Does the type of surgical approach affect the clinical outcome of total knee arthroplasty?

BACKGROUND: The aim of the study was to investigate the issue of medial midvastus (MMV) vs. medial parapatellar (MPP) approaches in total knee arthroplasty (TKA). It was hypothesized that the two surgical approaches would produce significantly different results with respect to patient-reported knee score outcome (hypothesis 1), short-term postoperative range of motion (ROM) (hypothesis 2), long-term postoperative ROM (hypothesis 3) and prosthesis survival (hypothesis 4). METHODS: A retrospective comparative study design was applied. Data sets were obtained from the state arthroplasty registry. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) data were analyzed from preoperative and 1 year postoperatively. The ROM data were analyzed for the time points preoperative, postoperative days 4 and 10 and 1 year. RESULTS: Available were 627 cases (407 MMV vs. 220 MPP) and 1 year postoperatively there were no significant differences between groups regarding the WOMAC scores (hypothesis 1). Early postoperatively on days 4 and 10 after TKA there were no differences between groups (p = 0.305 and p = 0.383, respectively, hypothesis 2). Likewise, ROM did not significantly differ between the groups 1 year after TKA (p = 0.338, hypothesis 3). The 5­year prosthesis survival did not differ between the groups and showed 94.46% (95% confidence interval, CI 90.69-96.73%) in the MMV group and 94.33% (95% CI 89.96-96.83%) in the MPP group (p = 0.664, hypothesis 4). CONCLUSION: Both surgical approaches produce equivalent clinical results in terms of early postoperative ROM, late postoperative ROM and 1­year WOMAC. The same prosthesis survival rates can be expected.

Treatment of tibial nonunion with bone defect using a heterotopic ossification as autologous bone graft: literature overview and case report.

INTRODUCTION: Nonunion after open fracture of the lower leg is a frequent complication with a prevalence of up to 40%. In cases with major bone defects, revision of the osteosynthesis with bone grafting is commonly performed. Until today, there is no report on treatment of a tibial nonunion with transplantation of a heterotopic ossification. PRESENTATION OF CASE: We present a case of a 27-year-old male patient, who suffered from a paragliding accident with major injuries. An open fracture of the lower leg (Gustilo-Anderson IIIB) was initially treated with external fixation and vacuum-assisted closure, followed by reamed intramedullary nailing. The tibia resulted in a bone defect situation with nonunion. It was successfully treated with revision, fibular osteotomy and transplantation of a heterotopic ossification, harvested from the ipsilateral hip. CONCLUSION: In special cases, autologous transplantation of a mature heterotopic ossification is an attractive bone graft option in treating nonunion defects.

Development and initial evaluation of a point-of-care educational app on medical topics in orthogeriatrics.

INTRODUCTION: Research by AOTrauma's orthogeriatrics education taskforce identified ongoing educational needs for surgeons and trainees worldwide regarding the medical management of older adults with a fracture. To address practicing surgeons' preference for increased use of mobile learning, a point-of-care educational app was planned by a committee of experienced faculty. The goals were to deliver the app to surgeons, trainees, and other healthcare professionals, to measure usage, and to evaluate the impact on patient care. MATERIALS AND METHODS: The committee of geriatricians and surgeons designed and developed four modules on osteoporosis, delirium, anticoagulation, and pain based on published evidence and the content was programmed into mobile app formats. A registration form was integrated and a 14-question online evaluation survey was administered to users. RESULTS: The AOTrauma Orthogeriatrics app was installed by 17,839 users worldwide between September 2014 and October 2015: Android smartphones (44%), iPhones (32%), iPads (15%), Android tablets (9%). 920 users registered and 100 completed the online evaluation: orthopedic/trauma surgeons (67%), residents/fellows (20%), and other professionals (13%). Ratings for all aspects were 4 or higher on a 1-5 Likert scale (5 = Excellent). 80% of evaluation respondents found the answer to their question or educational need on their last visit, and 26 of 55 respondents (47%) reported making a change in an aspect of their management of patients as a result of their learning from the app. CONCLUSION: The orthogeriatrics app reached its intended audiences and was rated highly as a method of providing education to help improve patient care. Content input by experienced faculty and app improvements based on user feedback were key contributors to successful implementation.

Fast and easy preoperative estimation of cancellous bone mineral density in patients with proximal femur fractures.

INTRODUCTION: Postoperative complications after hip fractures in osteoporotic bone such as implant cutout can be reduced by the use of specially designed implants or additional cement augmentation. It is not yet clear at which degree of osteoporosis, patients will profit from implant augmentation or specially designed implants for geriatric patients. As the surgeon ideally should obtain information on local bone quality at the site of implant anchorage already preoperatively, the aim of the study was to develop an easily applicable radiographic method to estimate bone quality in those patients. MATERIALS AND METHODS: 75 patients with unilateral hip fracture were included. Preoperatively, a CT scan with a calibration device was conducted. Postoperatively, DXA scans were performed. The proposed method measures local cancellous bone mineral density in the contralateral and uninjured femoral head. As a control, 15 young and healthy non-osteoporotic subjects were included. Inter- and intraobserver reliability was investigated for a subgroup of 20 patients. RESULTS: Study group patients had a mean BMD measured by CT scans of 194.2 mg/cm(3) (SD 40.4). There was a statistically significant correlation with data from DXA scans (r = 0.706, p < 0.001). The control group was significantly younger and showed a significantly higher BMD when compared to the study group (p < 0.001). Reliability evaluation showed no statistically significant difference in inter- and intraobserver measurements. Interclass correlation proved to be very high. CONCLUSION: The proposed method is an easily applicable, reliable and useful tool to estimate bone quality preoperatively using the contralateral hip as a reference. Obtained data may facilitate the decision-making towards the use of further therapeutic measures to improve implant anchorage in osteoporotic bone such as bone cement augmentation. Thus, our method allows for a more individualized surgical treatment of hip fracture patients adapted to the estimated cancellous bone quality of the patient.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases.

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.

Long-term functional outcome in geriatric hip fracture patients.

BACKGROUND: Fragility fractures are a major health care problem worldwide. The proportion of the geriatric population and the overall life expectancy will increase. Hip fractures are the most common fragility fractures needing surgery and nowadays treatment concepts are changing. We studied the long-term functional outcome and their influencing factors in patients treated without any interdisciplinary aspects. DESIGN AND SETTING: A retrospective cohort study with functional long-term follow-up examination was carried out in a level one trauma centre on hip fracture patients 80 years old and above treated without any formalized interdisciplinary aspects ("usual care"). PATIENTS: Of 281 consecutive patients who were treated 2005 and 2006 with usual care, 246 patients with a mean age of 86.8 years met our inclusion criteria. 69.1% died within the study period of 4.9 years. On the remaining patients, the residential status, the Barthel Index and the Parker Score were assessed. RESULTS: The mean Barthel Index was 49.6 and the mean Parker Score was 2.7. More than one-fourth of the survivors were found to be bedridden and 45% were not able to walk outside. 88% are bound to one floor and only 8% are able to walk unaided. Patients with more comorbidities and patients with subsequent fractures had significant higher mortality rates. Patients with trochanteric fractures had significant better functional outcome scores compared to patients with femoral neck fractures. Nursing home residents showed significant higher mortality rates and lower functional outcome scores. Patients who were transferred to a nearby acute geriatric hospital for further treatment had significantly higher functional outcome scores. CONCLUSION: This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function.

Analysis of the micro-migration of sliding hip screws by using point-based registration.

PURPOSE: The favored treatment for many hip fractures is a sliding hip screw, and its usage is expected to increase in the future. Failures can be reduced, and complications detected earlier by semi-automated CT image analysis. The most frequent failure is due to the screw cut-out from the femoral head. METHODS: An image-based method was developed for early detection of complications and assessment of anchorage quality relative to implant model, bone quality or tip-apex distance (TAD). This method evaluates micro-migration using CT images acquired at different time points (immediately post-op and 3-month later). Serial CT image registration and transformation methods were applied, including point-based registration, to achieve semi-automated evaluations. RESULTS: Qualitative and quantitative validation of the image registration was performed with measurement mean error determination by different observers. The micro-migration evaluation by clinicians compared favorably with semi-automated image-based results. CONCLUSION: Semi-automatic evaluation of hip screw micro-migration using CT images is feasible and can aid observation of convalescence. The method may be amenable to full automation, a future goal for this work.

A representative case of osteoporotic distal radius fracture.

We present a case with nonsimultaneous bilateral dorsally displaced unstable osteoporotic distal radius fractures treated by open reduction and internal fixation using a volar and dorsal locking-plate system in a 69-year-old man. On the left side the patient had a loss of reduction as a result of plate bending 1 week after palmar plating. Correction of the dorsopalmar tilt was achieved through additional dorsal plating. Three months later the same patient sustained a distal radius fracture on his right forearm. Open anatomic reduction could only be achieved using palmar and dorsal locking plates, and the large metaphyseal defect was filled with resorbable bone substitute. Six weeks after surgery the patient reported persisting wrist pain. The x-rays showed loss of reduction. Because of flexor tendon irritation, the plate had to be removed after healing malunited. At the final follow-up at 18 months, the patient showed good subjective results according to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire results. Active wrist motion was 60 degrees extension on the left and 55 degrees extension on the right. The active range of flexion was 50 degrees for left and right wrist, and active pronation and supination were unrestricted for both forearms. Grip strength was 50 kg on either side. Although recently good and excellent results have been reported treating distal radius fractures using volar locking plates in elderly individuals, we believe these implants still have their limits depending on local bone quality and fracture pattern. Decisionmaking for surgery versus conservative treatment should balance the risks and advantages for each patient accurately.