A Comparative Analysis of Perioperative Complications in Octogenarians and Patients under 60 Years of Age after Primary Cemented Total Knee Arthroplasty.

Introduction: Knee arthroplasty is exposed to demographic changes as patients age. An analysis of risk factors for surgical treatment decisions in patients over 80 years old is crucial. This study compared perioperative complications between groups of patients undergoing primary knee arthroplasty, under 60 years old and over 80 years old.Materials and Methods: For this retrospective study, data from 400 patients with primary cemented bi- and unicondylar total knee endoprosthesis during inpatient stay from 2017 to 2018 were analyzed. Patients aged 61-79 years (257) were excluded. An analysis of the remaining 143 patients was performed. The incidence of surgery-related and systemic complications (eg, urinary tract infections, electrolyte imbalances, and cases of pneumonia), the blood supply and C-reactive protein (CRP) as well as hemoglobin progression were compared across both age groups. Furthermore, a correlation between prevalent diseases and systemic complications were investigated. Statistical analysis was performed using IBM SPSS (Armonk, US).Results: Data analyses showed a significant difference in the occurrence of systemic complications and blood transfusion between the age groups (P = 0.001, phi = 0.44; phi= 0.55, P = 0.001). Surgical complications did not differ significantly between the age groups. Age-typical pre-existing conditions, especially arterial hypertension (P = 0.003), showed a significant association with the occurrence of systemic complications. In addition, high postoperative CRP values in elderly patients revealed an association to systemic complications (P = 0.008).Discussion and Conclusion: The study shows that primary cemented knee arthroplasty is a safe procedure without an increased incidence of surgical complications, even in elderly patients. The increased incidence of internal complications in octogenarians, in turn, should receive more attention in the perioperative course. The interdisciplinary preoperative optimization of pre-existing conditions and drug therapy, as well as close interdisciplinary assessments of elderly patients, should be ensured.

Same-gender differences in perioperative complications and transfusion management for lower limb arthroplasty.

INTRODUCTION: Total hip (THA) and knee arthroplasty (TKA) are surgical interventions for patients with primary and posttraumatic osteoarthritis. The present clinical investigation compared gender differences in THA and TKA. METHODS: Data from 419 patients following primary THA and TKA were collected. The occurrence of systemic and surgery-related complications, the units of blood transfused, and the change in Hb were investigated. Hb was collected preoperatively and at 1, 2, 4 and 7 days postoperatively. Statistical analysis was performed using the software IBM SPSS 28. RESULTS: There was no significant difference in surgery-related and general complications in men between THA and TKA. A significant difference between THA and TKA in systemic complications in women was observed. No significant difference between THA and TKA in related to surgery-related complications was evidenced. In men, no difference in Hb progression was observed. In women, a significant Hb drop was evidenced (p = 0.03). The rate of blood transfusion units in women was significantly greater in TKA than in THA (p = 0.001). No statistically significant difference was observed in men in the rate of transfusion between THA and TKA. CONCLUSION: Perioperative care should be organized differently for women and men. Furthermore, a differentiation between the procedures for each sex could prevent the occurrence of perioperative complicated courses.

Analysis of gender differences with traditional posterior stabilized versus kinematic designs in total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty (TKA) is a good treatment for end-stage knee osteoarthritis (KOA). Approximately 60% of the patients are females, and 40% are males. This study analyzed pre- and postoperative angle differences in the range of motion (ROM), and the occurrence of complications with traditional posterior stabilization versus kinematic TKA in relation to gender. METHODS: Data from 434 patients with primary cemented total knee arthroplasty from 2018 to 2021 were collected. Alpha and beta angles were determined pre- and postsurgery. The ROM was collected pre- and postoperatively and during follow-up. Additionally, perioperative complications, revision rate, and blood transfusion management were investigated. RESULTS: The pre- and postoperative alpha-angle between men and women was significantly different, as was the level of alpha-angle correction between men and women (p = 0.001; p = 0.003). Same-gender differences in pre- to postoperative alpha-angles between traditional and kinematic TKA were shown (women (w): p = 0.001; men (m); p = 0.042). High postoperative alpha angles led to less ROM in traditional TKA for women (p = 0.008). No significant gender differences in ROM, perioperative complications, or revision surgery and transfusion rates were found. CONCLUSION: Despite high gender differences in pre- and postoperative angles, only female patients with traditional arthroplasty and high postoperative alpha angles showed less ROM in the follow-up. This leads to the assumption that gender-related pre- and postoperative angle differences, and the degree of angle correction, do not influence the ROM or perioperative occurrence of complications. Both designs present safe procedures for both genders with a wide spectrum of axis deformities.

Excellent midterm survival and functional outcomes of a fully hydroxyapatite-coated cementless stem: first results of a prospective multicenter study.

BACKGROUND: The Polarstem (Smith & Nephew, Baar, Switzerland) is a tapered straight stem, an implant with an excellent survival rate. Although the most recent annual report of the National Joint Registry in the United Kingdom also reports excellent survivorship for the cementless Polarstem, no prospective studies have been published focusing on both its efficacy and clinical performance. Therefore, the present study was designed to prospectively evaluate its functional and radiographic outcomes at midterm. METHODS: This prospective observational study conducted at 3 independent orthopaedic hospitals was designed to collect data in patients undergoing cementless primary total hip arthroplasty (THA). A total of 225 total hip arthroplasties (75 at each site) were performed. The predominant diagnosis was primary osteoarthritis. Anteroposterior and lateral radiographs were obtained at each follow-up (3 months, and 1, 3, and 5 years). Survivorship and the Harris Hip Score (HHS) and Western Ontario and McMaster Universities Index (WOMAC) were calculated. RESULTS: Subjects experienced statistically significant improvements from baseline in mean HHS (48.5 to 88.0, P < .01) and WOMAC scores (58.6 to 9.3, P < .01) at all intervals through 5 years. The stem survivorship was 99.6% at 5 years with stem revision due to any reason. There were no observed cases of mechanical failure of the stem or signs of radiographic loosening. CONCLUSIONS: A revision rate of the femoral stem for any reason of 0.4%, as well as good clinical results based on HHS and WOMAC scores, was noted at 5-year follow-up. Therefore, safety and efficacy of the cementless Polarstem at midterm follow-up is confirmed.

Transfusions increase complications and infections after hip and knee arthroplasty: An analysis of 2760 cases.

BACKGROUND: Knee and hip replacement surgery are still the mainstay therapy for osteoarthritis. In spite of the improvement of techniques and implants, anemia is a relatively common complication, with transfusion rates of up to 23% in some centers. OBJECTIVE: The purpose of the study was to determine a correlation of transfusions to complications including infection since this topic is still being debated or even disputed in the literature. METHODS: This is a level III, single center retrospective observational cohort study of 2760 unilateral primary knee and hip replacements. Preoperative assessment, the number of transfusions and the occurrence of complications were collected and the correlations were analyzed using analysis of variance and logistic regression. RESULTS: Fifteen percent of all patients developed at least one complication. Transfusion rate was 9%. Risk factors for receiving a transfusion were female gender, hip replacement, American Society of Anesthesiologists' Score (ASA) > III, history of myocardial infarction, chronic cardiac disease, diabetes mellitus, chronic kidney disease, and length of surgery. The risk factors for developing a complication were: ASA score, presence of chronic renal insufficiency, and transfusion during hospital stay. Transfusion increases the risk of complications and infection rate. Complication rate with transfusion was 34.7% and without transfusion 13.2%. Infection rate without transfusion was 0.4% and with transfusion 2.82%. CONCLUSIONS: The complication rate is higher in transfused patients. The number of complications rises linearly with the number of transfusions. Infection rate is also higher after a transfusion. Efforts should be made to reduce the transfusion rate.

Bleeding in primary shoulder arthroplasty.

INTRODUCTION: The aim of this investigation was to analyse "total blood loss" (TBL), "blood transfusion rate" (BT) and the "amount of transfused blood units" (BU) between the different primary shoulder arthroplasty (SA) types: reverse, anatomical and stemless. Only primary SA was included. Further goal was to identify risk factors for TBL, amount of BU and BT rate. METHODS: A retrospective charts analysis of patients who received primary SA for degenerative shoulder pathology in our institution between 2004 and 2016 was performed. The demographic data, co-morbidities, haemoglobin and hematocrit level, BT rate, amount of transfused BU etc. were collected. TBL was estimated. Linear regression, log-linear poisson regression and logistic regression were used to compare the outcomes TBL, amount of transfused BU and BT rate, respectively, between different prosthesis types. RESULTS: Of 278 patients included in this study 209 received reverse, 57 anatomical and 12 stemless SA. Mean TBL was 392.7 ml in reverse, 394.6 ml in anatomical and 298.3 ml in stemless SA. The BT rate and mean amount of BU were, respectively, 14.4% and 0.32 in reverse and 8.77% and 0.23 in anatomical SA. None of the patients with stemless arthroplasty received BT. Significant risk factors for elevated TBL are operation time, higher BMI, male sex. Significant risk parameters for BT and higher amount of transfused BU are low BMI, cemented arthroplasty, coronary heart disease, ASA score > 2 and previous therapy with vitamin K antagonists. CONCLUSION: Although there were little differences between the blood transfusion rates in reverse vs. anatomical arthroplasty, there was no difference in total blood loss between these different prosthesis types. None of the patients with stemless arthroplasty received blood transfusion. There are various risk factors affecting total blood loss and blood transfusion rate. However, risk parameters influencing blood transfusion may be different to them affecting total blood loss.

Clubfoot associated with preaxial polydactyly.

We report on three children with bilateral, congenital clubfoot. Four of the six clubfeet were associated with preaxial polydactyly. Five of the six clubfeet were treated without extensive surgery. A plantigrade foot was achieved, even in the three clubfeet with polydactyly, using serial casting and percutaneous Achilles tenotomy. Casting was adapted according to the existing polydactyly. One case with tibial hemimelia and a complex clubfoot deformity with preaxial tarsal polydactyly required more comprehensive surgery. A foot with good weight-bearing function was also achieved in this case following resection of the accessory medial ray, including resection of the accessory tarsal bones and posterior release. Remaining limitations in mobility were ascribed to hindfoot pathologies.

Penetration of topical diclofenac sodium 4 % spray gel into the synovial tissue and synovial fluid of the knee: a randomised clinical trial.

PURPOSE: The present study was designed to evaluate the penetration of diclofenac sodium 4 % spray gel in synovial tissue, synovial fluid and blood plasma after topical application in subjects with joint effusions and planned total knee arthroplasty (TKA) due to osteoarthritis. METHODS: A total of 39 patients were randomised to two- or three-times daily application of diclofenac sodium 4 % spray gel to knees requiring surgery over a treatment period of 3 days. Within 8 h after the last application, TKA was conducted, and the diclofenac concentrations in synovial tissue, synovial fluid and blood plasma were measured by liquid chromatography. RESULTS: The median diclofenac concentration was approximately 10-20-fold higher in synovial tissue (36.2 and 42.8 ng/g) than in synovial fluid (2.6 and 2.8 ng/mL) or plasma (3.9 and 4.1 ng/mL) in both treatment groups. Dose proportionality for any compartment or treatment groups could not be detected. Treatment-related adverse events were noted in two cases and limited to skin reactions. CONCLUSION: Diclofenac sodium 4 % spray gel was found to penetrate the skin locally in substantial amounts and thus reach the desired target tissue. Concentrations were not dose-dependent, and application was well tolerated by 97.4 % of patients. Topical application of diclofenac should be considered a valuable alternative to systemic NSAID therapy in the initial treatment of osteoarthritis.

A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial.

BACKGROUND: Lumbar facet joint degeneration is a source of chronic low back pain, with an incidence of 15% to 45% among patients with low back pain. Various therapeutic techniques in the treatment of facet-related pain have been described in the literature, including intraarticular lumbar facet joint steroid injections and radiofrequency denervation. In this study, we compared the effectiveness of intraarticular facet joint steroid injections and radiofrequency denervation. METHODS: Our randomized, double-blind, controlled study included patients who received intraarticular steroid infiltrations in the lumbar facet joints (L3/L4-L5/S1) and patients who underwent radiofrequency denervation of L3/L4-L5/S1 segments. The inclusion criteria were based first on magnetic resonance imaging findings showing hypertrophy of the facet joints L3/L4-L5/S1 and a positive response to an intraarticular test infiltration of the facet joints L3/L4-L5/S1 with local anesthetics. The primary end point was the Roland-Morris Questionnaire. Secondary end points were the visual analog scale and the Oswestry Disability Index. All outcome assessments were performed at baseline and at 6 months. RESULTS: Fifty-six patients were randomized; 24 of 29 patients in the steroid injection group and 26 of 27 patients in the denervation group completed the 6-month follow-up. Pain relief and functional improvement were observed in both groups. There were no significant differences between the 2 groups for the primary end point (95% confidence interval [CI], -3 to 4) and for both secondary end points (95% CI for visual analog scale, -2 to 1; 95% CI for Oswestry Disability Index, -18 to 0). CONCLUSIONS: Intraarticular steroid infiltration or radiofrequency denervation appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results in terms of pain relief and function improvement, but improvements were similar in both groups.

Primary pyogenic spondylitis following kyphoplasty: a case report.

INTRODUCTION: Only ten cases of primary pyogenic spondylitis following vertebroplasty have been reported in the literature. To the best of our knowledge, we present the first reported case of primary pyogenic spondylitis and spondylodiscitis caused by kyphoplasty. CASE PRESENTATION: A 72-year old Caucasian man with an osteoporotic compression fracture of the first lumbar vertebra after kyphoplasty developed sensory incomplete paraplegia below the first lumbar vertebra. This was caused by myelon compression following pyogenic spondylitis with a psoas abscess. Computed tomography guided aspiration of the abscess cavity yielded group C Streptococcus. The psoas abscess was percutaneously drained and laminectomy and posterior instrumentation with an internal fixator from the eleventh thoracic vertebra to the fourth lumbar vertebra was performed. In a second operation, corpectomy of the first lumbar vertebra with cement removal and fusion from the twelfth thoracic vertebra to the second lumbar vertebra with a titanium cage was performed. Six weeks postoperatively, the patient was pain free with no neurologic deficits or signs of infection. CONCLUSION: Pyogenic spondylitis is an extremely rare complication after kyphoplasty. When these patients develop recurrent back pain postoperatively, the diagnosis of pyogenic spondylitis must be considered.

Reproducibility of different screening classifications in ultrasonography of the newborn hip.

BACKGROUND: Ultrasonography of the hip has gained wide acceptance as a primary method for diagnosis, screening and treatment monitoring of developmental hip dysplasia in infants. The aim of the study was to examine the degree of concordance of two objective classifications of hip morphology and subjective parameters by three investigators with different levels of experience. METHODS: In 207 consecutive newborns (101 boys; 106 girls) the following parameters were assessed: bony roof angle (α-angle) and cartilage roof angle (ß-angle) according to Graf's basic standard method, "femoral head coverage" (FHC) as described by Terjesen, shape of the bony roof and position of the cartilaginous roof. Both hips were measured twice by each investigator with a 7.5 MHz linear transducer (SONOLINE G60S® ultrasound system, SIEMENS, Erlangen, Germany). RESULTS: Mean kappa-coefficients for the subjective parameters shape of the bony roof (0.97) and position of the cartilaginous roof (1.0) demonstrated high intra-observer reproducibility. Best results were achieved for α-angle, followed by ß-angle and finally FHC. With respect to limits of agreement, inter-observer reproducibility was calculated less precisely. CONCLUSIONS: Higher measurement differences were evaluated more in objective scorings. Those variations were observed by every investigator irrespective of level of experience.

Expression of matrix metalloproteinases 1, 3, and 9 in degenerated long head biceps tendon in the presence of rotator cuff tears: an immunohistological study.

BACKGROUND: Long head biceps (LHB) degeneration, in combination with rotator cuff tears, can be a source of chronic shoulder pain. LHB tenotomy reduces pain and improves joint function although the pathophysiological context is not well understood. Tendon integrity depends on the extracellular matrix (ECM), which is regulated by matrix metalloproteinases (MMP). It is unclear which of these enzymes contribute to LHB but we chose to study MMP 1, 3, and 9 and hypothesized that one or more of them may be altered in LHB, whether diagnosed preoperatively or intraoperatively. We compared expression of these MMPs in both LHB and healthy tendon samples. METHODS: LHB samples of 116 patients with degenerative rotator cuff tears were harvested during arthroscopic tenotomy. Patients were assigned to 4 groups (partial thickness tear, full thickness tear, cuff arthropathy, or control) based upon intraoperative findings. Partial and full thickness tears were graded according to Ellman and Bateman's classifications, respectively. MMP expression was determined by immunohistochemistry. RESULTS: MMP 1 and 9 expression was significantly higher in the presence of rotator cuff tears than in controls whereas MMP 3 expression was significantly decreased. MMP 1 and 9 expression was significantly higher in articular-sided than bursal-sided partial thickness tears. No significant association was found between MMP 1 and 9 expression and full thickness tears, and the extent of the cuff tear by Bateman's classification. CONCLUSION: Increased MMP 1 and 9 expression, and decreased MMP 3 expression are found in LHB degeneration. There is a significant association between the size and location of a rotator cuff tear and MMP expression.

[Current status of revision total hip arthroplasty in Germany]. / Aktueller Stand der Hüftgelenksrevisionsendoprothetik in Deutschland.

BACKGROUND: Revision total hip arthroplasty (THA) has gained importance over the past few years. However, in the literature, there are many recommendations for both surgical intervention and postoperative rehabilitation. The purpose of this nationwide German survey was to identify the actual treatment of revision THA and to compare the findings of this study with guidelines in the current literature. MATERIALS AND METHODS: All orthopedic and traumatological hospitals listed in the "List of German Hospitals 2006" were invited via e-mail to take part in an anonymous survey. The questionnaire contained general questions such as hospital and department size and particular questions regarding the treatment of revision THA patients of each interviewed department. RESULTS: A total of 578 (44.7%) of all invited hospitals took part in this study. Out of these, 463 (78%) hospitals performed revision THA. Mostly, cementless revision stems and cementless press-fit cups were used as revision implants. Differences in proceeding revision THA were found in infection THA and in particular if the infection appeared early (after 6 weeks following implantation). In a high number of cases the patient was sent to inpatient rehabilitation in the early postoperative course with nursing aspects being more important for the elderly and immobile patient at this postoperative point. DISCUSSION AND CONCLUSION: In many aspects, revision THA is not performed consistently in Germany. In particular, in the postoperative course, a standardized therapeutic pathway was not always identified.