Smokers have increased risk of soft-tissue complications following primary elective TKA.

INTRODUCTION: Smoking has been associated with numerous adverse outcomes following surgical procedures. The purpose of this study was to investigate, whether smoking status at time of surgery influences the outcome of primary TKA. MATERIALS AND METHODS: Six hundred and eighty-one patients who underwent primary TKA between 2003 and 2006 were included in the study. Smoking status was defined as current, former, and never smoker. Complications leading to revisions were assessed until 17 years of follow-up. Functional outcome was evaluated using clinical scores: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Scale (VAS) for pain, Short Form-12 Physical and Mental Component Summaries (SF-12PCS/MCS), and Knee Society Function and Knee Score (KSFS and KSKS). RESULTS: At a mean follow-up of 95 months (± 47 months), 124 complications led to revision surgery. Soft-tissue complications (OR, 2.35 [95% CI 1.08-5.11]; p = 0.032), hematoma formation (OR, 5.37 [95% CI 1.01-28.49]; p = 0.048), and restricted movement (OR, 3.51 [95% CI 1.25-9.84]; p = 0.017) were more likely to occur in current smokers than never smokers. Current smokers were more likely to score higher at KSFS (p < 0.001) and SF-12PCS (p = 0.0197) compared to never smokers. For overall revision, differences were noted. CONCLUSION: Current smoking increases risk of soft-tissue complications and revision after primary TKA, especially due to hematoma and restricted movement. Smoking cessation programs could reduce the risk of revision surgery.

Spinal Surgery Site Infection Leading to Implant Loosening Is Influenced by the Number of Prior Operations.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Spinal surgery site infection and chronic implant infection are possible causes for ongoing pain, implant loosening, and failed back surgery syndrome. Evidence of chronic infection was found in 29.1% of revision cases but is also found in a considerable number of degenerative cases without prior surgery. Infection mechanisms and possible clinical correlations are unclear. METHODS: Retrospective analysis of standardized surgery site screening (swab, tissue samples, implant sonication) in 181 cases without clinical evidence of preoperative surgery site infection. RESULTS: Screening results of cases without prior spinal surgery (n = 49, 10.2% positive) were compared to cases with prior spine surgery without implant placement (e.g. micro discectomy) (n = 21, 23.8% positive), revision cases following singular spinal fusion (n = 73, 23.2% positive), and cases with multiple revisions (n = 38, 50.0% positive). Propionibacterium spp. detection rate increased to 80% in positive cases with multiple revisions. Implants in place during revision surgery had a significantly higher infection rate (32.4%) compared to no implant (14.2%, p = 0.007). Positive cases had a significantly higher pain level prior to surgery compared to negative cases (p = 0.019). Laboratory parameters had no predictive value. Logistic regression revealed that previous spinal surgeries (odds ratio [OR] 1.38 per operation, p < 0.001) and male sex (OR 1.15, p = 0.028) were independent predictive factors for infection. CONCLUSIONS: Previous spinal surgery is a risk factor for chronic surgery site infection, leading to chronic pain, implant loosening, and revision. The presence of Propionibacterium spp. was correlated with chronic implant loosening and was more likely with cumulative surgeries.

Revision Rates After Total Ankle Replacement: A Comparison of Clinical Studies and Arthroplasty Registers.

BACKGROUND: The aim of this study was to assess the outcome of total ankle replacement (TAR) regarding revision rates by comparing clinical studies of the last decade to data displayed in arthroplasty registers. The secondary aim was to evaluate whether dependent clinical studies show a superior outcome to independent publications. Additionally, revision rates of mobile bearing implants (MB-TARs) were compared to those of fixed bearing implants (FB-TARs). METHODS: Clinical studies on TARs between 2010 and 2020 were systematically reviewed, with the endpoint being a revision for any reason. The parameter "revision rate per 100 observed component years (CYs)" was calculated for each publication. The pooled revision rate for clinical studies was compared to the data reported in arthroplasty registers. In a second step, revision rates were subdivided and analyzed for independent and dependent publications and for FB-TARs and MB-TARs. RESULTS: A total of 43 publications met the inclusion criteria comprising 5806 TARs. A revision rate of 1.8 per 100 observed CYs was calculated, corresponding to a 7-year revision rate of 12.6%. The 3 arthroplasty registers included showed revision rates ranging from 8.2% to 12.3% after 7 years. No significant difference between dependent and independent publications nor between FB-TARs and MB-TARs was detected. CONCLUSION: Revision rates of clinical studies and arthroplasty registers are comparable. Surgeons can compare their own revision rates with those from this study. Dependent studies do not seem to be biased, and no superiority for one bearing type can be described. LEVEL OF EVIDENCE: Level III, systematic review of level III studies.

Septic Revision Total Knee Arthroplasty: Treatment of Metaphyseal Bone Defects Using Metaphyseal Sleeves.

BACKGROUND: Bone loss is a severe problem in septic revision total knee arthroplasty (RTKA). The use of porous coated metaphyseal sleeves is a promising treatment option for metaphyseal bone defects. The currently published midterm results remain limited and no study has been focused exclusively on septic cases. Our aim was to determine the implant survivorship (with special focus on osseointegration) and the clinical and radiological midterm outcome of metaphyseal sleeve fixation in septic RTKA surgery (minimum follow-up of 2 years). METHODS: We performed a clinical and radiographic examination of 56 patients with a history of prosthetic joint infection who underwent 2-stage RTKA with the use of porous coated metaphyseal sleeves. These examinations included evaluation of the American Knee Society Score, the Western Ontario and McMaster Universities Osteoarthritis Index, the Short Form (SF-36) Health survey as well as radiographic measurement to determine whether successful osseointegration had been achieved. RESULTS: Nine patients (16%) had to be re-revised at the time of follow-up (mean, 5.3 years; range, 2-11.2), all due to reinfection. We did not encounter any cases of aseptic loosening. The mean range of motion (92°, SD ± 21°), subjective satisfaction score (7, SD ± 2), American Knee Society Score (76, SD ± 19), Western Ontario and McMaster Universities Osteoarthritis Index (70, SD ± 20), SF-36 mental component summary (55, SD ± 14), and SF-36 physical component summary (35, SD ± 9) have shown satisfying results. CONCLUSION: Metaphyseal sleeves have shown very promising midterm results regarding clinical scores, osseointegration, and aseptic loosening. Our results are the first analyzing exclusively septic indications and indicate that they are a reliable fixation option in all bone defect types in septic RTKA patients.

Pedicle screw loosening is correlated to chronic subclinical deep implant infection: a retrospective database analysis.

PURPOSE: Spinal fusion is used for treatment of spinal deformities, degeneration, infection, malignancy, and trauma. Reduction of motion enables osseous fusion and permanent stabilization of segments, compromised by loosening of the pedicle screws (PS). Deep implant infection, biomechanical, and chemical mechanisms are suspected reasons for loosening of PS. Study objective was to investigate the frequency and impact of deep implant infection on PS loosening. METHODS: Intraoperative infection screening from wound and explanted material sonication was performed during revision surgeries following dorsal stabilization. Case history events and factors, which might promote implant infections, were included in this retrospective survey. RESULTS: 110 cases of spinal metal explantation were included. In 29.1% of revision cases, infection screening identified a germ, most commonly Staphylococcus (53.1%) and Propionibacterium (40.6%) genus. Patients screened positive had a significant higher number of previous spinal operations and radiologic loosening of screws. Patients revised for adjacent segment failure had a significantly lower rate of positive infection screening than patients revised for directly implant associated reasons. Removal of implants that revealed positive screening effected significant pain relief. CONCLUSIONS: Chronic implant infection seems to play a role in PS loosening and ongoing pain, causing revision surgery after spinal fusion. Screw loosening and multiple prior spinal operations should be suspicious for implant infection after spinal fusion when it comes to revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Langerhans-cell histiocytosis of the cervical spine in an adult patient: Case report and review of the literature.

Langerhans-cell histiocytosis (LCH) is a rare, benign bone tumor, usually occurring in children and younger adults under 20 years old. Only a few cases of solitary bone lesions of the adult spine are reported in literature, therapeutic guidelines or treatment regimens for lesions of the adult spine are not established yet to our knowledge.

Impact of preoperative antithrombotic therapy on blood management after implantation of primary total knee arthroplasty.

Red blood cell concentrates (RCC) substitution after total knee arthroplasty (TKA) is correlated with multifold of complications and an independent predictor for higher postoperative mortality. TKA is mainly performed in elderly patients with pre-existing polymorbidity, often requiring permanent preoperative antithrombotic therapy (PAT). The aim of this retrospective analysis was to investigate the impact of demand for PAT on inpatient blood management in patients undergoing TKA. In this study 200 patients were retrospectively evaluated after TKA for differences between PAT and non-PAT regarding demographic parameters, preoperative ASA score > 2, duration of operation, pre-, and intraoperative hemoglobin level, and postoperative parameters including amount of wound drainage, RCC requirement, and inpatient time. In a multivariate logistic regression analysis the independent influences of PAT, demographic parameters, ASA score > 2, and duration of the operation on RCC demand following TKA were analyzed. Patients with PAT were significantly older, more often had an ASA > 2 at surgery, needed a higher number of RCCs units and more frequently and had lower perioperative hemoglobin levels. Multivariate logistic regression revealed PAT was an independent predictor for RCC requirement. PAT patients are more likely to require RCC following TKA and should be accurately monitored with respect to postoperative blood loss.

Sports Activity after Low-contact-stress Total Knee Arthroplasty - A long term follow-up study.

The purpose of this study was to provide comprehensive long-term data about sports activity levels in patients following total knee arthroplasty (TKA) and to determine the impact of pre-operative function, pain and specific performed sports on the results. 236 patients who have undergone TKA for severe osteoarthritis of the knee were asked to provide specific information regarding exercised types of sports before surgery and after at least 10 years following TKA. Pre- and postoperative function and pain were evaluated by the use of Tegner-, WOMAC- and VAS Score. After a mean of 14.9 years, a significant improvement regarding pain and function was observed. Pre-operative Tegner- and WOMAC scores revealed significant positive correlations with the post-operative Tegner-Score. Accordingly, a high percentage of patients (70.9%) stayed actively involved in sports. Nevertheless, the number of performing patients has decreased according to the sports impact. 71.3% continued practising low-impact-, 43.7% intermediate-impact sports whereas only 16.4% kept performing high impact sports. We conclude that TKA is highly effective in long-time pain reduction as well as improvement of function. Additionally, we found considerable sports activities preserved in the investigated series. However, sports activities in particular, seem to decrease according to the impact of sports.

Early migration characteristics of a 180° porous-coated cup with 1-mm press fit.

INTRODUCTION: Evaluation of early cup movement is an important diagnostic tool to predict the likelihood of long-term implant loosening and clinical failure. The investigated cementless cup is clinically proven over 10 years, but there is a paucity of information that accurately describes the migration characteristics of this component. MATERIALS AND METHODS: We retrospectively analysed the clinical outcome and migration behaviour of 60 Pinnacle 100 shells after an average 3.8-year follow-up (range 2.1-5.4 years). For migration measurement, EBRA (Einzel-Bild-Röntgen-Analyse) digital software was applied. Clinical assessment was performed using the HHS, the UCLA score and the SF-36 health survey. RESULTS: The clinical outcome showed excellent results with a mean HHS of 95.4 (SD 7.1) and mean UCLA of 6.9 (SD 1.3). All implants were radiologically stable within the observation period and none of the cups was at risk for aseptical loosening. EBRA analysis revealed a mean total migration of 1.4 mm (SD 0.9) (95 % CI 1.1-1.6) at 3 years. Eight cups migrated more than 1 mm within the first three postoperative months, thereafter the migration curves flattened down. CONCLUSION: Surgeons may expect to find a variable amount of early migration when using the Pinnacle cup. To our knowledge, these are the first results, which show an early "impaction" of a cementless cup, followed by subsequent osseointegration. We believe that an appropriate long-term outcome of the investigated cup is ensured. The data of the present investigation will provide clinicians with useful baseline information with which to compare new cup designs.

Developmental dysplasia of the hip: impact of sonographic newborn hip screening on the outcome of early treated decentered hip joints-a single center retrospective comparative cohort study based on Graf's method of hip ultrasonography.

UNLABELLED: PURPOSE/BACKGROUND/INTRODUCTION: The aim of this study was to retrospectively evaluate the impact of neonatal sonographic hip screening using Graf's method for the management and outcome of orthopaedic treatment of decentered hip joints with developmental dysplasia of the hip (DDH), using three decades (1978-2007) of clinical information compiled in a medical database. METHODS: Three representative cohorts of consecutive cases of decentered hip joints were selected according to different search criteria and inclusion and exclusion parameters: (1) cohort 1 (1978-1982; n = 80), without sonographic screening; (2) cohort 2.1 (1994-1996; n = 91), with nationwide established general sonographic screening according to the Graf-method; (3) cohort 2.2 (2003-2005; n = 91), with sonographic screening including referred cases for open reduction from non-screened populations. These three cohorts were compared for the following parameters: age at initial treatment, successful closed reduction, necessary overhead traction, necessary adductor-tenotomy, rate of open reduction, rate of avascular necrosis (AVN) and rate of secondary acetabuloplasty. RESULTS: The age at initial treatment was reduced from 5.5 months in the first cohort to 2 months in the two subsequent two cohorts and the rate of successful closed reduction increased from 88.7 to 98.9 and 95.6%, respectively. There was a statistically significant improvement in six out of seven parameters with sonographic hip screening; only the rate of secondary acetabuloplasty did not improve significantly. CONCLUSION: Compared to the era before the institution of a sonographic hip screening programme according to the Graf-method in Austria in 1992, ultrasound screening based-treatment of decentered hip joints has become safer, shorter and simpler: "safer" means lower rate of AVN, "shorter" means less treatment time due to earlier onset and "simpler" means that the devices are now less invasive and highly standardized.

Surgery for pathological proximal femoral fractures, excluding femoral head and neck fractures: resection vs. stabilisation.

Pathological femoral head and neck fractures are commonly treated by arthroplasty. Treatment options for the trochanteric region or below are not clearly defined. The purpose of this retrospective, comparative, double-centre study was to analyse survival and influences on outcome according to the surgical technique used to treat pathological proximal femoral fractures, excluding fractures of the femoral head and neck. Fifty-nine patients with 64 fractures were operated up on between 1998 and 2004 in two tertiary referral centres and divided into two groups. One group (S, n = 33) consisted of patients who underwent intramedullary nailing alone, and the other group (R, n = 31) consisted of patients treated by metastatic tissue resection and reconstruction by means of different implants. Median survival was 12.6 months with no difference between groups. Surgical complications were higher in the R group (n = 7) vs. the S group (n = 3), with no statistically significant difference. Patients with surgery-related complications had a higher survival rate (p = 0.049), as did patients with mechanical implant failure (p = 0.01). Survival scoring systems did not correlate with actual survival. Resection of metastases in patients with pathological fractures of the proximal femur, excluding femoral head and neck fractures, has no influence on survival. Patients with long postoperative survival prognosis are at risk of implant-related complications.

No midterm benefit from low intensity pulsed ultrasound after chevron osteotomy for hallux valgus.

Chevron osteotomy is a widely accepted method for correction of symptomatic hallux valgus deformity. Full weight bearing in regular shoes is not recommended before 6 weeks after surgery. Low intensity pulsed ultrasound is known to stimulate bone formation leading to more stable callus and faster bony fusion. We performed a randomized, placebo-controlled, double-blinded study on 44 participants (52 feet) who underwent chevron osteotomy to evaluate the influence of daily transcutaneous low intensity pulsed ultrasound (LIPUS) treatment at the site of osteotomy. Follow-up at 6 weeks and 1 year included plain dorsoplantar radiographs, hallux-metatarsophalangeal-interphalangeal scale and a questionnaire on patient satisfaction. There was no statistical difference in any pre- or postoperative clinical features, patient satisfaction or radiographic measurements (hallux valgus angle, intermetatarsal angle, sesamoid index and metatarsal index) except for the first distal metatarsal articular angle (DMAA). The DMAA showed statistically significant (p = 0.046) relapse in the placebo group upon comparison of intraoperative radiographs after correction and fixation (5.2 degrees) and at the 6-week follow-up (10.6 degrees). Despite potential impact of LIPUS on bone formation, we found no evidence of an influence on outcome 6 weeks and 1 year after chevron osteotomy for correction of hallux valgus deformity.

The effect of a single infusion of zoledronic acid on early implant migration in total hip arthroplasty. A randomized, double-blind, controlled trial.

BACKGROUND: Aseptic loosening is the most frequent cause of implant failure in total hip arthroplasty. While a direct link between aseptic loosening and periprosthetic bone loss remains elusive, there is plentiful evidence for a close association with early implant migration. The present trial was primarily designed to evaluate whether a single infusion of 4 mg of zoledronic acid prevented early implant migration in patients with osteonecrosis of the femoral head. METHODS: Fifty patients were consecutively enrolled to receive either zoledronic acid or saline solution after cementless total hip arthroplasty. Radiographs, biochemical parameters of bone turnover, and the Harris hip-rating score were determined preoperatively and at each follow-up examination at seven weeks, six months, one year, and yearly thereafter. The median follow-up period was 2.8 years. RESULTS: We found a significant subsidence of the stem of up to a mean (and standard deviation) of -1.2 +/- 0.6 mm at two years within the control group, and the cups had a mean medialization of 0.6 +/- 1.0 mm and a mean cranialization of 0.6 +/- 0.8 mm (p < 0.001). Treatment with zoledronic acid effectively minimized the migration of the cups in both the transverse and the vertical direction (mean, 0.15 +/- 0.6 mm and 0.06 +/- 0.6 mm, respectively; p < 0.05), while only a trend to decreased subsidence of the stem was detected. Finally, the Harris hip score rapidly increased over time in both treatment groups, although this increase was significantly more pronounced in the zoledronate-treated group than in the control group (analysis of variance, p = 0.008). CONCLUSIONS: A single infusion of zoledronic acid shows promise in improving initial fixation of a cementless implant, which may improve the clinical outcome of total hip arthroplasty in patients with osteonecrosis of the femoral head.

Predictive value of seven preoperative prognostic scoring systems for spinal metastases.

Predicting prognosis is the key factor in selecting the proper treatment modality for patients with spinal metastases. Therefore, various assessment systems have been designed in order to provide a basis for deciding the course of treatment. Such systems have been proposed by Tokuhashi, Sioutos, Tomita, Van der Linden, and Bauer. The scores differ greatly in the kind of parameters assessed. The aim of this study was to evaluate the prognostic value of each score. Eight parameters were assessed for 69 patients (37 male, 32 female): location, general condition, number of extraspinal bone metastases, number of spinal metastases, visceral metastases, primary tumour, severity of spinal cord palsy, and pathological fracture. Scores according to Tokuhashi (original and revised), Sioutos, Tomita, Van der Linden, and Bauer were assessed as well as a modified Bauer score without scoring for pathologic fracture. Nineteen patients were still alive as of September 2006 with a minimum follow-up of 12 months. All other patients died after a mean period of 17 months after operation. The mean overall survival period was only 3 months for lung cancer, followed by prostate (7 months), kidney (23 months), breast (35 months), and multiple myeloma (51 months). At univariate survival analysis, primary tumour and visceral metastases were significant parameters, while Karnofsky score was only significant in the group including myeloma patients. In multivariate analysis of all seven parameters assessed, primary tumour and visceral metastases were the only significant parameters. Of all seven scoring systems, the original Bauer score and a Bauer score without scoring for pathologic fracture had the best association with survival (P < 0.001). The data of the present study emphasize that the original Bauer score and a modified Bauer score without scoring for pathologic fracture seem to be practicable and highly predictive preoperative scoring systems for patients with spinal metastases. However, decision for or against surgery should never be based alone on a prognostic score but should take symptoms like pain or neurological compromise into account.

Correlation between thigh pain and radiological findings with a proximally porous-coated stem.

Thigh pain has been consistently reported with cementless hip arthroplasty. The correlation between thigh pain and radiological findings and the clinical significance of thigh pain have not been studied in any detail. We carried out a retrospective study to analyse the performance of a proximally porous-coated cementless femoral component. Ninety-eight total hip arthroplasties were followed up clinically and radiologically for an average of 33 months (range: 12 to 64) after operation. The clinical results were good or excellent in 85 cases (87%). Thirteen patients (13%) reported thigh pain at latest follow-up. Subsidence of the stem was recorded in 10 cases, cortical thickening occurred in 14 hips (14%), and 17 hips (17%) presented proximal osteopenia. Proximally, radiolucent lines were observed in 11 cases. Thigh pain correlated with radiolucent lines, femoral thickening, fibrous fixation and stem migration. Bone remodelling was noted to continue even five years after implantation. Our observations demonstrated bone ingrowth in the majority of the cases and a low incidence of thigh pain. The correlation between radiological changes and thigh pain suggests implant micromotion and migration in some hips. Patients with thigh pain, changes in the proximal femur and progressive subsidence need further clinical and radiological follow-up.

Mesothelioma mortality in Europe: impact of asbestos consumption and simian virus 40.

BACKGROUND: It is well established that asbestos is the most important cause of mesothelioma. The role of simian virus 40 (SV40) in mesothelioma development, on the other hand, remains controversial. This potential human oncogene has been introduced into various populations through contaminated polio vaccines. The aim of this study was to investigate whether the possible presence of SV40 in various European countries, as indicated either by molecular genetic evidence or previous exposure to SV40-contaminated vaccines, had any effect on pleural cancer rates in the respective countries. METHODS: We conducted a Medline search that covered the period from January 1969 to August 2005 for reports on the detection of SV40 DNA in human tissue samples. In addition, we collected all available information about the types of polio vaccines that had been used in these European countries and their SV40 contamination status. RESULTS: Our ecological analysis confirms that pleural cancer mortality in males, but not in females, correlates with the extent of asbestos exposure 25 - 30 years earlier. In contrast, neither the presence of SV40 DNA in tumor samples nor a previous vaccination exposure had any detectable influence on the cancer mortality rate in neither in males (asbestos-corrected rates) nor in females. CONCLUSION: Using the currently existing data on SV40 prevalence, no association between SV40 prevalence and asbestos-corrected male pleural cancer can be demonstrated.

Role of free radicals in aseptic loosening of hip arthroplasty.

Fibrous pseudocapsule around hip implants is an invariable finding at revision operations and is believed to release inflammatory mediators that stimulate bone resorption. Reactive oxygen species have been proposed to be causative factors in various disorders with tissue fibrosis. We were interested in investigating whether aseptic loosening is connected with high oxidative stress, and in showing the underlying mechanism of periprosthetic fibrosis and its role in loosening. Levels of oxidative stress markers reduced (GSH) and oxidized (GSSG) gluthatione and malondialdehyde (MDA) were assayed in 28 loose hips and in 12 stable hips revised for high rate of wear and osteolysis. Collagen in the periprosthetic tissues was measured as hydroxyproline content. Osteolysis and polyethylene wear were graded. Increased oxidative stress measured by low GSH/GSSG ratio as well as by increased MDA level was established in patients compared to controls. Oxidative stress markers intercorrelated significantly. MDA and both GSH and GSSG levels correlated significantly with hydroxyproline level. Levels of GSSG and MDA were higher in hips with greater polyethylene wear. The results suggest that high oxidative stress may play a role in formation of a fibrous membrane observed at revision of loose hips. The fibrous pseudocapsule is probably related to high intraarticular pressure and expansion of the effective joint space. This study may elicit some aspects of the pathogenesis of aseptic hip loosening and aid in future investigations aiming at prevention of this complication.

Survival of cementless femoral components after osteonecrosis of the femoral head with different etiologies.

We reviewed 41 patients with 55 cementless total hip arthroplasty operated for advanced osteonecrosis. Patients were divided into 2 groups according to etiology of the osteonecrosis. The first group included 17 cases with osteonecrosis without a systemic disease and the second group 38 cases with osteonecrosis associated with a systemic disease. The follow-up was on average 6.4 years (range, 2-12.8). Eight (15.4%) stem revisions had to be performed; all of them were in the patients with a systemic disease. Ten-year survival rates with femoral revision as the endpoint were in the first group 100% and in the systemic disease group 68% (P = .03). The data of this retrospective study indicate a correlation between the survival of the femoral component and the etiology of the osteonecrosis.