Assessing the impact of distal femoral morphology using Citak's ratio: an independent risk factor for aseptic loosening in rotating hinge knee prosthesis.

BACKGROUND: Aseptic loosening (AL) is a frequent complication after rotating hinge knee (RHK) prosthesis. Citak's ratio has recently been developed to describe and classify distal femoral morphology into 3 groups (A, B, C). It consists in a ratio between the diameters of the femoral canal at 20 cm from the knee joint line and at 2 cm from the adductor tubercle. The objective of the study was to identify whether the femoral distal anatomical shape described with this ratio represents a risk factor for AL in RHK prosthesis. METHODS: Retrospective study of patients who had undergone primary or revision RHK prosthesis, with a follow-up of minimum 4 years. Citak's ratio was calculated, and patients were classified depending on its value. Univariate and bivariate statistical analysis was performed to identify AL risk factors. Receiver Operating Characteristics (ROC) analyses were conducted to examine diagnostic quality of the parameters of interest. RESULTS: Thirty-three patients were included. Most of them females (ratio 26:7), with a mean age of 78.2 (SD 6.9). Three patients presented AL (rate of 9%), all of them classified into group C (100%). Citak's ratio was significantly related to the AL rate (p < 0.001), and so was the femoral canal diameter at 20 cm from the knee joint (p 0.010). The ROC curve analysis yielded an Area Under the Curve (AUC) of 0.922 (CI 95% 0.819-1.000) for the Citak´s ratio. CONCLUSION: The inner femoral diameter at 20 cm proximal to the knee joint line and Citak's ratio help indentify patients at risk of AL after RHK prosthesis, and thus a better planning of the surgery.

Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis.

BACKGROUND: The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. STUDY METHODS: A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. RESULTS: The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. DISCUSSION: Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Autonomy with responsibility ¿Is informed consent just a signature on a paper? Evaluation in patients who underwent spine's surgery.

PURPOSE: To evaluate the information that patients undergoing spine surgery truly receive and assimilate when they sign their informed consent documents. METHODS: This was a retrospective study on patients who underwent spine arthrodesis or spine discectomy. Patients were given a full explanation of the surgical technique to be employed and its potential risks before they were included on the surgical waiting list. Before surgery, they were asked to sign an informed consent form. The studied variables included whether patients read the informed consent form, whether they recalled the surgical technique used or the spinal segment operated, whether they were aware of the surgical risks involved, and if they had looked for information about their procedure elsewhere. Answers were analyzed by age and educational level. RESULTS: Of a total of 458 total patients, only 51.9% answered all the questions. Sixty-three percent of patients said they had read the informed consent document before surgery. Although 91.6% of patients were aware of the spine segment operated, only 73.5% remembered the surgical technique employed. A total of 63.9% of patients could recall the vertebral levels operated. 39.1% were not aware of the surgical risks involved, and only 16.0% of patients admitted having looked for additional information. A statistically significant correlation was found between the search for additional information and young age (p < 0.001) on the one hand, and high educational level on the other (p = 0.023). CONCLUSION: Even though obtaining informed consent is an important procedure before spinal surgery, almost 40% of the patients in this study underwent surgery without reading the informed consent document or being aware of the risks posed by the procedure.

Hypoalbuminemia increases the risk of failure following one-stage septic revision for periprosthetic joint infection.

PURPOSE: Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI. METHODS: Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI. RESULTS: No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67. CONCLUSION: TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.

High reoperation and mortality rate after distal femoral replacement for periprosthetic knee fracture in the elderly.

PURPOSE: To analyze the outcomes of elderly patients with periprosthetic fractures around the knee operated on with a distal femur replacement (DFR). METHODS: We performed a retrospective case series study of eleven elderly patients who underwent DFR due to a periprosthetic fracture. Mean follow-up was 30.1 months (SD 28.1). Demographic, clinical and radiological data were reviewed. A descriptive analysis and a study of survival were conducted. Then, a comparative analysis between the patients who needed reoperation and did not need reoperation, and the patients who died and the patients who were alive during the follow-up was performed. RESULTS: Mean age was 77.1 years (SD 13.9). Reoperation rate was 36%, being infection the most common complication (27%). The risk of reoperation increased with a longer time between fracture and surgery. The 36.4% of patients died during the follow-up. Older age, need of blood transfusion and need of early reoperation were related to a higher risk of mortality. CONCLUSION: DFR could be a valuable option for knee periprosthetic fractures in elderly patients. However, surgeons should be aware of the high reoperation and mortality rate.

Pectoralis-major-pedicled bone window for revision of a shoulder arthroplasty.

PURPOSE: The aim of this study is to review our experience with the pectoralis-major-pedicled bone window for the revision of shoulder arthroplasty. METHODS: This study used the retrospective case series of six patients who underwent a pectoralis-major-pedicled bone window for revision of shoulder arthroplasty, with a minimum follow-up of 2 years. Demographic, clinical, and radiological data were analyzed. RESULTS: The mean age of the included patients was 72.6 years old (standard deviation (SD) 4.7), and 83.3% were women (5/1). The mean follow-up was 36.6 months (range 25-48 months). Five patients had a shoulder hemiarthroplasty and one patient a reverse shoulder arthroplasty. The indications for revision were pain in five patients and recurrent dislocation in one patient. No intraoperative complications were found. One patient developed a wound infection that required debridement and a two-stage revision. Despite complications, 2 years after surgery, the range of motions and functional scores were improved from preoperative levels. The difference between preoperative and postoperative VAS pain scores was 7.1 points (p < 0.001). The difference between preoperative and postoperative CSS and ASES questionnaires were 32 and 31.6 points, respectively (p < 0.001). At the final follow-up, all radiographs showed bone union of the osteotomy, good fixation of all components, without evidence of prosthetic loosening or migration. CONCLUSIONS: Revision of a shoulder arthroplasty using a pectoralis-major-pedicled bone window can be an effective treatment that can yield pain relief; however, improvements in motion and function were difficult to achieve.

Outcomes of cervical arthroplasty versus anterior cervical arthrodesis: a systematic review and meta-analysis of randomized clinical trials with a minimum follow-up of 7-year.

PURPOSE: Compare the outcomes of randomized clinical trials of cervical disc arthroplasty (CDA) versus anterior cervical discectomy with fusion (ACDF), with a minimum follow-up of 7 years. METHODS: Nine randomized clinical trials were selected. The clinical, radiological, and surgical outcomes were analyzed, including functional and pain scores, range of motion, adjacent segment degeneration, adverse events, and need for reoperation. RESULTS: 2664 patients were included in the study. Pooled results indicated that the CDA group had a significantly higher overall success rate (p < 0.001), a higher improvement in the neck disability index (NDI) (p = 0.002), less VAS arm pain (p = 0.01), and better health questionnaire SF-36 physical component (p = 0.01) than ACDF group. Likewise, the pooled results indicated a significantly higher motion rate (p < 0.001), less adjacent syndrome (p < 0.05), and a lower percentage of reoperation (p < 0.001) in the CDA group. There were no significant differences between the CDA and ACDF groups in the neck pain scale (p = 0.11), the health questionnaire SF-36 mental component (p = 0.10), and in adverse events (p = 0.42). CONCLUSION: In long-term follow-up, CDA showed a better overall success rate, better improvement in NDI, less VAS arm pain, better health questionnaire SF-36 physical component, a higher motion rate, less adjacent syndrome, and less reoperation rate than ACDF. No significant differences were found in the neck pain scale, SF-36 mental component, and in adverse events.

Is routine blood typing and screening necessary before primary total hip or knee arthroplasty in the 21st century?

BACKGROUND: Blood loss warranting transfusion is a relatively rare complication of major-joint arthroplasty procedures like total knee arthroplasty (TKA) and total hip arthroplasty (THA). Despite this rarity, pre-transfusion testing (blood typing, screening, and cross-matching) has become routine. We sought to determine if such routine testing is necessary for patients who undergo a primary TKA or THA by (1) measuring the current rate of intraoperative transfusions in primary TKA and THA patients, (2) identifying risk factors for transfusions, and (3) calculating the costs of such blood typing and screening. STUDY METHODS: We retrospectively examined the records of 992 patients who underwent primary TKA, THA, or unicompartmental knee arthroplasty (UKA) to identify patients requiring intra-operative or in-hospital postoperative transfusions. Demographic and baseline clinical and laboratory data also were collected and analyzed to identify predictors of transfusion. Cost analysis was performed. RESULTS: The rate of intraoperative transfusion was 1.7% (17/992 patients), with rates of 2.1%, 1.6%, and 0% for TKA, THA, and UKA respectively. The in-hospital transfusion rate was 10.3%, with corresponding postoperative transfusion rates of 9.1%, 12.9%, and 2%. The only baseline variable significantly linked to transfusions on multivariable analysis was preoperative hemoglobin level, with preoperative Hgb <12 g/dl predictive of transfusions in both TKA (p = .02) and THA (p = .024) patients. DISCUSSION: Our study suggests that pre-transfusion testing for all patients undergoing primary UKA, TKA or THA is unnecessary. We recommend reserving routine pre-transfusion testing for patients with preoperative hemoglobin levels below 12 g/dl.

Is routine blood typing and screening necessary for degenerative cervical spine surgery patients in specialty surgical hospitals?

BACKGROUND: Blood loss warranting transfusion is a relatively rare requirement for degenerative cervical spine surgery. Despite this rarity, pretransfusion testing (blood typing, screening, and cross-matching) has become routine in most parts of the world. We sought to determine if such routine testing is necessary for patients who undergo degenerative cervical spine surgery patients in specialty surgical hospitals by (1) measuring the current rate of intraoperative transfusions in degenerative cervical spine surgery and (2) identifying risk factors for transfusions. STUDY METHODS: Retrospective review was performed on patients who underwent degenerative cervical spine surgery in two institutions. Demographic and baseline clinical and laboratory data were collected and analyzed to identify predictors of transfusion. Bivariate and multivariate logistic regression analysis was performed to identify perioperative transfusion risk factors. RESULTS: Overall transfusion rate was 1.9% (7/372), with no emergent transfusions. Decreases between preoperative and postoperative hemoglobin and hematocrit were 1.4 (SD 1.1) g/dL and 7.2 (SD 4.1) %, respectively. Multivariate logistic regression identified preoperative Hgb lower than 12 gr/dl (OR 27.62; 95% CI 4.31-176.96; p < 0.001) as significant independent transfusion risk factor. The receiver operating characteristic (ROC) curve for the model showed a very good discriminatory power with an area under the curve of 0.91. DISCUSSION: Our study suggests that pretransfusion testing for all patients undergoing degenerative cervical spine surgery is unnecessary. We recommend that only patients with preoperative Hgb lower than 12 gr/dl would routinely need pretransfusion testing.

A meta-analysis of bone morphogenetic protein-2 versus iliac crest bone graft for the posterolateral fusion of the lumbar spine.

The impact of autologous iliac crest bone graft versus BMP-2 to improve fusion rates for posterolateral fusion (PLF) of the lumbar spine remains unanswered. Single-institution-centered data dominate the literature, providing results that may be contradictory or inconclusive. The aim of this paper is to analyze data pooled from multiple well-controlled studies that examined both ICBG and BMP-2 for use in PLF. This meta-analysis also provides details of success in different subsets of patients with variable risk factors for delayed and non-unions. Six high-quality randomized clinical trials were selected. Efficacy, morbidity, quality of life, and safety were compared between the BMP-2 group and the ICBG group. A total of 908 patients were included in the study. At 24 months, 94% of patients achieved fusion in the BMP-2 group and 83% in the ICBG group. At 6 and 12 months, the fusion was also greater in the BMP-2 group (86% vs. 60% and 88% vs. 80%, respectively). Surgical time, intraoperative blood loss, and hospitalization days also showed significant differences in favor of the experimental group (p < 0.01). There were no differences between two groups in the Oswestry Disability Index, 36-Item Short Form Health Survey and Back Pain Score, whereas a greater number of additional surgical procedures were performed in the ICBG group (p = 0.001). In conclusion, the use of BMP-2 in PLF reduced the surgical morbidity and had more beneficial effects on the fusion rate. The quality of life based on clinical scores was the same in both groups.

Patient outcomes after humeral fracture surgery during the COVID-19 outbreak in Spain.

BACKGROUND: The global spread of the 2019 novel coronavirus (COVID-19) has profoundly affected the way we conduct our health care practices. The goal of this paper is to report the outcomes of 11 patients who underwent humeral fracture surgery in the first few weeks of the COVID-19 outbreak in Spain. METHODS: This was a retrospective case series of 11 patients who underwent humeral fracture surgery during the first weeks of the COVID-19 outbreak in Spain, between March 10 and April 25, 2020. The clinical outcomes of these operative patients were monitored up to May 12, 2020, the final date of follow-up, a minimum of 15 days after all patients were discharged from the hospital. COVID-19 infection, mortality, demographic, clinical, and laboratory data were analyzed. RESULTS: Thirty-six humeral fractures were recorded between March 10 and April 25, 2020. During this period, humeral fracture fixation was the third most common surgery for fracture in our institution after hip fracture and ankle fracture surgery. Eleven patients underwent surgery (30.5%), of whom 7 were women (63.3%). The mean age was 64.8 years (standard deviation, 13.5). Nine operated cases had a proximal humerus fracture and 2 had a humeral shaft fracture. One of the 11 patients was positive for SARS-CoV-2 on the basis of the quantitative reverse transcription polymerase chain reaction of throat swab samples. The overall median surgical time was 101.2 minutes (standard deviation, 28.4). The overall median hospital length stay for the patient discharged was 2.2 days (range, 1-4 days). No COVID-19 nosocomial intrahospital infection occurred, and no patient reported COVID-19 infection during the 15 days after hospital discharge. No intrahospital mortality was recorded. Furthermore, no COVID-19 infection was reported in the shoulder surgeons who performed the surgeries. CONCLUSIONS: Although humeral fractures were not the most frequent fractures during this outbreak, some required surgery. With good preoperative management that included reverse transcription polymerase chain reaction for COVID-19 and chest radiographs, protective measurements for the surgical team, and rapid discharge of the patients, we were able to operate on 11 humeral fractures with no COVID-19 nosocomial intrahospital infection in the patients or in the shoulder surgeons who performed the surgeries.

Nosocomial infection with SARS-CoV-2 and main outcomes after surgery within an orthopaedic surgery department in a tertiary trauma centre in Spain.

AIMS: The purpose of the present study is to analyse clinical data of a series of cases who developed nosocomial infection with SARS-CoV-2 in an orthopaedic and traumatology department. PATIENTS AND METHODS: In this non-interventional retrospective study, carried out at a tertiary hospital within the Spanish National Health System, all adult patients who were admitted in the Orthopaedic Surgery and Traumatology Department between March 9th and May 4th, 2020, were included. Clinical, biological and radiological data, as well as mortality rates, were collected from hospital medical records. RESULTS: A total of 293 periods of hospitalization were analysed in 288 patients. Mean age was 66.1 years old and 57.3% were females. Nineteen patients (6.48%) met the inclusion criteria to be categorized as a nosocomial infection with SARS-CoV-2. In a comparison between patients with and without nosocomial infection, age, mortality and hospital length of stay were statistically significant (p < 0.05). The median time from admission to diagnosis of SARS-CoV-2 infection in our cohort was 16 days (6-86 days). No statistically significant differences were found in sex, living situation, reason of admission or period of admission (even if we observed that most of the nosocomial infections (78.9%) occurred in March). CONCLUSION: We have found a 6.48% of nosocomial infection with SARS-CoV-2, but with an important reduction of it after undergoing preventing protocols that included screening RT-PCR test for COVID-19. Age and hospital length stay were statistically significant risk factors for nosocomial infection with SARS-CoV-2. For the progressive restoration of the surgical activity, we recommend to correctly select the patients in elective surgery and to encourage fast-track programs and early discharge of patients with fractures.

Shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in the elderly.

PURPOSE: The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up. MATERIAL AND METHODS: Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated. RESULTS: All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results. CONCLUSIONS: Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.

Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic, biomechanical and clinical outcomes.

PURPOSE: The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture. MATERIALS AND METHODS: It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts' anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated. RESULTS: The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes. CONCLUSIONS: Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

Surgeon's Experience and Accuracy of Preoperative Digital Templating in Primary Total Hip Arthroplasty.

Purpose: Preoperative planning has become essential in performance of total hip arthroplasty (THA). However, data regarding the effect of the planner's experience on the accuracy of digital preoperative planning is limited. The objective of this study was to assess the accuracy of digital templating in THA based on the surgeon's experience. Materials and Methods: A retrospective study was conducted. An analysis of 98 anteroposterior pelvic radiographs, which were individually templated by four surgeons (two hip surgeons and two orthopaedic residents) using TraumaCad® digital planning, was performed. A comparison of preoperatively planned sizes with implanted sizes was performed to evaluate the accuracy of predicting component size. The results of preoperative planning performed by hip surgeons and orthopaedic residents were compared for testing of the planner's experience. Results: Femoral stem was precisely predicted in 32.4% of cases, acetabular component in 40.3%, and femoral offset in 76.7%. Prediction of cup size showed greater accuracy than femoral size among all observers. No differences in any variable were observed among the four groups (acetabular cup P=0.07, femoral stem P=0.82, femoral offset P=0.06). All measurements showed good reliability (intraclass correlation coefficient [ICC] acetabular cup: 0.76, ICC femoral stem: 0.79). Conclusion: The results of this study might suggest that even though a surgeon's experience supports improved precision during the planning stage, it should not be restricted only to surgeons with a high level of experience. We consider preoperative planning an essential part of the surgery, which should be included in training for orthopaedics residents.