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BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.
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Artroplastia de Reemplazo de Rodilla , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Vendajes , Técnica Delphi , Reoperación , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiología , SuturasRESUMEN
BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.
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Artroplastia de Reemplazo de Cadera , Técnica Delphi , Humanos , Consenso , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiología , Cicatrización de Heridas , Técnicas de Cierre de Heridas , Europa (Continente) , Canadá , Suturas , Estados UnidosRESUMEN
BACKGROUND: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success. METHODS: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices. RESULTS: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care. CONCLUSIONS: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.
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Connexin 43 (Cx43) is crucial for the development and homeostasis of the musculoskeletal system, where it plays multifaceted roles, including intercellular communication, transcriptional regulation and influencing osteogenesis and chondrogenesis. Here, we investigated Cx43 modulation mediated by inflammatory stimuli involved in osteoarthritis, i.e., 10 ng/mL Tumor Necrosis Factor alpha (TNFα) and/or 1 ng/mL Interleukin-1 beta (IL-1ß), in primary chondrocytes (CH) and osteoblasts (OB). Additionally, we explored the impact of synovial fluids from osteoarthritis patients in CH and cartilage explants, providing a more physio-pathological context. The effect of TNFα on Cx43 expression in cartilage explants was also assessed. TNFα downregulated Cx43 levels both in CH and OB (-73% and -32%, respectively), while IL-1ß showed inconclusive effects. The reduction in Cx43 levels was associated with a significant downregulation of the coding gene GJA1 expression in OB only (-65%). The engagement of proteasome in TNFα-induced effects, already known in CH, was also observed in OB. TNFα treatment significantly decreased Cx43 expression also in cartilage explants. Of note, Cx43 expression was halved by synovial fluid in both CH and cartilage explants. This study unveils the regulation of Cx43 in diverse musculoskeletal cell types under various stimuli and in different contexts, providing insights into its modulation in inflammatory joint disorders.
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Condrocitos , Conexina 43 , Interleucina-1beta , Osteoartritis , Osteoblastos , Factor de Necrosis Tumoral alfa , Humanos , Conexina 43/metabolismo , Conexina 43/genética , Condrocitos/metabolismo , Osteoblastos/metabolismo , Factor de Necrosis Tumoral alfa/metabolismo , Factor de Necrosis Tumoral alfa/farmacología , Interleucina-1beta/metabolismo , Interleucina-1beta/farmacología , Osteoartritis/metabolismo , Osteoartritis/patología , Osteoartritis/genética , Líquido Sinovial/metabolismo , Cartílago Articular/metabolismo , Cartílago Articular/patología , Células Cultivadas , Anciano , Persona de Mediana Edad , Inflamación/metabolismo , Inflamación/genética , Inflamación/patología , Cartílago/metabolismo , Cartílago/patología , Artropatías/metabolismo , Artropatías/patología , Artropatías/genéticaRESUMEN
Background: Asbestos is a foremost occupational carcinogen globally. Despite the prohibition under Law 257/1992, Italy persists as one of the European nations most burdened by asbestos-related diseases (ARDs). This research assessed ARD cases in asbestos-exposed workers from the Province of Palermo, Italy, spanning 2010-2021. Methods: Data acquisition utilized the epidemiological dataset from the 'Service of Prevention and Safety on Work Environment' under the Prevention Department of Palermo's Local Health Authority (LHA). Results: Between 2010 and 2021, we identified 245 ARD instances, comprising 163 Asbestosis/Pleural plaques, 41 Lung Cancers, 38 Mesotheliomas, and 3 unspecified cases. Multivariate analysis indicated a notable decline in temporal exposure for mesothelioma (HR=0.933; 95% CI=0.902-0.965) and lung cancer (HR=0.93; 95% CI=0.90-0.978) relative to pleural plaques/asbestosis. Tobacco use displayed a pronounced correlation with lung cancer (smoker HR=64.520 95% CI=13,075-318.390; former smoker HR=20.917 95% CI=4,913-89.048). A significant link was observed between mesothelioma and pleural plaques/asbestosis in those employed in shipbuilding and repair (HR=0.371 95% CI=0.155-0.892). Conclusions: ARDs persist in clinical observations, even following the 1992 cessation of asbestos-related activities, emphasizing an enduring public health challenge. Enhancing prevention strategies is paramount, focusing on amplifying anamnestic and occupational data collection, thereby facilitating superior early diagnosis strategies for these maladies in the occupationally exposed cohort.
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Amianto , Asbestosis , Neoplasias Pulmonares , Enfermedades Profesionales , Exposición Profesional , Humanos , Italia/epidemiología , Exposición Profesional/efectos adversos , Asbestosis/epidemiología , Asbestosis/etiología , Amianto/efectos adversos , Masculino , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/etiología , Persona de Mediana Edad , Femenino , Anciano , Enfermedades Profesionales/epidemiología , Enfermedades Profesionales/etiología , Mesotelioma/epidemiología , Mesotelioma/etiología , Adulto , Factores de Tiempo , Neoplasias Pleurales/epidemiología , Neoplasias Pleurales/etiología , Fumar/epidemiología , Fumar/efectos adversosRESUMEN
BACKGROUND: Acetabular cup positioning in total hip arthroplasty (THA) is closely related to outcomes. The literature has suggested cup parameters defined by the Lewinnek safe zone; however, the validity of such measures is in question. Several studies have raised concerns about the benefits of using the Lewinnek safe zone as a predictor of success. In this study we elected to use prospective surgeon targets as the basis for comparison to see how successful surgeons are positioning their cup using standard instruments and techniques. METHODS: A prospective, global, multicenter study was conducted. Cup positioning success was defined as a composite endpoint. Both cup inclination and version needed to be within 10° of the surgeon target to be considered a success. Radiographic analysis was conducted by a third-party reviewer. RESULTS: In 170 subjects, inclination, target versus actual, was 44.8° [standard deviation (SD 0.9°)] and 43.1° (SD 7.6°), respectively (p = 0.0029). Inclination was considered successful in 84.1% of cases. Mean version, target versus actual, was 19.4° (SD 3.9°) and 27.2° (SD 5.6°), respectively (p < 0.0001). Version was considered successful in 63.4% of cases, and combined position (inclination and version) was considered successful in 53.1%. CONCLUSION: This study shows that with traditional methods of placing the cup intraoperatively, surgeons are only accurate 53.1% of the time compared with a predicted preoperative plan. This study suggests that the inconsistency in cup positioning based on the surgeon's planned target is potentially another important variable to consider while using a mechanical guide or in freehand techniques for cup placement in THA. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, NCT03189303.
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Artroplastia de Reemplazo de Cadera , Prótesis de Cadera , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/instrumentación , Humanos , Estudios Prospectivos , Femenino , Masculino , Anciano , Persona de Mediana Edad , Acetábulo/cirugíaRESUMEN
BACKGROUND: The purpose of this study is to compare peri-operative and short-term outcomes in patients who underwent elective total hip replacement (THA) for primary osteoarthritis (OA) with direct anterior approach (DAA) versus a pair-matched cohort of patients who underwent robotic-assisted THA with posterolateral approach. MATERIALS AND METHODS: Data from consecutive patients who underwent elective hip replacement from 2021 to 2023 for primary OA were retrospectively retrieved and divided into two groups: the DAA group, who underwent THA with the DAA approach using conventional instruments, and the robotic posterolateral (R-PL group), who underwent robot arm-assisted THA with the posterolateral approach. Comparative assessed outcomes were: operative time, radiographical implant positioning, intake of rescue analgesics, blood loss, transfusion rate, leg length discrepancy and functional outcomes (Harris hip score and forgotten joint score). RESULTS: A total of 100 pair-matched patients were retrieved with a mean age of 66.7 ± 10.7 (range: 32-85) years and a mean follow-up of 12.8 ± 3.6 (range: 7-24) months. No differences in patients' characteristics were detected. Patients in the R-PL group required less rescue tramadol (p > 0.001), ketorolac (p = 0.028) and acetaminophen (p < 0.001). There was no significant difference in the operative time between (MD = 5.0 min; p = 0.071). Patients in the DAA group had significantly lower Hb levels at day 1 (p = 0.002) without significant differences in transfusion rate (p = 0.283). Patients in the R-PL group had shorter length of stay (LOS) with a mean difference of 1.8 days [p < 0.001; 95% confidence interval (CI) 1.4-2.3]. No difference in clinical outcomes was found [leg length discrepancy (LLD), p = 0.572; HHS, p = 0.558; forgotten joint score (FJS), p = 0.629]. No radiographical differences were measured in cup inclination (MD = 2.0°, p = 0.069), malpositioning [odd ratio (OR) = 0.2; p = 0.141], stem alignment (OR = 0.3; p = 0.485) and stem sizing (OR = 1.5; p = 1.000). There was no difference in complication rate except for lateral femoral cutaneous nerve damage, which was higher in DAA group (p < 0.001). CONCLUSIONS: R-PL and DAA THA had comparable short-term clinical and radiological outcomes along with similar complication rates. The R-PL group showed significantly lower Hb drop, rescue analgesic consumption and shorter LOS. This is a preliminary study and no strong recommendation can be provided. Further prospective randomized trials are requested to further investigate the cost-effectiveness of robotic surgery in THA. LEVEL OF EVIDENCE: Level IV, case-control study.
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Artroplastia de Reemplazo de Cadera , Osteoartritis , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Persona de Mediana Edad , Anciano , Estudios de Casos y Controles , Estudios Retrospectivos , Diferencia de Longitud de las PiernasRESUMEN
PURPOSE: To investigate whether artificial intelligence (AI) can differentiate septic from non-septic total hip arthroplasty (THA) failure based on preoperative MRI features. MATERIALS AND METHODS: We included 173 patients (98 females, age: 67 ± 12 years) subjected to first-time THA revision surgery after preoperative pelvis MRI. We divided the patients into a training/validation/internal testing cohort (n = 117) and a temporally independent external-testing cohort (n = 56). MRI features were used to train, validate and test a machine learning algorithm based on support vector machine (SVM) to predict THA infection on the training-internal validation cohort with a nested fivefold validation approach. Machine learning performance was evaluated on independent data from the external-testing cohort. RESULTS: MRI features were significantly more frequently observed in THA infection (P < 0.001), except bone destruction, periarticular soft-tissue mass, and fibrous membrane (P > 0.005). Considering all MRI features in the training/validation/internal-testing cohort, SVM classifier reached 92% sensitivity, 62% specificity, 79% PPV, 83% NPV, 82% accuracy, and 81% AUC in predicting THA infection, with bone edema, extracapsular edema, and synovitis having been the best predictors. After being tested on the external-testing cohort, the classifier showed 92% sensitivity, 79% specificity, 89% PPV, 83% NPV, 88% accuracy, and 89% AUC in predicting THA infection. SVM classifier showed 81% sensitivity, 76% specificity, 66% PPV, 88% NPV, 80% accuracy, and 74% AUC in predicting THA infection in the training/validation/internal-testing cohort based on the only presence of periprosthetic bone marrow edema on MRI, while it showed 68% sensitivity, 89% specificity, 93% PPV, 60% NPV, 75% accuracy, and 79% AUC in the external-testing cohort. CONCLUSION: AI using SVM classifier showed promising results in predicting THA infection based on MRI features. This model might support radiologists in identifying THA infection.
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Artroplastia de Reemplazo de Cadera , Femenino , Humanos , Persona de Mediana Edad , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Inteligencia Artificial , Imagen por Resonancia Magnética/métodos , Algoritmos , Edema , Estudios RetrospectivosRESUMEN
Osteoarthritis (OA) is a chronic disease characterized by joint tissue disruption and inflammation with a paucity of therapeutic options. Chondrocyte in vitro models are commonly used as the first step in evaluating new approaches and rely on the stimulation of an OA-like phenotype with inflammation often the method of choice. Inflammatory priming is frequently based on cytokines used at concentrations very far from the reality in the patients' synovial fluid (SF). The aim of this work was to compare the transcriptional response of chondrocytes to different inflammatory conditions: the high levels of IL1ß that are used for standardized inflammation protocols, OA-SF, IL1ß, IL6 and IFNγ at SF-like concentrations both individually and simultaneously to mimic a simplified "in vitro" SF. Both high IL1ß and OA-SF strongly influenced chondrocytes, while SF-like concentrations of cytokines gave weak (IL1ß alone or in combination) or no (IL6 and IFNγ alone) outcomes. Chondrocytes under the two most powerful polarizing conditions had a clearly distinct fingerprint, with only a shared albeit molecularly divergent effect on ECM stability, with IL1ß mainly acting on ECM degrading enzymes and OA-SF accounting for a higher turnover in favor of fibrous collagens. Moreover, OA-SF did not induce the inflammatory response observed with IL1ß. In conclusion, although partially similar in the endpoint phenotype, this work intends to encourage reflection on the robustness of inflammation-based in vitro OA models for molecular studies on chondrocytes.
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Osteoartritis , Líquido Sinovial , Humanos , Condrocitos , Interleucina-6/genética , Osteoartritis/tratamiento farmacológico , Citocinas/uso terapéutico , InflamaciónRESUMEN
While advanced imaging strategies have improved the diagnosis of bone-related pathologies, early signs of bone alterations remain difficult to detect. The Covid-19 pandemic has brought attention to the need for a better understanding of bone micro-scale toughening and weakening phenomena. This study used an artificial intelligence-based tool to automatically investigate and validate four clinical hypotheses by examining osteocyte lacunae on a large scale with synchrotron image-guided failure assessment. The findings indicate that trabecular bone features exhibit intrinsic variability related to external loading, micro-scale bone characteristics affect fracture initiation and propagation, osteoporosis signs can be detected at the micro-scale through changes in osteocyte lacunar features, and Covid-19 worsens micro-scale porosities in a statistically significant manner similar to the osteoporotic condition. Incorporating these findings with existing clinical and diagnostic tools could prevent micro-scale damages from progressing into critical fractures.
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BACKGROUND: We evaluated the reliability of intraoperative assessment of leukocyte esterase (LE) in synovial fluid samples from patients undergoing reimplantation following implant removal and spacer insertion for periprosthetic joint infection (PJI). Our hypothesis was that a positive intraoperative LE test would be a better predictor of persistent infection than either serum C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) or the combination of serum CRP and ESR. METHODS: The records of 76 patients who received a 2-stage exchange for PJI were retrospectively reviewed. Synovial fluid was collected for LE measurement during surgery before arthrotomy in 79 procedures. Receiver operating characteristic curves were generated. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under the curve (AUC) of LE, CRP, ESR, and CRP + ESR were calculated. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value of the LE assay were 82%, 99%, 90%, and 97%, respectively. Receiver operating characteristic analysis revealed an LE threshold of 1.5 between the first (negative) and the second (positive) level of the ordinal variable, so that a grade starting from 1+ was accurate for a diagnosis of persistent infection (AUC 0.9044). The best thresholds for the CRP and the ESR assay were 8.25 mg/L (82% sensitivity, 84% specificity, AUC 0.8416) and 45 mm/h (55% sensitivity, 87% specificity, AUC 0.7493), respectively. CONCLUSION: The LE strip test proved a reliable tool to diagnose persistence of infection and outperformed the serum CRP and ESR assays. The strip test provides a valuable intraoperative diagnostic during second-stage revision for PJI.
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Artroplastia de Reemplazo de Cadera , Infecciones Relacionadas con Prótesis , Biomarcadores , Sedimentación Sanguínea , Proteína C-Reactiva/análisis , Hidrolasas de Éster Carboxílico , Humanos , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Reimplantación , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Líquido Sinovial/químicaRESUMEN
Connexin 43 (Cx43) exerts pivotal functions in articular chondrocytes (CH). It is involved in the communication among cells and between cells and the extracellular environment, and it contributes to the maintenance of the correct cell phenotype. The pro-inflammatory cytokine TNFα induces a reduction in Cx43 expression in CH. Here, we studied the dynamics of this decrease in expression. We evaluated Cx43 protein and gene expression and the involvement of C-terminal domain (CTD) cleavage and proteasomal degradation. Treatments able to counteract TNFα action were also examined, together with Gap Junction (GJ) functionality and Cx43 localization. TNFα induced a significant reduction in Cx43 expression already at day 1, and the down modulation reached a peak at day 3 (-46%). The decrease was linked to neither gene expression modulation nor CTD cleavage. Differently, the proteasome inhibitor MG132 reverted TNFα effect, indicating the involvement of proteasomal degradation in Cx43 reduction. In addition, the co-treatment with the anabolic factor TGF-ß1 restored Cx43 levels. Cx43 decrease occurred both at the membrane level, where it partially influenced GJ communication, and in the nucleus. In conclusion, TNFα induced a rapid and lasting reduction in Cx43 expression mostly via the proteasome. The down modulation could be reverted by cartilage-protective factors such as MG132 and TGF-ß1. These findings suggest a possible involvement of Cx43 perturbation during joint inflammation.
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Condrocitos , Conexina 43 , Factor de Necrosis Tumoral alfa , Condrocitos/efectos de los fármacos , Condrocitos/metabolismo , Conexina 43/metabolismo , Uniones Comunicantes/metabolismo , Humanos , Factor de Crecimiento Transformador beta1/metabolismo , Factor de Necrosis Tumoral alfa/metabolismo , Factor de Necrosis Tumoral alfa/farmacologíaRESUMEN
Background and Objectives: Sex and gender-related differences may influence the outcome of patients undergoing total hip arthroplasty (THA). The present paper aims to depict the importance of sex and gender-related issues in the perioperative management of patients undergoing THA to improve clinical outcomes and prevent postoperative complications. Materials and Methods: From January 2002 to August 2022, OVID-MEDLINE, EMBASE, SCOPU S, Web of Science, Google Scholar, and PubMed were searched to identify relevant studies for further analysis. The search strategy included the following terms: (("gender-related differences" [MeSH Terms] OR "sex-related differences" [All Fields]) OR ("gender indicators" [MeSH Terms] OR "sex" [All Fields])) AND ("total hip arthroplasty" [MeSH Terms] OR (total hip replacement [All Fields])). Results: Twenty-eight papers were included in this current concepts review. Sex and gender-related differences were analyzed with regard to the following points: (1) surgical approach, robotic surgery, scar cosmesis, and implant choice; (2) postoperative clinical outcome and complications; (3) sexual activity after THA; and (4) psychological status and daily functional requirements. The data analysis showed that female patients need more specific attention in the preoperative, intraoperative, and postoperative phases to improve clinical and functional outcomes, reduce complications risk, and manage patient satisfaction. Conclusions: THA outcomes may be influenced by sex and gender-related factors which should be carefully assessed and addressed in patients undergoing surgery to improve the postoperative outcomes of patients' satisfaction and reduce postoperative complications that can differ between the two sexes.
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Artroplastia de Reemplazo de Cadera , Masculino , Humanos , Femenino , Artroplastia de Reemplazo de Cadera/efectos adversos , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Satisfacción del Paciente , Conducta Sexual , Resultado del TratamientoRESUMEN
BACKGROUND: Very little has been published about the diagnostic performance of MRI in total hip arthroplasty (THA) infection. PURPOSE: To determine the diagnostic performance of conventional MRI features and of new lymph nodal indices to identify infection in patients with failed THA. STUDY TYPE: Retrospective. POPULATION: In all, 119 patients (66 females; age 66.9 ± 12.4 years) with failed THA. FIELD STRENGTH/SEQUENCES: Metal artifact reduction sequence (MARS) protocol including short tau inversion recovery and turbo spin-echo T1 - and T2 -weighted sequences at 1.5T. ASSESSMENT: Patients underwent pelvis MRI prior to failed THA revision. MRIs were reviewed to identify periprosthetic bone destruction, soft-tissue mass, effusion, synovitis, lamellated synovitis, extracapsular edema, fibrous periprosthetic membrane, bone edema, and extracapsular collection/sinus tract. The number and maximum diameter of inguinal, obturator and iliac lymph nodes of the affected hip were assessed and normalized to those of the unaffected hip to calculate the ratio of nodal size (RNS), ratio of node number (RNN), difference of nodal size (DNS), and difference of node number (DNN). STATISTICAL TESTS: The Mann-Whitney U-and chi-square test were used. Diagnostic performance of indices and odds ratios (OR) were calculated. RESULTS: RNS, RNN, DNS, and DNN indices were significantly different (P = 0.000) between infected and noninfected THA, with accuracies ranging from 84.8% (RNS) and 93.1% (RNN). All other MRI features were significantly more prevalent in infected THA (P ≤ 0.002), except bone destruction, periarticular soft-tissue mass, and fibrous membrane (P ≥ 0.031). Sensitivities ranged from 7.9% (soft-tissue mass) to 76.3% (effusion/bone edema), specificity from 45.7% (bone destruction) to 97.5% (synovitis/lamellated synovitis), accuracy from 49.6% (bone destruction) to 81.5% (synovitis), OR from 0.261 (soft-tissue mass) to 35.550 (synovitis). DATA CONCLUSION: Conventional MRI features have limited accuracy to differentiate septic and aseptic THA failure. Lymph nodal indices, particularly those related to nodal number, may represent biomarkers of THA infection. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY STAGE: 2.
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Artroplastia de Reemplazo de Cadera , Linfadenopatía , Anciano , Artroplastia de Reemplazo de Cadera/efectos adversos , Femenino , Articulación de la Cadera , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Childhood hip infections can result in serious sequelae during adulthood, including persistent pain, functional limitations, and premature THA. When THA is performed in patients who had hip joint infections during childhood, surgeons surmise these arthroplasties are at an increased risk of complications and incomplete recovery. However, the degree to which this is true is not well characterized and has varied across a large number of small, retrospective studies. QUESTIONS/PURPOSES: (1) What proportion of THAs performed in patients who had pediatric septic arthritis result in periprosthetic joint infection? (2) What are the Harris hip scores associated with these reconstructions? (3) What proportion of these patients develop complications after THA? (4) What proportion of patients undergo revision after these THAs? METHODS: For this systematic review, we searched the MEDLINE (PubMed), Scopus, and CINAHL (EbscoHost) electronic databases. We evaluated studies published in English between 1980 and 2020 that had a minimum of 10 patients (with a minimum of 2 years of follow-up) in whom sequelae of septic arthritis of the hip were treated with single-stage THA. We also evaluated studies reporting clinical outcomes by means of the Harris hip score, along with a radiographic assessment of the prosthesis. Updates of previous studies using the same database, case reports, surgical technique reports, systematic reviews, and expert opinions were excluded. No restrictions were applied regarding study design and loss to follow-up. A total of 430 studies were identified through the initial search, and 11 studies were included after applying the inclusion and exclusion criteria. All but two studies, which included a historical control group, were retrospective case series. A total of 691 patients with a mean age of 45 years were involved. A total of 599 patients underwent cementless THAs, 84 patients underwent hybrid THA (cemented stems), and the remaining eight patients received a cemented THA. A total of 287 additional procedures were performed on the acetabulum, including autografting, allografting, and medial wall osteotomies; in three hips, tantalum augments were used. Three hundred thirty-five additional procedures were performed on the femora, including 223 shortening osteotomies and 112 greater trochanter osteotomies. The mean follow-up duration ranged from 5.5 to 15.2 years (minimum follow-up range 2-13 years). To assess the quality of the studies, we used the Methodological Index for Non-randomized Studies and the Assessment of Quality in Lower-limb Arthroplasty, for which a higher score represents a better study quality. The mean Methodological Index for Non-randomized Studies score for case series was 9 of 16 (range 6-12), and 19 and 18 of 24 for the two comparative studies. The mean reporting quality of the Assessment of Quality in Lower Limb Arthroplasty score was 6 of 8 (range 3-8). RESULTS: Because of loss to follow-up, which was not consistently reported in the source studies, we caution the reader that the estimates provided here likely underestimate the risks of adverse events and overestimate the mean hip scores. The pooled proportion of patients in whom infections developed was 1% (seven of 691 THAs). Considering only studies published in the past 10 years, the proportion was 0.7% (two of 276 THAs). The Harris hip score increased from a mean of 52 ± 6 points before THA to a mean of 88 ± 2 points after THA. The pooled proportion of complications, including sciatic nerve palsy, femoral nerve palsy, intraoperative periprosthetic fracture, deep venous thrombosis, and dislocation, was 11% (76 complications among 691 THAs). The pooled proportion of patients who underwent revision was 8% (53 revisions of any components for any reason among 691 THAs) at a mean follow-up interval of 9.1 ± 3 years. CONCLUSION: In THAs for sequelae of childhood septic arthritis, reinfections were uncommon, whereas generally, infection rates were slightly higher than those reported for conventional primary THAs. However, the duration of follow-up might have been insufficient to identify all patients in whom infections later developed, and the available data were not adequate to precisely detect the minimum quiescent period to avoid reinfections. Moreover, the studies in this systematic review were retrospective, and selection bias, transfer bias, and assessment bias likely influenced our findings. The general effect of these biases is to cause an underestimation of the harms of the intervention. Complications, especially intraoperative fracture and nerve palsy, were common in patients with the most-severe infections. Further data on this topic are needed, ideally from multicenter or registry studies with even longer follow-up durations. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Artritis Infecciosa/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Articulación de la Cadera/cirugía , Prótesis de Cadera/efectos adversos , Infecciones Relacionadas con Prótesis/microbiología , Reinfección , Adulto , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/microbiología , Artritis Infecciosa/fisiopatología , Artroplastia de Reemplazo de Cadera/instrumentación , Fenómenos Biomecánicos , Trasplante Óseo , Remoción de Dispositivos , Femenino , Articulación de la Cadera/microbiología , Articulación de la Cadera/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Osteotomía , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Rango del Movimiento Articular , Recuperación de la Función , Reoperación , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: During the COVID-19 pandemic there has been a massive reduction of arthroplasty services due to reallocation of hospital resources. The unique challenge for clinicians has been to define which arthroplasty patients most urgently require surgery. The present study aimed to investigate priority arthroplasty procedures during the pandemic and in the reinstatement period from the surgeon's perspective. MATERIAL AND METHODS: An online survey was conducted among members of the European Hip Society (EHS), European Knee Associates (EKA) and other invited orthopaedic arthroplasty surgeons (experts) from across the world. The survey consisted of 17 different arthroplasty procedures/indications of which participants were asked to choose and rank the most important 10. RESULTS: Four hundred and thirty-nine arthroplasty surgeons from 44 countries responded. The EHS and EKA had a 43% response rate of members. In weighted average points, the majority of respondents (67.5 points) ranked 'acute fractures requiring arthroplasty (Periprosthetic fractures, THA/hemi-arthroplasty for femoral neck fractures)' as priority indication number one, followed by 'first-stage explantations for acute PJI (periprosthetic joint infection)' in second place and priority indication (45.9 points) three as 'one-stage revision for acute PJI' (39.7 points). CONCLUSIONS: There was agreement that femoral neck fractures, periprosthetic fractures, and acute infections should be prioritised and cannot be postponed in the setting of the COVID-19 pandemic. As arthroplasty procedures are being resumed in most countries now, there has also been a relaxation of lockdown rules in most countries, which might cause a so-called second wave of the pandemic. Therefore, the results of the current study present a proposal by experts as to which operations should be prioritised in the setting of a second wave of the pandemic.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , COVID-19 , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Control de Enfermedades Transmisibles , Humanos , Pandemias , Reoperación , SARS-CoV-2 , Encuestas y CuestionariosRESUMEN
BACKGROUND: The study's aim was to summarize the recommendations given by members of the European Hip Society (EHS) regarding sport activities after total hip arthroplasty (THA). METHODS: Members of the EHS were invited to complete an online web-based questionnaire including recommendations for 47 sports disciplines. The questions regarding the specific sports were also divided into 4 subcategories: "allowed," "allowed when experienced," "not allowed", and "no opinion." Four intervals for resuming the sports activities after THA were evaluated: within 6 weeks after THA, 6 to 12 weeks after THA, 12 weeks to 6 months after THA, and more than 6 months after THA. Consensus on resuming sports was analyzed. RESULTS: A total of 150 (32.9%) EHS members participated in the survey. Agreement was found for 5 sports activities in the first 6 weeks after THA, for 10 activities, 6 to 12 weeks after surgery, for 26 activities, 3 to 6 months after THA, and for 37 of 47 activities, 6 months after surgery. Sports activities which were not allowed after THA were handball, soccer and football, basketball, full contact sports, and martial arts. CONCLUSION: This is the first report describing the recommendations of European hip arthroplasty surgeons on resuming sport activity after THA. Most physical activities were allowed for the patients 6 months after THA. The experience of the patient in performing a distinct sport activity did not influence the recommendations to return to former sports activities. European surgeons are progressively mitigating restrictions to sports after THA. Further studies should evaluate the effects of this trend on patients' outcome and implant survival.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Deportes , Ejercicio Físico , Humanos , Volver al Deporte , Encuestas y CuestionariosRESUMEN
BACKGROUND: To diagnose periprosthetic joint infection (PJI) preoperatively, ultrasound-guided joint aspiration (US-JA) may not be performed when effusion is minimal or absent. We aimed to report and investigate the diagnostic performance of ultrasound-guided periprosthetic biopsy (US-PB) of synovial tissue to obtain joint samples in patients without fluid around the implants. METHODS: One-hundred nine patients (55 men; mean age: 68 ± 13 years) with failed total hip arthroplasty (THA) who underwent revision surgery performed preoperative US-JA or US-PB to rule out PJI. RESULTS: Sixty-nine of 109 patients had joint effusion and underwent US-JA, while the remaining 40 with dry joint required US-PB. Thirty-five of 109 patients (32.1%) had PJI, while 74/109 (67.9%) had aseptic THA failure. No immediate complications were observed in both groups. Technical success of US-PB was 100%, as the procedure was carried on as planned in all cases. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US-JA were 52.2%, 97.8%, 92.3%, 80.3%, and 82.6%, while for US-PB, they were 41.7%, 100%, 100%, 80%, and 82.5%, respectively, with no significant difference (P = .779). Using the final diagnosis as reference standard, we observed a moderate agreement with both US-JA (k = 0.56) and US-PB (k = 0.50). CONCLUSION: We present a novel US-guided technique to biopsy periprosthetic synovial tissue of failed THA to rule out PJI. We found similar diagnostic performance as compared with traditional US-JA. This supports future larger studies on this procedure that might be applied in patients without joint effusion.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Prótesis de Cadera , Infecciones Relacionadas con Prótesis , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/efectos adversos , Biomarcadores , Biopsia , Prótesis de Cadera/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Sensibilidad y Especificidad , Líquido Sinovial , Ultrasonografía IntervencionalRESUMEN
PURPOSE: We previously described the radical changes occurred in an orthopaedic hospital in Milan (Italy) during the first SARS-CoV-2 pandemic outbreak. Currently, during the second wave, the situation is still far from normality. Here we describe the changes that took place, and are still ongoing, in the clinical practice. METHODS: Number and type of admissions, outpatients activity, ER and urgent procedures in SARS-CoV-2 negative and positive patients have been analyzed over seven weeks (October 26th-December 13th, 2020) and compared with the correspondent period in 2019 and the same timeframe during the first wave (February 24th-April 10th). RESULTS: 2019 vs. 2020: Overall admissions decreased by 39.8%; however, while admissions for elective surgery dropped by 42.0%, urgent surgeries increased by 117.0%. Rehabilitation admissions declined by 85.2%. White and green priority ER consultations declined by 41.6% and 52.0%, respectively; yellow and red increased by 766.7% and 400.0%, respectively. Second vs. first wave: Overall admissions increased by 58.6% with a smoother decrement in weekly admissions than during the first wave. Disparity of acute admissions vs. rehabilitation expanded: Acute cases increased by 63.6% while rehabilitation cases decreased by 8.7%. Admissions to triage procedures increased by 72.3%. CONCLUSIONS: Activity levels are far from normality during the second COVID-19 wave. Elective surgery and outpatients-related activities are still strongly limited compared to 2019 while the number of urgent cases treated increased consistently. SARS-CoV-2 positive emergencies are slightly higher than during the first wave. These important changes are expected to impact on health service and hospital budget for long.
Asunto(s)
COVID-19 , Ortopedia , Hospitales , Humanos , Italia/epidemiología , Pandemias , SARS-CoV-2RESUMEN
BACKGROUND: Treatment of hip fractures during the coronavirus disease 2019 (COVID-19) pandemic has posed unique challenges for the management of COVID-19-infected patients and the maintenance of standards of care. The primary endpoint of this study is to compare the mortality rate at 1 month after surgery in symptomatic COVID-positive patients with that of asymptomatic patients. A secondary endpoint of the study is to evaluate, in the two groups of patients, mortality at 1 month on the basis of type of fracture and type of surgical treatment. MATERIALS AND METHODS: For this retrospective multicentre study, we reviewed the medical records of patients hospitalised for proximal femur fracture at 14 hospitals in Northern Italy. Two groups were formed: COVID-19-positive patients (C+ group) presented symptoms, had a positive swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and received treatment for COVID-19; COVID-19-negative patients (C- group) were asymptomatic and tested negative for SARS-CoV-2. The two groups were compared for differences in time to surgery, survival rate and complications rate. The follow-up period was 1 month. RESULTS: Of the 1390 patients admitted for acute care for any reason, 477 had a proximal femur fracture; 53 were C+ but only 12/53 were diagnosed as such at admission. The mean age was > 80 years, and the mean American Society of Anesthesiologists (ASA) score was 3 in both groups. There was no substantial difference in time to surgery (on average, 2.3 days for the C+ group and 2.8 for the C- group). As expected, a higher mortality rate was recorded for the C+ group but not associated with the type of hip fracture or treatment. No correlation was found between early treatment (< 48 h to surgery) and better outcome in the C+ group. CONCLUSIONS: Hip fracture in COVID-19-positive patients accounted for 11% of the total. On average, the time to surgery was > 48 h, which reflects the difficulty of maintaining normal workflow during a medical emergency such as the present pandemic and notwithstanding the suspension of non-urgent procedures. Hip fracture was associated with a higher 30-day mortality rate in COVID-19-positive patients than in COVID-19-negative patients. This fact should be considered when communicating with patients and/or their family. Our data suggest no substantial difference in hip fracture management between patients with or without COVID-19 infection. In this sample, the COVID-19-positive patients were generally asymptomatic at admission; therefore, routine screening is recommended. LEVEL OF EVIDENCE: Therapeutic study, level 4.