Osteosarcoma After Total Knee Arthroplasty: A Case Report.

CASE: A 79-year-old woman presented with a periprosthetic fracture 8 years after a total knee arthroplasty (TKA). Radiographs demonstrated tibial implant loosening with severe osteolysis. A high-grade osteosarcoma around the prosthesis was diagnosed, and a supracondylar femoral amputation was performed. After 2 years, no complications have occurred. CONCLUSIONS: A malignant tumor around a TKA is extremely rare. Surgeons should remain vigilant with patients who present with rapidly progressive or very aggressive implant loosening with osteolysis. Owing to its complexity and potentially devastating prognosis, treatment should be guided by a specialist multidisciplinary team. Complex limb salvage procedures or amputation is usually required.

Single-injection nerve blocks for total knee arthroplasty: femoral nerve block versus femoral triangle block versus adductor canal block-a randomized controlled double-blinded trial.

INTRODUCTION: Femoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes. METHODS: This is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively. RESULTS: Seventy-eight patients (G1, n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3. CONCLUSION: For patients undergoing TKA, FTB and ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority does not translate to worse functional outcomes at any time point. FNB is associated with better pain control at 6, 24 and 48 h after surgery, while ACB presents the highest cumulative opioid requirement. CLINICAL TRIAL REGISTRATION: This study was registered in clinicaltrials.gov (NCT03518450; https://clinicaltrials.gov/ct2/show/NCT03518450 ; submitted March 17, 2018).

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.

Efficacy of Presurgical Interventions to Promote Smoking Cessation: A Systematic Review.

The aim of this study was to evaluate the efficacy of presurgical interventions for promoting smoking cessation in terms of achieving smoking abstinence and reducing surgical complication rates. A systematic review of randomized clinical trials (RCTs) published from March 2009 to April 2021 was performed following the PRISMA guidelines. References were found in MEDLINE (via PubMed), Web of Science (WOS), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). RCTs comparing the efficacy of a smoking cessation program directed at an intervention group (IG) versus the usual intervention or another directed at a control group (CG) were included. No language restrictions were applied in the search. All approaches to smoking cessation were admitted (face-to-face, telephone, group, individual, multicomponent, etc.), as were all methods for assessing abstinence, follow-up times, surgical specialties, definitions of smokers, and all types of surgical complications. Four hundred forty-four references were pulled out, and 79 duplicates were discarded. We excluded 346 records that were after application of the inclusion/exclusion criteria. In addition to the remaining 19 articles, 1 article obtained from citation searches was also assessed. We finally included 11 original articles in this systematic review, corresponding to 9 studies, because 2 of the RCTs had 2 different articles referring to different aspects of the same study. The results showed long-term postoperative (6 to 12 months) abstinence rates between 25.0% and 36.4% in RCTs with intensive multicomponent interventions, versus rates about 13.0% in brief interventions. Two multicomponent interventions obtained significant improvements regarding the reduction of short-term postoperative surgical complications. In conclusion, presurgical multicomponent smoking cessation interventions are more effective than brief interventions in terms of achieving abstinence and reducing surgical complications. The follow-up time and the intensity of the interventions were predictors of dropout.

Preoperative mechanical axis has no influence on reoperation rate in primary rotating-hinge knee arthroplasty.

Background: The purpose of the study is to evaluate reoperation rate and its relationship to preoperative mechanical axis of rotating-hinge TKA used as the primary implant in complex knees. Methods: Patients subjected to primary TKA with a rotating-hinge knee prosthesis due to primary osteoarthritis between 2010 and 2019 were retrospectively reviewed. Preoperative mechanical axis was measured using the last preoperative telemetry x-ray image. Preoperative axis was classified according to the type of deformity (varus or valgus) and its magnitude (0-15°, 16-25° or >25°). Reoperation rate (with or without implant removal) was the primary outcome of the current study. We studied if the preoperative mechanical axis (either varus-valgus, or magnitude of malalignment) was related to implant survival rate. Results: Forty-two patients were included in the study. Mean follow-up was 51.42 ± 31.88 months. The 83.3% of patients presented a valgus axis while the 16.7% presented a varus axis. Need of reoperation occurred in eight patients (19.0%). However, no patients (0%) required implant removal with revision TKA. No association was seen between the preoperative mechanical axis and risk of reoperation (p = 0.16). Conclusion: In selected situations that do not permit less constrained implants, primary rotating-hinge arthroplasty could be a good alternative. Risk of reoperation does not seem to depend upon the preoperative mechanical axis when using a rotating-hinge knee prosthesis for primary arthroplasty in non-tumoral complex knees.

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.

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.

Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament.

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment. METHODS: A historical cohort of patients who underwent arthroscopic total or partial excision of the anterior cruciate ligament due to mucoid degeneration between 2011 and 2014 were reviewed. The minimum follow-up was 3 years. Demographic, radiological, and histological findings, type of surgery, and clinical pre- and postoperative data were analyzed. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period. RESULTS: Seventeen females (67%) and eight males (33%) were included in the final analysis. The mean age at the time of surgery was 57 years (range, 31 to 78 years). Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. No reconstruction was performed at the same time. A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Anterior cruciate ligament reconstruction was required in only one young patient due to disabling instability. At last follow-up, the mean visual analogue scale score, International Knee Documentation Committee score, and Tegner Lysholm Knee score improved (p < 0.01). CONCLUSIONS: Our study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. However, young patients should be forewarned about the risk of instability, and an anterior cruciate ligament reconstruction could be necessary.

Avulsion of the Femoral Attachment of the Medial Collateral Ligament of the Knee Associated to Complete Tear of the Posterior Cruciate Ligament: A Case Report.

Medial collateral ligament (MCL) of the knee is one of the most commonly injured ligaments of the knee. Incidence of posterior cruciate ligament (PCL) injuries can vary widely. Conservative treatment has shown good clinical outcomes and relatively rapid return to play in both injuries alone. We present the case of a 38-year-old male who presented a combined MCL avulsion injury and PCL tear treated surgically. The PCL was reconstructed using the double-bundle Achilles allograft technique. Within the same surgery, a medial femoral incision was performed to reinsert the avulsion of the bone fragment rotated and distally retracted together with the MCL with bone anchors and Spike Washer. Two years after surgery, the patient enjoyed a 0/140-degree range of motion for flexion/extension. He had returned to sports and was pain-free. In conclusion, femoral avulsion of the MCL associated to PCL injury is a rare and nondescribed injury that, as opposed to most MCL isolated injuries, might benefit from early surgical reconstruction.

Mid-Term Outcomes and Complications with Cementless Distal Locking Hip Revision Stem with Hydroxyapatite Coating for Proximal Bone Defects and Fractures.

We revised the first 100 revision total hip arthroplasties using a cementless distal locking revision stem conducted in our referral centre. Average follow-up was 9.2 years (range: 5.5-12 years). Harris Hip Score improved from 42.5 to 81.6, and none had thigh pain at last follow-up. No significant stress shielding, osteolysis, or radiologic loosening was found. All patients showed radiological evidence of secondary implant osseointegration. Overall survival was 97% with three patients being revised: two stem ruptures and one subsidence. We could trace these complications to technical errors. These findings suggest that a diaphyseal fixation of the revision stem with distal locking can provide the needed primary axial and rotational stability of the prosthesis. This would allow further bony ingrowth, enhanced by the hydroxyapatite coating.

Revision anterior cruciate ligament reconstruction using tibial or hamstring tendon allografts.

PURPOSE: To report outcomes of revision anterior cruciate ligament (ACL) reconstruction using tibial or hamstring tendon allografts and to compare with another study using non-irradiated fresh-frozen bone-patellar tendon-bone allografts. METHODS: Records of 12 men and 7 women aged 18 to 53 (mean, 33) years who underwent revision ACL reconstructions using tibial tendon (n=17) or hamstring tendon (n=2) allografts were retrospectively reviewed. At the time of primary ACL reconstruction, hamstring autografts (n=8) and bonepatellar tendon-bone allografts (n=11) were used. The mean time interval between surgeries was 93 (range, 11-225) months. The causes of failure were traumatic injury (n=7) and technical or biological reasons (n=12). The physical activity level was high in 2 patients, medium in 10, and low in 7. For clinical assessment, the Lysholm test, International Knee Documentation Committee (IKDC) scale, and visual analogue scale (VAS) for pain were used. Patient satisfaction was also assessed. RESULTS: Four of the patients had laxity and were dissatisfied or very dissatisfied with the outcome; the failure rate was 21%. The mean IKDC score was 63% (range, 25-100%), and the mean Lysholm score was 74% (range, 30-100%). Comparing our patients with those in another study using bone-patellar-bone allografts, there was no significant difference in terms of the VAS for pain, IKDC score, and Lysholm score. Comparing our patients with and without chondral and/or meniscal lesions, there was significant difference in terms of the Lysholm score only (86±11 vs. 57±28, p=0.043). Comparing patients who had used hamstring tendon autografts at the primary ACL reconstruction with those who had used bonepatellar tendon-bone autografts, there was significant difference in terms of the VAS for pain only (4.4±3.1 vs. 1.6±1.0, p=0.020). CONCLUSION: Revision ACL reconstruction using tibial or hamstring tendon allografts provided acceptable results, similar to those using the bone-patellar tendon-bone allografts.

Fracture of the anteromedial tibial plateau associated with posterolateral complex injury: case study and literature review.

We report an unusual case of anteromedial tibial plateau compression fracture following hyperextension and forced varus of the knee, resulting in an anterior bone fragment large enough to require osteosynthesis. This uncommon lesion was associated with posterolateral complex injury, diagnosed with magnetic resonance imaging (MRI), while both cruciate ligaments were preserved. After proceeding with tibial plateau osteosynthesis, a peroneal tendon allograft was used for supplementation repair of the lateral collateral ligament and biceps tendon in a single surgical intervention. Tibial plateau fractures are often associated with soft-tissue involvement, mainly of the anterior cruciate ligament and external meniscus. Posterolateral complex injuries also occur with a mechanism of forced varus and hyperextension. These lesions require an accurate diagnosis to avoid future knee instability; moreover, adequate treatment in the acute phase provides a better functional outcome. Physicians should suspect associated posterolateral complex injury when an anteromedial tibial plateau fracture is diagnosed. MRI allows adequate diagnosis and permits surgical treatment in one procedure.

Radiologic assessment of all unfused lumbar segments 7.5 years after instrumented posterior spinal fusion.

STUDY DESIGN: Prospective observational single-cohort study. OBJECTIVE: To analyze long-term radiographic changes in all unfused lumbar segments after instrumented posterolateral lumbar fusion. SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration (ASD) after lumbar fusion may be a consequence of biomechanical stress or result from constitutional factors. Most studies analyzing ASD only investigate the motion segments immediately above and below the fusion. None compares adjacent segments to all the other unfused segments after instrumented posterior fusion. METHODS: Using the distortion-compensated roentgen analysis method, disc height, dorsoventral displacement, and lordosis were measured in 212 unfused segments from 62 patients, on digitized standing radiographs taken before fusion surgery and after a mean follow-up of 7.5 years (range, 4-11 years). The effect of covariables, such as age, length of follow-up, fusion level, number of fused segments, and sagittal and spinopelvic parameters on the preoperative to follow-up changes, were analyzed using a repeated-measurement model. RESULTS: No changes were observed at the segments located below the fusion. All the unfused segments above the fusion showed the same significant loss of disc height. Loss of disc height did not depend on fusion parameters, correlated weakly with age and length of follow-up, and correlated highly across adjacent unfused segments. CONCLUSIONS: After posterior lumbar instrumented fusion, radiographic changes suggesting disc degeneration appear homogeneously at several levels cephalad to fusion and seem to be determined by individual characteristics.

Osteosarcoma of the talus: a case report.

The reported incidence of osteosarcoma of the foot is very low. Osteosarcoma of the talus is extremely rare and few cases have been reported in the literature. The clinical findings are not typical, and osteosarcoma of the talus can be easily misdiagnosed, resulting in a delay in proper treatment. We report the case of a patient with osteosarcoma of the talus, from a series of 120 osteosarcomas treated at our hospital between 1966 and 2002.