alignment especially has gained increasing attention since it is considered a cornerstone for improved clinical outcomes. Various alignment techniques have been described, but none proved to be optimal and there is a lack of general consensus on which alignment provides best results. The aim of this narrative review is to describe the different types of coronal alignments in TKA, correctly defining the main principles and terms.
Assuntos
Artroplastia do Joelho , Prótese do Joelho , Osteoartrite do Joelho , Humanos , Artroplastia do Joelho/métodos , Articulação do Joelho/cirurgia , Osteoartrite do Joelho/cirurgiaRESUMO
OBJECTIVE: Identification of periprosthetic joint infection (PJI)-related pathogens is crucial to decide what is the correct surgical strategies and the most secure timing to re-implant in case of two-stage revision. The purpose of the present study is to review the literature to identify the features of each exams which are used to identify the pathogens associated with PJI, to evaluate which are the most sensitive and specific and to set up an algorithm to decide when, in the field of two-stage revision, it's the ideal timing to re-implant. MATERIALS AND METHODS: We did a systematic review of the literature to look for peer-reviewed papers of any evidence level focusing on: (1) Microbiological and molecular exams for identification of PJI-related pathogens. (2) Nuclear imaging methods, which can help in the identification of a PJI. Special attention was focused to analyse which is the sensitivity and specificity of these exams. RESULTS: Overall, 64 manuscripts met the criteria of the systematic search at point 1 and 7 manuscripts at point 2. Among microbiological and molecular exams, the average of sensitivity and specificity were respectively 65.6% and 94.4% for cultural exams, 74.1% and 95.2% for molecular diagnosis and 86.9% and 96% for MicroDTTect. Among nuclear imaging methods, the average of sensitivity and specificity were respectively 94% and 69 % for three-phase bone scintigraphy and 100% and 62.5% for [18F] Fluoro-2-deoxyglucose-positron emission tomography/computed tomography. CONCLUSIONS: In two-stage revision after PJI, taking into account the sensitivity and specificity values, just a few microbiological and molecular exams and nuclear imaging methods should be considered in the decision process to re-implant the components.
Assuntos
Infecções Relacionadas à Prótese/microbiologia , Artroplastia de Quadril , Humanos , Imageamento por Ressonância Magnética , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/cirurgia , Sensibilidade e EspecificidadeAssuntos
Hemofilia A/complicações , Hemofilia A/cirurgia , Doenças Musculares/etiologia , Doenças Musculares/cirurgia , Ossificação Heterotópica/etiologia , Ossificação Heterotópica/cirurgia , Adulto , Articulação do Quadril/patologia , Articulação do Quadril/fisiopatologia , Humanos , Articulação do Joelho/patologia , Articulação do Joelho/fisiopatologia , Prótese do Joelho , Masculino , Ossificação Heterotópica/fisiopatologia , Osteotomia , Músculo Quadríceps , Amplitude de Movimento ArticularRESUMO
Haemophilic arthropathy is the most common clinical manifestation of haemophilia, secondary to recurrent haemarthroses and chronic synovitis. Modern bleeding-preventing drugs have limited significantly the incidence of severe arthropathy, and primary approach is usually conservative. Use of intra-articular injections of hyaluronan acid is considered one of the most efficient treatments for early stages of articular degenerative diseases. Assessment of long-term effectiveness of intra-articular administration of hyaluronic acid (HA) in knees, ankles and elbows of patients affected by haemophilic arthropathy was done for 46 patients (10 elbows, 24 knees and 25 ankles) affected by haemophilic arthropathy. They received injections of HA and were evaluated with Visual Analogue Scale, Short Form-36, World Federation of Haemophilia score and Petterson score with a 6-year mean follow-up. Most of the patients showed improvement in pain relief and functional recovery without any complications: only a limited number of patients (8.6%) found poor results, undergoing surgery or other further treatments in the follow-up period for persistent pain or limitation. Viscosupplementation is an effective therapeutic strategy in early stages of haemophilic arthropathy, with no complications and long-term good clinical results.
Assuntos
Hemofilia A/complicações , Hemofilia B/complicações , Ácido Hialurônico/uso terapêutico , Artropatias/tratamento farmacológico , Viscossuplementos/uso terapêutico , Adulto , Idoso , Feminino , Seguimentos , Hemofilia A/tratamento farmacológico , Hemofilia B/tratamento farmacológico , Humanos , Ácido Hialurônico/administração & dosagem , Injeções Intra-Articulares , Artropatias/etiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Dor/tratamento farmacológico , Medição da Dor , Qualidade de Vida , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Viscossuplementos/administração & dosagem , Adulto JovemRESUMO
Total knee arthroplasty following complex fractures of the tibial plateau is considered a challenge for orthopaedic surgeons and clinical outcomes may vary. A total of 29 total knee replacements were performed after a tibial plateau fracture: 25 patients (16 women, 9 men; average age: 57 years; mean follow-up: 92 months) were available. We had two significative complications: one partial avulsion of the patellar tendon, conservatively treated by bracing, and one case of deep venous thromboembolism, managed with low molecular weight heparin. In two cases (8%) there was a failure of the implant; nine cases were excellent, nine good, four fair and one poor. A percentage of patients with previous complex proximal tibia fractures had an increased rate of postoperative complications due to anatomical deformity, functional deficiency and post-traumatic arthritis and required solutions similar to revision surgery. Total knee arthroplasty is a suitable solution for the treatment of these challenging cases: compared to primary knee replacement, final KSS score is generally lower, but improvement is similar due to poorer pre-operative scores.
Assuntos
Artroplastia do Joelho , Fraturas da Tíbia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
We reviewed the long-term results at ten to 12 years of 118 total hip replacements in 109 patients using a second-generation hemispherical cementless acetabular component (Reflection) designed to address the problem of backside wear. Five patients (five hips) died and six patients (seven hips) were lost to follow-up. The remaining 98 patients (106 hips) had a mean age of 62.9 years (34.0 to 86.2) A rate of revision for aseptic loosening of 0.9%, and predictable results were found with respect to radiological evidence of fixation, lack of pain, walking ability, range of movement and function. One component was revised for aseptic loosening, and of the 101 hips (95.2%) that did not have a revision, minor osteolytic lesions of the pelvis were seen in six (5.9%). Kaplan-Meier survival analysis for the total cohort of 118 hips revealed a 96.4% survival at both ten (95% confidence interval 90 to 98) and 12 years (95% confidence interval 86 to 98).
Assuntos
Artroplastia de Quadril/instrumentação , Articulação do Quadril/cirurgia , Prótese de Quadril , Desenho de Prótese/normas , Acetábulo , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/normas , Cimentos Ósseos , Análise de Falha de Equipamento , Seguimentos , Humanos , Pessoa de Meia-Idade , Osteoartrite do Quadril/cirurgia , Falha de Prótese , Estatística como Assunto , Fatores de TempoRESUMO
The purpose of this paper was to evaluate the results of acetabular revisions with the use of an oblong revision cup that is designed with its longitudinal diameter elongated relative to its transverse diameter. Between 1996 and 2001, 62 hips in 60 patients underwent an acetabular revision with the insertion of a LOR acetabular component. Seven hips were lost to follow-up or the patients died; the remaining 55 hips (53 patients) remained in follow-up for an average of 7.2 years (range: 5.0-10.1 years). One socket was revised for aseptic loosening, and another was operated on for a late polyethylene liner dissociation. The average Harris hip score (HHS) improved from 34 to 79. Results were rated as excellent in 16 hips, good in 28, fair in six and poor in three. Radiographic analysis demonstrated an improvement in the average vertical displacement of the hip centre: 49 hips had a well-fixed, bone-ingrown cup and four had a stable fibrous union. For large superolateral acetabular bone deficiencies, this implant facilitated a complex reconstruction without the need for bulk structural acetabular bone grafts, provided good clinical results and showed satisfactory stability at the midterm follow-up.
Assuntos
Acetábulo/cirurgia , Artroplastia de Quadril/instrumentação , Prótese de Quadril , Acetábulo/diagnóstico por imagem , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Falha de Prótese , Radiografia , Reoperação , Resultado do TratamentoRESUMO
The results of 24 modular Genesis II (Smith & Nephew, Memphis, TN, USA) total knee arthroplasties, performed in 20 patients with haemophilia were prospectively reviewed. The hypothesis that the use of a new-generation implant and advanced, more aggressive hematological care, will result in a decrease rate of complications and better functional results for the haemophilic patients with TKA was tested. The mean age at the time of surgery was 36 years (25 to 44). All the patients were reviewed clinically and radiologically with an average follow-up of 4.4 years (2 to 7 years). At the final follow-up the knee score improved from an average of 23 points (11 to 45) to 86 points (62 to 100; p<0.001). The mean knee flexion contracture improved from 22 degrees (0 degrees to 45 degrees ) to 3 degrees (0 degrees to 10 degrees ; p<0.0001). The mean total flexion arc improved from 69 degrees (5 degrees to 130 degrees ) to 92 degrees (80 degrees to 145 degrees p<0.001). The results of our study confirm that the introduction of modular design may improve the functional results of TKA in haemophilic arthropathy which results in a better range of motion and lower flexion contracture.
Assuntos
Artroplastia do Joelho/métodos , Hemartrose/cirurgia , Hemofilia A/complicações , Hemofilia B/complicações , Avaliação de Resultados em Cuidados de Saúde , Adulto , Fatores de Coagulação Sanguínea/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Seguimentos , Hemartrose/etiologia , Humanos , Infusões Intravenosas , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Prótese do Joelho , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Índice de Gravidade de DoençaRESUMO
Unicompartmental knee arthroplasty (UKA) is considered the treatment of choice in patients with single compartment arthritis of the knee at early stages or with osteonecrosis limited to one compartment. However, results in the literature are still controversial and it is a technically difficult procedure. The main goal of UKA is to restore the articular space of the afflicted compartment, without influencing the limb alignment. Selection of patients and pre-operative planning are crucial. The necessity to improve functional results and to reduce immobilization of the patients has led to the development of minimally invasive surgery. Applied to UKA, this approach reduces blood loss and surgical time, causes fewer symptomatic postoperative complications, and permits earlier recovery compared to the traditional incision. The shorter incision makes careful pre-operative planning essential. We briefly review the indications for UKA, the pre-operative clinical and radiological assessment, and the surgical procedure.
RESUMO
Metal reinforcement rings, systems used widely in the past for prosthetic revision surgery, are still effective, in that they allow us to restore the correct hip rotation center and protect the bone grafts used to increase acetabular bone stock. To provide a better definition of the current indications for use of reinforcement rings in acetabular revisions we conducted a retrospective study in a group of 25 patients in whom a Ganz reinforcement ring was used in association with autoclaved cancellous bone grafts. The Ganz ring is made of titanium and it has a lower hook that contributes to the mechanical stability of the implant. Mean age of patients was 72.5 years. Pre-revision acetabular bone defects were divided according to the Paprosky classification system: type 2A: 2 cases; type 2B: 6 cases; type 2C: 6 cases; type 3: 6 cases; type 3B: 5 cases. Clinical and radiographic results were evaluated after a mean follow-up of 4.6 years. Score based on the Harris evaluation form went from a mean preoperative value of 45 points to 92 points after revision. Overall, clinical results were excellent in 9 cases (36%), good in 12 cases (48%), fair in 3 cases (12%), poor in 1 case (4%). Radiographically, we observed a significant reduction (62%) in mean vertical distance of the hip rotation center after revision, that contributed to reduction in hypometria of the limb submitted to surgery, ranging from a mean preoperative value of 2.2 cm to 0.72 cm after surgery. Stability of the implant in time was evaluated based on the Gill criteria. None of the cases required further revision surgery; in 3 cases (12%) with type 3 preoperative defects, the implant was judged to be probably or possibly loosened because of the presence of radiolucent lines.
Assuntos
Artroplastia de Quadril/instrumentação , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Articulação do Quadril/diagnóstico por imagem , Articulação do Quadril/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Reoperação , Estudos Retrospectivos , Fatores de TempoRESUMO
Peak bone mass is an important determinant of future bone mass and of the risk of osteoporosis and subsequent fractures. Although some information concerning bone mineral density (BMD) in adults affected with systemic lupus erythematosus (SLE) is available, few data on children and adolescents have been reported. Many variables, such as duration and activity of the disease, reduced sun exposure, and steroid therapy have been suggested as risk factors in the pathogenesis of osteoporosis in SLE. In this study, we longitudinally evaluated, by dual energy X-ray absorptiometry (DEXA), the BMD of 20 young patients affected with juvenile SLE (JSLE), in order to establish the degree of osteoporosis and the influence of steroid treatment, among other clinical variables. At baseline, the mean BMD in JSLE patients was 0.978 g/cm2 and in controls 1.038 g/cm2 (P = 0.31). At 1 year (time 2), this value became 0.947 g/cm2 in JSLE children; the mean individual difference was 0.28 g/cm2 (3.4%). Only in those patients aged 19-25 years BMD was significantly lower than in controls, both at baseline and at time 2. Considering the steroid treatment, no significant difference between the two groups was found either at baseline or at time 2; however, the mean yearly BMD loss in the steroid patients was 0.031 g/cm2 (3.5%) vs. 0.005 g/cm2 (0.5%) in those who had not taken steroids. A significantly inverse correlation between BMD and the cumulative dosage of corticosteroids has been detected. BMD produced a significantly inverse correlation to the cumulative dosage of corticosteroids; no significant correlation has been found between BMD and disease activity or duration.
Assuntos
Densidade Óssea/efeitos dos fármacos , Lúpus Eritematoso Sistêmico/complicações , Osteoporose/etiologia , Esteroides/efeitos adversos , Absorciometria de Fóton , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Estudos Longitudinais , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Lúpus Eritematoso Sistêmico/fisiopatologia , MasculinoRESUMO
Osteoporosis, a common clinical feature in children affected with Juvenile Rheumatoid Arthritis (JRA), is generally divided into two forms, a localized juxta-articular osteoporosis of the single joints and a generalized reduction of bone mass due to the disease itself, joint involvement and steroid treatment. Recently Dual Energy X-ray Absorptiometry (DEXA) has been suggested for Bone Mineral Density (BMD) measurement. In the present study DEXA has been used to investigate the lumbar spine BMD in JRA patients as compared to healthy children. Our results showed that BMD is reduced in JRA patients (BMD 0.685 g/cm2) when compared to healthy children (BMD 0.722 g/cm2), and it is significantly lower in the group of patients treated with steroids (BMD 0.623 g/cm2) when compared to those treated with nonsteroidal antiinflammatory drugs (BMD 0.710 g/cm2). The analysis of all risk factors of bone loss indicated that steroids represent the only parameter of significant negative correlation with BMD.
Assuntos
Absorciometria de Fóton , Anti-Inflamatórios/efeitos adversos , Artrite Juvenil/complicações , Densidade Óssea , Osteoporose/etiologia , Adolescente , Anti-Inflamatórios/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Artrite Juvenil/tratamento farmacológico , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Osteoporose/induzido quimicamente , Análise de Regressão , EsteroidesRESUMO
Five cases of septic loosening of total knee arthroplasty were treated by two-stage revision using a cement mixed with antibiotic. The spacer block was responsible for greater mechanical stability of the joint in the interval between the two stages of the operation, and the association of the antibiotic favored resolution of septic complications, allowing at the same time for systemic antibiotic treatment at doses lower than usual. In all of the cases treated reimplantation was performed in conditions of apparent sterility. The minimum amount of time between the first operation and reimplantation was 3 months, maximum was 5 months. Four to 18 months after reimplantation there was no recurrence of infection. Despite the short follow-up, the technique used appears to constitute a valid solution for septic complications in total knee arthroplasty.
Assuntos
Prótese do Joelho/métodos , Falha de Prótese , Infecções Relacionadas à Prótese , Idoso , Feminino , Seguimentos , Humanos , Prótese do Joelho/instrumentação , Pessoa de Meia-Idade , Recidiva , Reoperação , Sepse , Fatores de TempoRESUMO
The authors describe their experience in the treatment of severe acetabular osteolysis using bone grafts and cementless screwed acetabulum. They define the criteria that directed them towards this choice and the surgical method used in relation to bone loss caused by failure of the previous prosthesis. In light of their experience, the advantages and the drawbacks to using a cementless acetabulum in hip reimplantation are described, with particular analysis of the peculiar features of the P.M. acetabulum that, because it is screwed and has a truncated-conical design, permits stabilization of the grafts without the use of further instrumentation, and obtains effective primary stability even when there is discontinuity of the bottom or of the acetabulum.
Assuntos
Acetábulo/cirurgia , Reabsorção Óssea/cirurgia , Transplante Ósseo , Prótese de Quadril/efeitos adversos , Reabsorção Óssea/etiologia , Humanos , Reoperação , Índice de Gravidade de DoençaRESUMO
The authors report the method used and long-term results for 61 acetabular reimplantations involving screwed truncated-conical acetabula and bone grafts. Mean follow-up was 6.3 years. From a clinical point of view the cases classified as excellent were 14 (24.1%), good 26 (44.8%), fair 12 (20.7%), and poor 6 (10.4%). As for radiographic evaluation, the acetabulum appeared to be stable in 37 cases (63.8%), there was fibrous stability in 13 cases (22.4%), the radiographic findings had shown uncertain stability in 5 cases (8.6%), and the acetabulum was unstable in 3 cases (5.2%). Long-term results show that the biological stabilization and, in particular, the implantation of screwed acetabula, when technically correct, may constitute a valid solution in revision surgery for the acetabular component.
Assuntos
Acetábulo/cirurgia , Parafusos Ósseos , Prótese de Quadril/instrumentação , Acetábulo/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Transplante Ósseo , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Reoperação , Fatores de TempoRESUMO
The authors report the indications and short-term results obtained in a series of 99 total hip prostheses with a screwed acetabulum and cemented stem. The principles which inspired their choice and the criteria used to select patients are discussed. The results obtained, evaluated both clinically and radiographically, are satisfactory, particularly with regards to percentage of pain symptoms in the femur.
Assuntos
Cimentos Ósseos , Prótese de Quadril , Acetábulo , Idoso , Parafusos Ósseos/estatística & dados numéricos , Feminino , Seguimentos , Prótese de Quadril/estatística & dados numéricos , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Desenho de Prótese/estatística & dados numéricos , Falha de PróteseRESUMO
The authors state the indications and report the results of 43 revision arthroplasties performed with cementless total hip implants. They describe both the criteria leading to this therapeutic decision and the technique employed given the bone loss caused by the failure of the previous arthroplasty. The long-term results are analyzed with particular reference to radiographic evidence of implant stability.
Assuntos
Cimentos Ósseos , Prótese de Quadril/métodos , Falha de Prótese , Idoso , Artroplastia , Transplante Ósseo , Feminino , Seguimentos , Articulação do Quadril/diagnóstico por imagem , Prótese de Quadril/estatística & dados numéricos , Humanos , Masculino , Radiografia , ReoperaçãoRESUMO
The authors state the indications and report the results of their first 35 consecutive AGC total knee arthroplasties. Both the characteristic of the prosthesis and the modalities of the application technique are analyzed. The results are evaluated from a clinical and radiographic point of view.
Assuntos
Prótese do Joelho , Idoso , Cimentos Ósseos , Feminino , Seguimentos , Humanos , Articulação do Joelho/diagnóstico por imagem , Prótese do Joelho/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , RadiografiaRESUMO
In 1984 a "bone bank" containing femoral heads taken from live donors was created at the 2nd Orthopaedic Department of the University of Florence. The authors emphasize that these bones are very easy and inexpensive to obtain and store. They describe the organization of the "bone bank" and present the results of its first four years of activity.