Assocation between trapezium size and failure of total trapeziometacarpal prosthesis. A survival analysis.

AIMS: To assess the survival function of cementless total trapezium metacarpal prostheses (TTMPs) at 20 years, to compare survival functions by trapezium size, and to evaluate the association between the instantaneous risk of TTMP failure and small trapezium size using a multivariate Cox regression model. METHODS: This observational cohort study included 221 consecutive patients with a mean follow-up after TTMP of 137.3 months (maximum of 246 months). Kaplan-Meier and actuarial life-table methods were used to evaluate the survival function of thecohort. Kaplan-Meier survival curves were compared by trapezium size. Multivariate Cox regression analysis was used to determine the effect of potential confounders on the association between small trapezium and the instantaneous risk of TTMP failure. RESULTS: At the end of follow-up, there was a 89.01% chance of the TTMP surviving for 246 months or more. There was an association between TTMP survival time and trapezium size showing a significant trend such that the survival curves weresignificantly higher with larger trapezium size (Mantel-Cox test, p = 0.0001; WilcoxonBreslow test, p = 0.0002; Tarone-Ware test, p = 0.0001).The unadjusted Cox regression model showed a significant association between small trapezium size (smaller than 9 mm) and the instantaneous risk of TTPM failure (HR: 7.37, 95% CI: 2.46-22.07). In the multivariate Cox analysis, "age", "trapezium morphology", and "complications" were confounders in the association between small trapezium size and the hazard ratio of prosthetic failure (HR = 3.76; 95% CI 0.96 to 13.82). CONCLUSION: These results confirm the long-term functional survival of TTMP prostheses and reveal a significant increase in trend of the survival curve with larger trapezium size. Patient age, trapezium morphology, and the presence of post-surgical complications are confounders in the association between small trapezium size and the hazard ratio of TTMP failure.

Total Knee Arthroplasty in Octogenarians: Should We Still Be so Restrictive?

Demand for total knee arthroplasty (TKA) in octogenarians will increase in subsequent years as society ages. We conducted a retrospective observational study in octogenarians operated on with TKA between 2015 and 2019, comparing preoperative and postoperative Knee Society Score (KSS), Knee Society Function Score (KSFS), extension and flexion balance, and radiologic alignment using a paired Student t-test. A chi-squared test was used to correlate mortality with Charlson comorbidities index score and with ASA scale. Kaplan-Meier analysis was performed to calculate patient survival. In this period 36 patients ≥80 years underwent TKA, with a mean age of 81.6 years. Of these, 24 patients (66.7%) were classified as ASA II and 12 (33.3%) as ASA III. Sixteen patients (44.4%) were Charlson 0, 14 (38.9%) Charlson 1, two (5.6%) Charlson 2, and four (11.1%) Charlson 3. KSS, KSFS, flexion and extension range, and radiologic alignment were statistically significant (p < 0.001) when comparing preoperatory and post-operatory data. No correlation (p > 0.05) was found between mortality and ASA or Charlson score. Seven patients (19.4%) suffered a medical complication and two patients experienced surgical complications. Four patient died (11.1%) during follow-up. The mean patient survival was 67.4 months. Patients ≥80 years achieve clinical improvement after TKA. Comorbidities, not age, are the burden for surgery in older patients.

Long-Term Results of Joint Arthroplasty with Total Prosthesis for Trapeziometacarpal Osteoarthritis in Patients over 65 Years of Age.

Trapeziometacarpal osteoarthritis (TMCOA) is a highly prevalent disease in the older population. Many different types of surgical treatments are possible, depending on the degree of joint involvement, the personal and professional circumstances of the patient and the preferences of the orthopedic surgeon. This paper evaluated the clinical and radiological results of consecutive cohorts of patients over 65 years old treated with total joint arthroplasties (TJA) of the ball and socket type (B&S) for TMCOA, with a minimum of 10 years follow-up. The survival rate (Kaplan-Meier) of the functional prostheses at 10 years was 92.2% (95% CI (89.1%, 96.1%). These functional arthroplasty patients, after 10 years of follow-up, showed little or no pain, good function and good key pinch, without radiological alterations. TJAs of the B&S type are a long lasting, effective and reliable alternative to surgical treatment of TMCOA in patients over 65 years of age, when they are performed with the patient selection criteria and surgical technique described throughout this study.

Three-sectioning method: A procedure for studying hard tissues and large pieces under light and electron microscopy.

The histological study of hard pieces such as tendons and calcified lesions and tissues is a field that has been gaining increased attention owing to the rapid development of implantable prostheses, among other factors. In these studies, serial sectioning is utilized to detect areas of interest throughout the entire piece, as it enables the application of the appropriate light and electron microscopy techniques in these areas. We propose the "three-sectioning method" that subjects the pieces to three consecutive cycles of embedding and sectioning to localize and study the areas of interest, as an efficient technique for these histological studies. The pieces were first embedded in epoxy resin and then cut into thick sections (approximately 300 µm) for the first cycle. Next, areas of interest selected on these thick sections were re-embedded in epoxy resin to be sectioned again (second sectioning) to obtain a series of semithin sections (1-3 µm). These semithin sections are usually studied using the most relevant techniques for light microscopy. Smaller areas of interest are selected to be cut into ultrathin sections (60-90 nm) for transmission electron microscopy. If necessary, the selected areas of the semithin sections can be embedded again, and then cut into new ultrathin sections. The different kinds of sections we have described here may also be studied using scanning electron microscopy. This systematic method facilitates correlative microscopy from lower to higher magnifications along with the usage of a broad variety of histological techniques including electron microscopy.

Effect of weight loss on bone metabolism in postmenopausal obese women with osteoarthritis.

BACKGROUND: The choice of hypocaloric diets in obesity can affect bone health. AIMS: The aim of this study is to assess the effect of a hypocaloric diet in postmenopausal obese women and to determine the influence of weight reduction on bone metabolism. METHODS: This was a non-randomised, single-treatment study in 96 postmenopausal women with a body mass index (BMI) greater than 35kg/m2 and osteoarthritis. The patients received a formula diet with two intake levels of a normocaloric hyperproteic formula (1035kcal (25% protein)). Anthropometry and biochemistry with CrossLaps, osteocalcin, parathyroid hormone (PTH) and 25-OH vitamin D were measured. Consumption of protein, calcium and vitamin D were determined at the beginning of and 3 and 6 months into the study. The response to treatment was compared (high-responder (HR): weight loss greater than 15%, and low-responder (LR): weight loss less than 15%). RESULTS: The mean age was 64.2 (7.5) years. After 6 months of treatment, a weight loss of 10.2% (8.2-13.8) was observed. There was a significant increase in vitamin D (HR: 21.8% (36.2) vs. LR: 22.7% (36.9), p=0.93) and CrossLaps (HR: 26.8% (19.5-35.2)) vs. LR: 13.3% (-6.1 to 27.9), p=0.01). The loss of more than 15% of initial body weight was an independent risk factor for an increase in CrossLaps (OR: 4.22 (1.1-16.8), p=0.04). CONCLUSIONS: In postmenopausal obese women, weight loss was associated with an increase in the biochemical parameters of bone resorption. The increase in resorption parameters was related to the magnitude of weight loss.

Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study.

BACKGROUND: Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS: We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS: Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS: The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.

Influence of a meal-replacement diet on quality of life in women with obesity and knee osteoarthritis before orthopedic surgery.

BACKGROUND: Knee osteoarthritis is a disease with a high prevalence in our environment, especially in women. Weight loss can improve the quality of life of these patients before surgery. OBJECTIVES: To evaluate the effect of a meal-replacement diet on weight loss, body composition, and the improvement of the quality of life in obese women with knee osteoarthritis pending surgery. METHODS: One branch intervention study was performed over three months on 81 women with a body mass index greater than 30 kg/m2 with knee osteoarthritis before surgery. Patients received a hyperproteic meal-replacement diet with two bottles of an oral nutrition supplement in lunch and dinner (1,035 kcal). Anthropometric parameters, and body composition were measured. The quality of life was assessed by WOMAC and SF-36 test. RESULTS: The mean age of the patients was 62.23 (8.50) years. The percentage of weight loss was 8.23% (4.04). An improvement in the SF-36 total score was observed (basal: 49.35 [20.41], three months: 58.71 [17.07], p < 0.01). There was an improvement in WOMAC test (basal: 49.24% [25.53], three months: 40.59% [21.76], p < 0.01). It was observed that a 10% improvement in the SF-36 test was independently related to weight loss (OR: 1.2 [1.03-1.36], p < 0.02) adjusted by age and changes in body composition. CONCLUSIONS: In women with osteoarthritis of the knee treated with a meal-replacement diet, there is a significant decrease in weight and fat mass with a relative increase of the latter. There is an improvement in the quality of life according to SF-36 and WOMAC. There is an independent relationship between weight loss and SF-36 improvement.

Factors influencing recurrence and progression of Dupuytren's disease treated by Collagenase Clostridium histolitycum.

AIM OF THE STUDY: The purpose of this study was to determine the recurrence rate, possible adverse reactions and factors influencing recurrence and progression of Dupuytren's disease (DD) treated with Collagenase from Clostridium histolyticum (CCH). METHOD: This was a prospective study of 71 patients with DD treated with CCH from 2011 to February 2013, with a minimum follow-up period of four years. Clinical, functional, patient satisfaction, drug safety and factors influencing recurrence and disease progression were evaluated. RESULTS: In all patients, the rupture of the cord was achieved after the injection, reducing joint contracture. In five patients (7%) we verified the existence of disease recurrence during the follow-up. In 11 patients (15.5%) there was a disease progression. Three patients have been surgically operated on, without added surgery difficulty; the rate of recurrence and progression was higher in grades III and IV of Tubiana, in proximal interphalangeal (PIP) punctures, and was earlier in patients younger than 60 years. DISCUSSION: No serious local complications or general complications were observed with this method. The recurrence of DD, following criteria of Felici, is mainly observed in young patients with greater severity of the disease and at the PIP level. Progression is influenced by the same factors. Patients operated on after recurrence have no added difficulty in the surgical technique, as it has also been published in other studies. CONCLUSIONS: Patients with the lowest rates of recurrence and progression were those with a single cord in the metacarpophalangeal (MCP), a grade II of Tubiana, and were older than 60 years.

Intervertebral Disc Repair by Allogeneic Mesenchymal Bone Marrow Cells: A Randomized Controlled Trial.

BACKGROUND: Degenerative disc disease often causes severe low-back pain, a public health problem with huge economic and life quality impact. Chronic cases often require surgery, which may lead to biomechanical problems and accelerated degeneration of the adjacent segments. Autologous mesenchymal stromal cells (MSC) treatments have shown feasibility, safety and strong indications of clinical efficacy. We present here a randomized, controlled trial using allogeneic MSC, which are logistically more convenient than autologous cells. METHODS: We randomized 24 patients with chronic back pain diagnosed with lumbar disk degeneration and unresponsive to conservative treatments into 2 groups. The test group received allogeneic bone marrow MSCs by intradiscal injection of 25 × 10 cells per segment under local anesthesia. The control group received a sham infiltration of paravertebral musculature with the anesthetic. Clinical outcomes were followed up for 1 year and included evaluation of pain, disability, and quality of life. Disc quality was followed up by magnetic resonance imaging. RESULTS: Feasibility and safety were confirmed and indications of clinical efficacy were identified. MSC-treated patients displayed a quick and significant improvement in algofunctional indices versus the controls. This improvement seemed restricted to a group of responders that included 40% of the cohort. Degeneration, quantified by Pfirrmann grading, improved in the MSC-treated patients and worsened in the controls. CONCLUSIONS: Allogeneic MSC therapy may be a valid alternative for the treatment of degenerative disc disease that is more logistically convenient than the autologous MSC treatment. The intervention is simple, does not require surgery, provides pain relief, and significantly improves disc quality.

The young patient and the medial unicompartmental knee replacement.

PURPOSE: Younger patients with unicompartmental degenerative knee joint diseases present a therapeutic dilemma. The purpose of this study is to evaluate the long-term results of the Oxford phase III unicompartmental knee replacement through a minimally invasive approach in the young patient. METHODS: We have studied a total of 51 patients (59 interventions) who underwent the Oxford Phase III Unicompartmental Knee Replacement. A clinical, radiographical and functional evaluation was performed twelve years after intervention. RESULTS: According to the American Knee Society Score using Insall's criteria overall results of unicompartmental knee arthroplasty showed an excellent or good outcome for 53 knees (96.36%), fair for 1 (1.81%) and poor for 1 (1.81%) in the postoperative long term. The survival rate of the implants was close to 95% at follow-up. CONCLUSIONS: Twelve years follow-up results of UKA through a minimally invasive exposure in young patients demonstrate predictably good outcomes.

Treatment of Knee Osteoarthritis With Allogeneic Bone Marrow Mesenchymal Stem Cells: A Randomized Controlled Trial.

BACKGROUND: Osteoarthritis is the most prevalent joint disease and a common cause of joint pain, functional loss, and disability. Conventional treatments demonstrate only modest clinical benefits without lesion reversal. Autologous mesenchymal stromal cell (MSC) treatments have shown feasibility, safety, and strong indications for clinical efficacy. We performed a randomized, active control trial to assess the feasibility and safety of treating osteoarthritis with allogeneic MSCs, and we obtain information regarding the efficacy of this treatment. METHODS: We randomized 30 patients with chronic knee pain unresponsive to conservative treatments and showing radiological evidence of osteoarthritis into 2 groups of 15 patients. The test group was treated with allogeneic bone marrow MSCs by intra-articular injection of 40 × 10(6) cells. The control group received intra-articular hyaluronic acid (60 mg, single dose). Clinical outcomes were followed for 1 year and included evaluations of pain, disability, and quality of life. Articular cartilage quality was assessed by quantitative magnetic resonance imaging T2 mapping. RESULTS: Feasibility and safety were confirmed and indications of clinical efficacy were identified. The MSC-treated patients displayed significant improvement in algofunctional indices versus the active controls treated with hyaluronic acid. Quantification of cartilage quality by T2 relaxation measurements showed a significant decrease in poor cartilage areas, with cartilage quality improvements in MSC-treated patients. CONCLUSIONS: Allogeneic MSC therapy may be a valid alternative for the treatment of chronic knee osteoarthritis that is more logistically convenient than autologous MSC treatment. The intervention is simple, does not require surgery, provides pain relief, and significantly improves cartilage quality.

Radial tunnel syndrome: results of surgical decompression by a postero-lateral approach.

PURPOSE: Our purpose is to describe the results obtained in surgical treatment of a series of patients with symptoms of radial tunnel syndrome. METHODS: We performed a prospective study on 42 patients (43 limbs) operated for radial tunnel syndrome between 1996 and 2010, using a posterior-external approach. RESULTS: Using the Roles and Maudsley criteria, 21 patients had excellent results (48.8%), 16 good (37.2%) and six fair results (13.9%). Most patients were satisfied with the surgery, reporting symptom relief and improved functionality. CONCLUSIONS: Radial tunnel syndrome consists of intermittent compression of the posterior interosseous nerve in the forearm, with pain and functional disability of the forearm, without motor or sensory electromyogram alterations. Because it is often confused with enthesitis of the epicondyle muscle insertions (an entity often occurring simultaneously), differential diagnosis is necessary with treatment-resistant epicondylitis. The most effective treatment is surgical, releasing all possible nerve compression sites.

Rhizarthrosis fourth grade of eaton with hyperextension of the metacarpophalangeal joint.

INTRODUCTION: Restoration of thumb function with a painfree, stable, and mobile joint with preserved strength are the main goals of treatment of painful arthritis of the thumb. We present our clinical experience in surgical treatment of this disease, in its highest degree of affectation. PRESENTATION OF CASE: A 57-year-old woman presents with a 2-year history of worsening pain at the base of her right, dominant, trapezial-metacarpal (TM) joint. Her thumb metacarpophalangeal (MCP) joint hyperextends 30° with lateral pinch. Radiographs demonstrate Eaton stage IV degenerative changes of her TM joint and no arthritis of her thumb MCP joint. She was successfully treated with a modified Burton-Pellegrini arthroplasty and sesamoidesis to the metacarpal head. DISCUSSION: In cases of advanced rhizarthrosis conventional surgery does not serve to correct deformities of the metacarpophalangeal joint that may affect to the postsurgical outcomes. CONCLUSION: rhizarthrosis management must be carried out in a global way. When a surgical treatment is planned, all deformities must be taken into account.

Long-term results of the retrocapital metatarsal percutaneous osteotomy for hallux valgus.

PURPOSE: The current trend in hallux valgus surgery is directed toward percutaneous procedures. However, no evidence that any of these methods of treatment are superior to the others has been described, excepting studies in the long term. The aim of this study was to analyse a series of patients who had undergone a percutaneous distal retrocapital osteotomy of the first metatarsal, and had been followed up for ten years. METHODS: We carried out a clinical and radiological evaluation of 115 feet ten years after surgery. RESULTS: The AOFAS scale results in the tenth postoperative year remained significantly favourable compared to their corresponding values in the preoperative period, yielding an improvement of 42.2 points overall on average. In relation to radiological findings, the mean hallux angle was maintained below 20 °, with a mean intermetatarsal angle of 8.1 °. CONCLUSION: Percutaneous retrocapital metatarsal osteotomy for treatment of mild to moderate hallux valgus is effective in the long term, with the advantages of a minimally invasive procedure.

Long-term effects of preserving or splitting the carpal ligament in carpal tunnel operation.

Carpal tunnel syndrome is treated very successfully by surgical release of the flexor retinaculum. However, in some patients, all symptoms are not resolved. Weakness in grip strength and pain in the thenar and hypothenar areas corresponding to the end of the transverse ligament after its complete section have been described as common complications of classical neurolysis of the median nerve. This study presents here the long-term results of decompression operation of the median nerve at the wrist, conserving the transverse ligament, as well as its comparison with the classical open neurolysis with a complete section of the ligament. This is an analysis of a retrospective cohort of 114 patients, who were operated on for carpal tunnel syndrome. A clinical, electromyographic, and dynamometric evaluation of the patients studied was carried out in a comparative analysis of the surgical techniques used (flexor retinaculum lengthening according to the Simonetta technique and classical open neurolysis of the median nerve), in a period of 10 years after the operation. The ligamentoplasty technique, in the long-term, contributes to better results of manual force, with a smaller resolution of tingling sensations than the neurolysis with complete section of the transverse ligament. For those patients who do not present a severe clinical or electromyographic syndrome, and in addition require manual effort for their daily activities, the technique of ligamentoplasty, according to Simonetta, is a surgical option to be taken into account.

Oxford phase 3 unicondylar knee arthroplasty through a minimally invasive approach: long-term results.

PURPOSE: Surgical treatment options for medial compartment osteoarthritis of the knee include high tibial osteotomy, total knee arthroplasty or unicompartmental knee arthroplasty (UKA), depending on the patient's age, level of physical activity and the degree of deformity. METHODS: In this study, we evaluated the long-term results of patients who underwent the Oxford cemented meniscal-bearing unicondylar knee prosthesis through a minimally invasive approach including a clinical, functional and radiographic assessment. RESULTS: Favourable clinical and radiological outcomes were registered overall at ten years after surgery. Overall results of UKA according to the American Knee Society (AKS) using Insall's criteria showed an excellent or good outcome for 492 knees (96.28 %), fair for 11 (2.15 %) and poor for eight (1.57 %) in the post-operative long term. CONCLUSIONS: We believe that with appropriate surgical technique, patient selection, prosthetic design and specific training, surgeons should achieve good outcomes with the added advantages of a minimally invasive approach. High volume for this technique is important in our opinion.

[Neurolysis of the median nerve in the elderly: a long term evaluation]. / La neurólisis del nervio mediano en el paciente anciano: evaluación a largo plazo.

PURPOSE: Carpal tunnel release by opening the flexor retinaculum is considered a satisfactory treatment. However, several factors, like ageing, may influence postoperative results. We present the long term outcomes in elderly patients. METHODS: This is an historical prospective long term study of 52 patients who received surgical treatment of carpal tunnel syndrome when they were 65 or older. We have carried out a clinical-functional (with the Levine questionnaire), electromyographic and dynamometric valuation of the patients studied, up to ten years from the surgery. RESULTS: The results of Levine's questionnaire, revealed favourable data for a mean follow-up of 10.35 years, with a mean improvement in the clinical score of 1.93 points (95% confidence interval [CI]: 1.72-2.17) and in the functional score of 0.83 points (95% CI: 0.68-0.99). Similarly, the electromyographic values showed a significant improvement compared to preoperative ones (mean difference of sensory velocity of 8.43m/s, 95% CI: 8.17-11.63; mean difference of motor latency of 1.65ms, 95% CI: 1.24-2.25). The data on grip strength did not reach statistical significance. CONCLUSIONS: In elderly patients, complete section of the carpal transverse ligament, allows maintaining favourable differences in most of the parameters studied, ten years after surgery, making the surgical treatment a recommendable option.