Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society.

BACKGROUND: Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS). METHODS: An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol. RESULTS: A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol. CONCLUSIONS: A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Early failure of an uncemented femoral stem, as compared to two other stems with similar design, following primary total hip arthroplasty performed with direct anterior approach.

INTRODUCTION: An increased risk of early femoral component loosening has been reported using the direct anterior approach (DAA) compared with other common surgical approaches. However, long-term data are scarce. The purpose of this study is: (1) to determine the incidence of early femoral loosening in a high volume, single surgeon's practice utilising the DAA approach; and (2) to examine the effect of stem design and type of coating on aseptic loosening in the early and mid-term postoperative period. METHODS: A retrospective review of 1650 consecutive patients (1800 hips) who underwent total hip arthroplasty (THA) using the DAA between August 2011 and December 2017 was conducted at our institution. 3 types of uncemented femoral stems (Quadra-S, Avenir, TwinSys), with similar design, but different coating, were implanted. Patients were evaluated clinically and radiologically at 4 weeks, 3 months, 1 year, and annually thereafter. RESULTS: After a mean follow-up of 46.4 months, the total incidence of revision for aseptic loosening was 0.44% (n = 8). All loose stems were Quadra-S, failing to achieve osseointegration, for an overall incidence of 0.96% (p = 0.002). None of the other stems were loose. Radiolucent lines around the proximal stem portion were visible in 75 Quadra-S stems (4.1%) on radiographs taken at 1 year postoperatively and continued to deteriorate at the latest follow-up. CONCLUSIONS: In this specific cohort of patients, the increased rate of femoral stem aseptic loosening was implant-related and was attributed only to a specific type of femoral stem (Quadra-S). No relation to other factors was proven suggesting that the surface characteristics of this femoral stem and the lack of bioactive coating are responsible for the observed early femoral failures. These findings should be confirmed by additional registry work and larger population sample sizes are needed to evaluate the prosthesis performance after implantation through the DAA.

Searching for the 'winner' hip fracture patient: the effect of modifiable and non-modifiable factors on clinical outcomes following hip fracture surgery.

BACKGROUND: Various factors, other than the quality of surgery, may influence clinical outcomes of hip fracture patients. We aimed to evaluate the relative impact of several factors on functional outcome, quality of life, re-fracture and mortality rates following surgery for hip fractures. METHODS: We studied 498 (62.2%) women and 302 (37.8%) men with a mean age of 81.3 years (range, 60-95) with hip fractures (femoral neck and pertrochanteric). The mean follow-up was 74 months (range 58-96). Various patient-related and surgery-related parameters were recorded and correlated to both objective and subjective mobility, functional recovery and quality of life scales. Mortality and re-fracture rates were also evaluated. RESULTS: Using multiple regression analysis, age >80 years (p = 0.000; 95% CI, 1.077-1.143) and ASA score III and IV (p = 0.000; 95% CI, 2.088-3.396) (both non-modifiable factors) both proved to be independent (s.s.) factors affecting mortality rates. Age <80 years (p = 0.000; 95% CI, 0.932-0.974), surgery delay less (modifiable factor) than 48 hours (p = 0.046; 95% CI, 0.869-0.999), low dementia CDR index (p = 0.005; 95% CI, 0.471-0.891) (non-modifiable factor), and osteoporosis medical treatment (modifiable factor) (p = 0.006; 95% CI, 0.494-0.891) were shown to be independent (s.s.) factors affecting HOOS-symptoms. Osteoporosis medical treatment used proved to be an independent (s.s.) factor affecting HOOS-daily activities (p = 0.049; 95% CI, 0.563-1.000) and quality of life (E-Qol-5D) (p = 0.036; 95% CI, 0.737-1.325). CONCLUSIONS: A hip fracture patient aged <80 years old, with an ASA I-II, with low dementia CDR index and on osteoporosis medication has a better chance of an improved outcome (winner patient).

Anatomy Learning from Prosected Cadaveric Specimens Versus Plastic Models: A Comparative Study of Upper Limb Anatomy.

Human cadaveric prosections are a traditional, effective, and highly appreciated modality of anatomy learning. Plastic models are an alternative teaching modality, though few studies examine their effectiveness in learning of upper limb musculoskeletal anatomy. The purpose of this study is to investigate which modality is associated with a better outcome, as assessed by students' performance on examinations. Overall, 60 undergraduate medical students without previous knowledge of anatomy participated in the study. Students were assigned into two groups. Group 1 attended lectures and studied from cadaveric prosections (n = 30) and Group 2 attended lectures and used plastic models in the laboratory (n = 30). A knowledge assessment, including examination with tag questions (spot test) and written multiple-choice questions, was held after the end of the study. Students' perceptions were also investigated via an anonymous questionnaire. No significant difference in students' performance was observed between the group using prosections and the group using plastic models (32.2 ± 14.7 vs 35.0 ± 14.8, respectively; P = 0.477). Similarly, no statistically significant difference was found regarding students' satisfaction from using each learning modality (P = 0.441). Plastic models may be a valuable supplementary modality in learning upper limb musculoskeletal anatomy, despite their limitations. Easy to use and with no need for maintaining facilities, they are highly appreciated by students and can be useful when preparing for the use of cadaveric specimens.

Total hip arthroplasty in patients with osteoporosis.

There is a high prevalence of osteoporosis in patients undergoing total hip arthroplasty. There are several clinically relevant questions related to the management of such cases: the effect of ageing; the initial osseointegration of implants, especially when cementless THA is used; the effect of medical osteoporosis treatment on bone-implant interface; the incidence of intraoperative and late periprosthetic fractures, and the long-term survival of both cemented and cementless total hip arthroplasty performed for proximal femoral fractures and hip osteoarthritis. A critical review of the literature is presented in an attempt to draw practical conclusions.

Overestimation of the risk of revision with Kaplan-Meier presenting the long-term outcome of total hip replacement in older patients.

INTRODUCTION: The purpose of the present study was (i) to review the long-term outcome of cemented Charnley total hip replacements (THRs) performed by 1 surgeon (GH), 20 to 42 years ago, in patients ≥60 years, using both the Kaplan-Meier (KM) and the cumulative incidence (CI) methods, and (ii) to compare the estimations of the 2 statistical methods. METHODS: We evaluated the outcome of 306 consecutive primary cemented THRs that were performed in 265 patients. The final clinical, radiographic assessment and satisfaction of living patients were also included. The survivorship was estimated with the use of KM and CI methods and the relative difference between their estimations was calculated. RESULTS: Living patients' final clinical results were significantly improved in comparison with respective preoperative ones, and all the acetabular and 91% of femoral components considered as well fixed. 95% of these patients reported satisfaction. The risk of revision at 25 years, with revision for aseptic loosening for 1 or both components as the endpoint, with 21 hips at risk, assessed with KM analysis was 6.9% and with CI approach was 3.9%. The relative difference between KM and CI estimations was increasing during follow-up, reaching up to 76.8% at 25 years. CONCLUSIONS: We concluded that fixation of implants with cement in older patients had satisfactory long-term results and can serve as a benchmark with which to compare newer fixation methods (hybrid and uncemented) and materials. However, KM method, in studies that include older population with long-term follow-up, may significantly overestimate the risk of revision and clinicians could consider using besides the cumulative incidence of competing risk method.

An attempt to throw light on congenital hip disease terminology and anticipation of clinical outcomes when treated with total hip arthroplasty.

The terminology of the wide spectrum of hip deformities seen during the neonatal, infantile and adult life period remains controversial, mainly due to the indiscriminate use of the terms dysplasia, subluxation, congenital hip disease, developmental hip disease, congenital dislocation, etc. This has a serious implication on the anticipation of clinical outcomes, complications and comparison of different reconstructive techniques when these patients are treated with total hip arthroplasty in adulthood. Journals, specialising in this field, should publish homogeneous series (type of the disease, reconstruction technique, implants) in order to clarify arguments and anticipate clinical outcomes.

Complicated septic arthritis after knee arthroscopy in a 75-year-old man with osteoarthritis and a popliteal cyst.

A 75-year-old man presented in shock secondary to septic arthritis of the knee. The patient, with a known history of knee osteoarthritis, was treated elsewhere for mechanical locking symptoms and effusion with arthroscopic debridement, and developed septic arthritis, which disseminated to the leg and foot after a tear in the capsule, and a ruptured pyogenic popliteal cyst. Open debridement of the knee joint, and drainage of the abscesses of the leg and foot, were performed. Antibiotic-loaded cement beads were left in the residual space. Debridement was repeated and cement beads removed after 4 days, and finally the infection was eradicated without any serious consequences for the patient. There is debate over arthroscopic intervention for osteoarthritic knees. The presence of a popliteal cyst, which is a rather common finding in the latter, could be related to a significant number of complications, such as septic arthritis.

Clinical outcome study and radiological findings of Zweymuller metal on metal total hip arthroplasty. a follow-up of 6 to 15 years.

We report the clinical and radiological outcome of 99 Zweymuller metal on metal total hip arthroplasties in 84 patients followed up prospectively for a mean period of 9.5 (range, 6-15) years. There were 29 (34.5%) male and 55 (65.5%) female patients with a mean age of 62.85 years (range, 50-70 years) at the time of surgery. All patients had osteoarthritis. One acetabular component and one stem were revised due to aseptic loosening. One femoral stem was revised due to a periprosthetic fracture. HHS score improved from a preoperative mean of 62.56 points (SD 8.87) to a final postoperative follow-up mean of 93.48 (SD 7.7). Cumulative success rate for both implants at 13 years, with aseptic loosening as the end point, was 97.05%, while for both implants at 13 years, with revision for any reason as the end point, it was 91.17%. Satisfactory results were observed with the use of this prosthesis.

Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report.

INTRODUCTION: Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery. CASE PRESENTATION: We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively. CONCLUSION: A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.

The influence of the acromioclavicular joint degeneration on supraspinatus outlet impingement and the acromion shape.

PURPOSE: To assess the anatomic association of acromioclavicular joint degeneration to supraspinatus outlet impingement and the acromion shape. METHODS: Sagittal oblique magnetic resonance images of 49 shoulders in 49 patients were reviewed. 29 of them (mean age, 59 years) underwent surgery for impingement with or without rotator cuff tear (group 1), whereas the 20 controls (mean age, 27 years) were treated for shoulder instability without rotator cuff disease or acromioclavicular joint derangement (group 2). The supraspinatus outlet and the acromion shape of the 2 groups were compared. RESULTS: The difference in the mean supraspinatus outlet between groups 1 and 2 was 11% (514 vs 577 mm[2], p=0.095) and between the subgroup (of group 1) with full thickness rotator cuff tears and group 2 was 17% (481 vs 577 mm[2], p=0.036). Six of the acromions in group 1 were type III (hooked) compared to none in group 2. CONCLUSION: In severe acromioclavicular degeneration, distal clavicular excision is recommended, even in cases with an asymptomatic acromioclavicular joint, so as to prevent further osteophyte formation.

Novel model for studying hematogenous infection in an experimental setting of implant-related infection by a community-acquired methicillin-resistant S. aureus strain.

The aim of this study is to establish a new experimental model of hematogenous implant-related infection (IRI) by a community-acquired methicillin-resistant S. aureus (CA-MRSA) strain. Cylindrical porous tantalum intramedullary implants were inserted in the proximal right tibia of 30 male white rabbits after administration of antibiotic prophylaxis. Four weeks later and without antibiotic prophylaxis, 20 animals received 1 ml of inoculum of two different concentrations (study groups A and B) of CA-MRSA strain through an ipsilatelar femoral artery catheter. The remaining 10 received normal saline instead (control group C). Surviving animals were sacrificed 4 weeks later. Sterile bone, bone marrow biopsies, and implants were harvested for culture and histological evaluation. Ten animals receiving 5 x 10(8)cfu/ml (group A) died within 48-72 h due to septic shock. Blood cultures were positive; histology demonstrated acute infection. Ten animals received bacterial load of 3 x 10(8)cfu/ml (group B) and all survived; two had negative Gram-stain and cultures but PCR and RT-PCR results demonstrated the viability of the microorganisms, while periprosthetic osteolysis and histological evaluation indicated subacute osteomyelitis; eight animals established periprosthetic infection, osteomyelitis, and septic arthritis documented by positive Gram-stain, cultures, subperiosteal reaction, and chronic infection on histology. Control group specimens demonstrated no signs of infection. Histopathological semiquantitative scoring was used to compare the three groups. Comparison of groups A and B with control group and between group A and B showed statistically significant difference (p < 0.05) in all parameters except for periosteal reaction between groups B and C (p = 0.354). This novel, reproducible experimental model will facilitate the study of hematogenous CA-MRSA IRIs.

Incision stretching in primary TKA: what is the real length of our approach?

This article examines the extent of anterior knee soft-tissue stretching that occurs in patients undergoing primary total knee arthroplasty for 331 consecutive patients. At the time of surgery, an anterior knee incision was drawn on the knee. Measurements were taken of the length of the incision with the knee in maximum extension and 90 degrees degrees of flexion. Incision length was 5.7 cm longer in flexion than extension. The surgical incision site stretched an average of 23.6% in flexion compared to the resting extension length.

Rotator cuff interval reconstruction.

Five pairs of cadaveric shoulders underwent posterior and anterior drawer and inferior sulcus tests in five progressive conditions: intact, vented, following opening of the rotator cuff interval, reconstruction of the interval, and transfer of the coracoacromial ligament. The surgical treatments--vented, open rotator cuff interval, reconstruction, and coracoacromial ligament transfer--had an effect compared to the intact shoulders on the inferior stiffness (P = .00002) and on the anteroposterior stiffness (P = .00031). The difference between the stiffness of the reconstructed rotator cuff interval compared to the coracoacromial ligament transfer was significant for loading in the AP direction (P = .006) and for loading in the inferior direction (P = .005).

Changes of meniscal interhorn distances: an in vivo magnetic resonance imaging study.

The aim of this study was to evaluate the changes of the internal (IID) and external meniscal interhorn distance (EID) of the medial and the lateral meniscus under loading. Sagittal magnetic resonance images of 15 knees were studied. The medial and lateral meniscus were examined with the knee at 0 degrees and 30 degrees of flexion, under no load, with load equal to 50% of body weight and with load equal to 100% of body weight. Under no load, the mean IID was 19.9 mm for the medial meniscus and 12.3 mm for the lateral meniscus and the mean EID was 44.6 mm for the medial meniscus and 34.4 mm for the lateral meniscus. Under load equal to 50% and 100% of patient's body weight, there was a significant increase in both distances (p<0.05). Under constant loading, flexion of the knee from 0 degrees to 30 degrees , decreased the EID of both menisci. In conclusion, loading increases both IID and EID. Knee position affects only the EID. The quality of magnetic resonance images may affect the reliability of such measurements.