Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up.

BACKGROUND: The aim of this prospective study was to investigate bone mineral density (BMD) changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes. METHODS: In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected. RESULTS: A total of 17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology, or need for revision surgery between the osteoporosis and nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable. CONCLUSION: BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for the treatment of displaced 3- or 4-part fractures with ORIF.

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND: Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. METHODS: Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57-80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics. RESULTS: Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19). CONCLUSION: Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting. TRIAL REGISTRATION: According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained.

High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace-A Microdialysis Porcine Study.

Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 µg/mL)). During the two dosing intervals, mean fT > MIC (4 µg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 µg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 µg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI.

Weight-based cefuroxime dosing provides comparable orthopedic target tissue concentrations between weight groups - a microdialysis porcine study.

Antibiotic prophylaxis is a key element in prevention of surgical site infections. For the majority of orthopedic procedures, antibiotic administration follows fixed dosing regimens irrespective of weight. However, this may result in insufficient antibiotic target tissue concentrations and higher risk of surgical site infections in obese individuals. The aim of this study was to investigate the effect of weight-based cefuroxime dosing on plasma and target tissue concentrations. Eighteen female pigs were allocated into three groups differentiated by weight: 53-57 kg, 73-77 kg, and 93-97 kg. Microdialysis catheters were placed for continuous sampling in bone, muscle, and subcutaneous tissue during an 8h sampling interval. Blood samples were collected as reference. Cefuroxime was administered intravenously as a bolus according to weight (20 mg/kg). The primary endpoint was the time above the cefuroxime minimal inhibitory concentration for Staphylococcus aureus (T > MIC (4 µg/mL)). Comparable target tissue T > MICs (4 µg/mL) were found between weight groups. Mean T > MIC ranged between 116-137 min for plasma, 118-154 min for bone, 109-146 min for the skeletal muscle, and 117-165 min for subcutaneous tissue across the groups. Weight-based cefuroxime (20 mg/kg) dosing approach provides comparable perioperative plasma and target tissue T > MIC (4 µg/mL) in animals between 50-100 kg body weight, and thus a comparable prophylaxis of surgical site infections.

High Completeness and Accurate Reporting of Key Variables Make Data from the Danish Shoulder Arthroplasty Registry a Valuable Source of Information.

PURPOSE: The Danish Shoulder Arthroplasty Registry (DSR) is a nationwide database providing data for research and health care monitoring. The aim of this study was to validate the DSR by (1) assessing registration completeness, (2) comparing key variables with information from medical records, (3) assessing the number and proportion of missing data for key variables. MATERIALS AND METHODS: The completeness of registration in the DSR from 2006-2015 was assessed for primary arthroplasties by comparing the number of arthroplasties reported to the DSR with the number of arthroplasties recorded by the Danish National Patient Register which is an administrative database used by the Danish healthcare authorities to monitor all hospitalizations including shoulder arthroplasty surgery. Positive predictive values (PPV) were used to estimate the accuracy of the reporting in a randomly selected population. Information retrieved from medical records were used as gold standard. The number of missing values for each variable was evaluated to depict if these registrations were missing at random. RESULTS: The completeness of reporting was 94.4. The PPV for the three major indications: osteoarthritis, fracture and rotator cuff arthropathy was 92%, 97%, and 94%, respectively. PPV was high for resurfacing arthroplasty (93%) and reverse shoulder arthroplasty (93%), but low for total shoulder arthroplasty (79%) and hemiarthroplasty (83%). The proportion of missing data in DSR was less than 1% for age, gender, previous surgery, indication and arthroplasty type and these can be regarded as missing at random. CONCLUSION: The study showed that data from the DSR are sufficiently valid to be used for research and quality monitoring. Lower PPV's for total shoulder arthroplasty and hemiarthroplasty are possibly related to inadequate definitions and mutually nonexclusive items in the reporting form. Regular validation is necessary since the data reported to the registry continuously evolve because of changes in clinical practice.

High prevalence of persistent pain 6 months after arthroscopic subacromial decompression and/or acromioclavicular joint resection.

PURPOSE: The aims of this prospective study were to determine the prevalence of pain 6 months after arthroscopic subacromial decompression (ASD) and/or acromioclavicular joint resection (AC resection), to reveal causes of the pain, and to identify risk factors for persistent pain. METHODS: Preoperatively, patients were tested for their endogenous capacity to modulate pain and completed questionnaires concerning psychological vulnerability. Patients with pain 6 months after surgery were examined by an experienced orthopaedic surgeon to reveal any shoulder pathology responsible for the pain. RESULTS: Data from 101 patients were available for analysis 6 months after surgery. Thirty-six patients had persistent pain: 32 underwent examination by the surgeon who identified shoulder pathology in ten patients, but not in the remaining 22 in whom ongoing insurance case, unemployment, and a general tendency to worry were risk factors for persistent pain. CONCLUSION: The prevalence of persistent pain 6 months after ASD and/or AC resection was 35.6% (95% CI 26.1-45.8%) and the proportion of patients with shoulder pathology was 9.9%. An association between ongoing insurance case, unemployment, general tendency to worry (t-STAI), and unexplained persistent pain 6 months after surgery was found.

High quality of care did not imply increased hospital spending- nationwide cohort study among hip fracture patients.

OBJECTIVE: To examine whether fulfilment of process performance measures reflecting national guidelines is associated with in-hospital costs among hip fracture patients. DESIGN: Nationwide, population-based follow-up study. SETTING: Public hospitals in Denmark. PARTICIPANTS: A total of 20 458 patients 65 years or older admitted with a hip fracture between 2010 and 2013. INTERVENTION: Quality of care defined as fulfilment of process performance measures reflecting recommendations from national clinical guidelines, which previously have been shown to be associated with lower mortality and readmission risk. The measures included systematic pain assessment; mobilisation within 24 h post-operatively; assessment of basic mobility before admission and discharge; and receiving a rehabilitation programme before discharge, anti-osteoporotic medication and fall prevention. MAIN OUTCOME MEASURES: Total costs defined as the sum of hospital costs used for treating the individual patients according to the Danish Reference Cost Database. RESULTS: Within the index admission, fulfilling 50 to >75% of the performance measures was associated with lower adjusted costs (EUR 2643) than was fulfilling 0-50% of these measures (EUR 3544). The lower costs were mainly due to savings on further treatment and fewer bed days. Mobilisation within 24 h after surgery and assessment for need of anti-osteoporotic medication were associated with the largest cost differences, corresponding to adjusted cost differences of EUR 3030 and EUR 3538, respectively. The cost difference was lower when all costs related to hospitalisation within the first year were considered. CONCLUSIONS: These findings indicate that high quality of care does not imply higher hospital spending and may be associated with cost savings.

Short-term results after arthroscopic resection of synovial plicae in the radiohumeral joint: a case series of 64 procedures.

INTRODUCTION: Painful Synovial Plicae (SP) in the posterolateral corner of the radiohumeral joint may be confused with lateral epicondylitis. The SP may impinge between the radial head and the humeral capitellum causing pain and snapping. The aim of this study was to evaluate the short-term results after arthroscopic plica resection of the elbow. METHODS: In this case series, we included a consecutive series of 64 arthroscopies (60 patients) with arthroscopic plica resection of the elbow. Inclusion criteria were six months of lateral elbow pain and unsuccessful conservative treatment. Patients had either ultrasonography verified plicae or pain on palpation of the plica. Patients were evaluated with an Oxford Elbow Score (OES) preoperatively, after three months and after mean 22 months (range: 12-31) of follow-up. Furthermore, baseline characteristics were recorded including, gender, age, body mass index (BMI), occupation, smoking and cartilage damage. RESULTS: The mean age was 44 years (range: 18-66). In 13 elbows, International Cartilage Repair Society (ICRS) grade 1 lesions were present in association with the plica. Preoperatively the mean OES was 19 (95% CI: 17-20). At three and 22 month follow-up the OES increased to 33 (95% CI: 30-36) and 35 (95% CI: 32-38), respectively (p < 0.001). Cartilage injury and gender did not affect the outcome. We reported no complications. DISCUSSION: Arthroscopic plica resection of the elbow indicates an improved OES after three and 22 months. A randomized prospective trial is needed to validate the effect of arthroscopic treatment of synovial elbow plicae.

No dislocations after primary hip arthroplasty with the dual mobility cup in displaced femoral neck fracture in patients with dementia. A one-year follow-up in 20 patients.

PURPOSE: The aim of this study was to describe the dislocation rates, reoperation rates and mortality 30 day and one year following THA with AVANTAGE® dual mobility cup among dementia patients with an acute displaced intracapsular femoral neck fracture. PATIENTS AND METHODS: From 2010 to 2014 we identified 20 hip fracture patients with dementia, who have had total hip arthroplasty with the AVANTAGE® dual mobility cup. The primary outcome was dislocation. Secondary outcomes were revision surgery, 30 days and one year mortality, time to surgery and length of hospital stay. RESULTS: Follow-up time was one year. None of the patients experienced dislocation or received revision surgery in the follow-up period. The 30-days mortality rate was 25% (confidence interval (CI) 95%; 4-46%) and the one year mortality was 45% (CI 95%; 21-69). Mean time to surgery was 27 h (CI 95%; 20-37 h) and mean length of hospital stay was 5.5 days (CI 95%; 4, 0-7, 6 days). CONCLUSION: THA with the dual-mobility cup seems favourable in the treatment of patients with a displaced femoral neck fracture and patients with dementia. Correct placement of the cup is pivotal and technically demanding. Not all orthopedic surgeons perform total hip arthroplasty while challenges regarding the logistics can be encountered since time to surgery is known to affect the mortality negatively.

Local Anesthesia Combined With Sedation Compared With General Anesthesia for Ambulatory Operative Hysteroscopy: A Randomized Study.

PURPOSE: The purpose of this study was to compare two anesthetic techniques for postoperative pain after ambulatory operative hysteroscopy. DESIGN: A randomized trial. METHODS: Women (N = 153) scheduled for ambulatory operative hysteroscopy were assigned to receive either paracervical local anesthesia combined with sedation (group LA + S; n = 76) or general anesthesia (group GA; n = 77). Primary outcome was the worst pain intensity score in the postanesthesia care unit (PACU) rated by the patients on a numerical rating scale. FINDING: Data from 144 patients were available for analysis (LA + S: n = 69; GA: n = 75). There were no significant differences in worst pain intensity between groups in the PACU (P = .13) or after discharge from PACU (P = .40). In group LA + S, fewer patients received treatment with intravenous fentanyl intraoperatively (P < .01) and time until discharge from PACU was shorter (P < .01). More patients in group LA + S experienced vomiting after discharge (P < .05). CONCLUSIONS: Local anesthesia with sedation can be recommended as a first choice anesthetic technique for operative ambulatory hysteroscopy.

Can improved quality of care explain the success of orthogeriatric units? A population-based cohort study.

BACKGROUND: admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms. OBJECTIVE: to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively. DESIGN: population-based cohort study. MEASURES: using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged ≥65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders. RESULTS: admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar. CONCLUSIONS: admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture.

Comorbidities in Patients With Anterior Cruciate Ligament Reconstruction Compared With Matched Controls Without Anterior Cruciate Ligament Injury From Danish Registries.

PURPOSE: To describe and compare comorbidity among anterior cruciate ligament (ACL)-reconstructed patients and a gender- and age-matched group without ACL injury. Furthermore, we sought to evaluate the impact of comorbid diseases on the risk of ACL revision surgery. METHODS: This case-control study included 13,443 unilateral primary ACL-reconstructed patients from the Danish Knee Ligament Reconstruction Register matched on gender and age with a comparison group without ACL injury. Information on medical comorbid conditions was obtained from the Danish National Registry of Patients. The prevalence of all comorbid conditions was described for ACL-reconstructed patients and the comparison group in terms of (1) the Charlson Comorbidity Index (CCI); (2) International Classification of Diseases, Tenth Revision disease chapters; and (3) more common chronic diseases in a younger population. Finally, we assessed the risk of ACL revision surgery according to the more common chronic diseases in a younger population, using Cox regression analysis. RESULTS: Although we found a large variety of diseases present among ACL-reconstructed patients, the percentage of patients with a CCI equal to 0 was high in both groups. ACL-reconstructed patients generally had a slightly lower prevalence of almost all International Classification of Diseases, Tenth Revision-classified comorbid disease groups compared with the comparison group without ACL injury. As expected, the prevalence of most diseases increased slightly with rising age. Furthermore, we found that having back pain or diseases of the back did alter the risk of revision surgery. CONCLUSIONS: ACL-reconstructed patients are found to be generally healthy individuals with a low prevalence of serious and chronic diseases compared with an age- and gender-matched control group from the general population. A large variety of diseases are present in the ACL-reconstructed group but with very low prevalence rates and low CCIs, indicating that the severity of their illness is limited. LEVEL OF EVIDENCE: Level III, case-control study.

Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: a randomised controlled trial.

PURPOSE: Arthroscopic anterior cruciate ligament (ACL) reconstruction is a painful procedure requiring intensive postoperative pain management. Femoral nerve block is widely used in ACL surgery. However, femoral nerve block does not cover the donor site of the hamstring tendons. Local infiltration analgesia is a simple technique that has proven effective in postoperative pain management after total knee arthroplasty. Further, local infiltration analgesia covers the donor site and is associated with few complications. It was hypothesised that local infiltration analgesia at the donor site and wounds would decrease pain and opioid consumption after ACL reconstruction with hamstring tendon graft. METHODS: Sixty patients undergoing primary ACL surgery with hamstring tendon graft were randomised to receive either local infiltration analgesia or femoral nerve block. Pain was scored on the numeric rating scale, and use of opioid, range of motion and adverse effects were assessed at the postoperative recovery unit (0 h), 3, 24 and 48 h, postoperatively. RESULTS: There were no significant differences between the groups in pain intensity or total opioid consumption at any of the follow-up points. Further, there were no differences between groups concerning side effects and range of motion. CONCLUSIONS: Local infiltration analgesia and femoral nerve block are similar in the management of postoperative pain after ACL reconstruction with hamstring tendon graft. Until randomised studies have investigated femoral nerve block combined with infiltration at the donor site, we recommend local infiltration analgesia in ACL reconstruction with hamstring tendon graft.

Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction.

BACKGROUND: The choice of graft for anterior cruciate ligament reconstruction (ACLR) remains controversial, and despite numerous studies, there is still an ongoing debate on this topic. The 2 most widely used grafts are the hamstring tendon and patellar tendon. HYPOTHESIS: In this study, we hypothesized that the revision rate after primary ACLR is greater when using hamstring tendon grafts compared with patellar tendon grafts. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: From the nationwide population-based Danish Knee Ligament Reconstruction Registry, we identified all primary ACLR procedures (n = 13,647) performed in Denmark between July 2005 and December 2011. The end point was revision ACLR. As other end points, we used objective measurements and patient-reported outcome scores. Revision rates and relative risk estimates for revision ACLR were calculated using Cox multiple regression. RESULTS: The use of hamstring tendon grafts increased from 68% in 2005 to 85% in 2011. The cumulative revision rates for hamstring tendon grafts at 1 and 5 years were 0.65% (95% confidence interval [CI], 0.51%-0.82%) and 4.45% (95% CI, 3.94%-5.01%), respectively. For patellar tendon grafts, the revision rate was 0.16% (95% CI, 0.05%-0.50%) at 1 year and 3.03% (95% CI, 2.27%-4.05%) at 5 years. The adjusted overall relative risk of revision surgery in the hamstring tendon group compared with the patellar tendon group was 1.41 (95% CI, 1.03-1.92), and the adjusted relative risk of undergoing revision surgery performed after 1 and 5 years was 3.82 (95% CI, 1.20-12.2) and 1.90 (95% CI, 0.43-8.40), respectively. CONCLUSION: In this population-based study, the use of hamstring tendon grafts in ACLR was associated with an increased risk of revision compared with patellar tendon grafts, in particular during the first year after surgery. These results demonstrate that both hamstring and patellar tendon grafts reveal good results after ACLR and suggest that graft selection should be based on an individual evaluation of patient demands and graft morbidity.

Validation of the Danish version of the Oxford Elbow Score.

INTRODUCTION: The Oxford Elbow Score (OES) is a patient-related outcome measure quantifying quality of life in relation to elbow disorders. This 12-item patient-administered English questionnaire comprises three domains: function, social-psychological status and pain. The purpose of this study was to examine the structure and reliability of the Danish version of the OES (D-OES). MATERIAL AND METHODS: A total of 130 patients who had total elbow arthroplasty (TEA) surgery performed in the period from 1981 to 2008 completed the D-OES. The Disability of the Arm, Shoulder and Hand score (DASH) and the Mayo Elbow Performance Score (MEPS) were also completed with a view to examining the convergent validity of the D-OES. In 45 cases, the questionnaire was completed twice to allow for calculation of test-retest reliability. The structure of the questionnaire was tested using Rasch analysis. RESULTS: Overall internal consistency tested by Cronbach's alpha was 0.99. The test-retest reliability correlation coefficient was 0.99. Expressed in terms of Pearson's correlation coefficient, the convergent validity of the D-OES's functional, social-psychological and pain domain was 0.78, 0.80 and 0.81, respectively, for the MEPS and -0.66, -0.58 and -0.49, respectively, for the DASH. The 12 items of the D-OES fitted the Rasch model, and the multidimensionality of the OES was confirmed. CONCLUSION: The Danish 12-item OES is a valid and reliable-patient administered questionnaire that can be used to quantify quality of life in patients with TEA.

Increased risk of revision after anteromedial compared with transtibial drilling of the femoral tunnel during primary anterior cruciate ligament reconstruction: results from the Danish Knee Ligament Reconstruction Register.

PURPOSE: The goal was to study revision rates and clinical outcome after anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) technique versus the transtibial (TT) technique for femoral drill hole placement. METHODS: A total of 9,239 primary ACL reconstruction procedures were registered in the Danish Knee Ligament Reconstruction Register between January 2007 and December 2010. The failure of the 2 different femoral drilling techniques was determined using revision ACL reconstruction as the primary endpoint. As secondary endpoints, we used the pivot-shift test and instrumented objective test as well as patient-reported outcome, registered in the Danish Knee Ligament Reconstruction Register. Relative risks (RRs) with 95% confidence intervals (CI) were calculated. RESULTS: We identified 1,945 AM and 6,430 TT primary ACL procedures. The cumulative revision rates for ACL reconstruction after 4 years with the AM and TT techniques were 5.16% (95% CI: 3.61%, 7.34%) and 3.20% (95% CI: 2.51%, 4.08%), respectively. The adjusted overall RR for revision ACL surgery in the AM group was 2.04 (95% CI: 1.39, 2.99), compared with the TT group. Use of the AM technique increased from 13% of all operations in 2007 to 40% in 2010. AM technique was further associated with increased RRs of positive pivot shift of 2.86 (95% CI: 2.40, 3.41) and sagittal instability of 3.70 (95% CI: 3.09, 4.43), compared with the TT technique. CONCLUSIONS: This study found an increased risk of revision ACL surgery when using the AM technique for femoral drill hole placement, compared with the TT technique, in the crude data as well as the stratified and adjusted data. Our finding could be explained by technical failures resulting from introduction of a new and more complex procedure or by the hypothesis put forward in prior studies that compared with a nonanatomic graft placement, a greater force is carried by the anatomic ACL reconstruction and, hence, there is a concomitant higher risk of ACL rupture. LEVEL OF EVIDENCE: Level II, prospective comparative study.

What factors predict failure 4 to 12 years after periacetabular osteotomy?

BACKGROUND: The goal of periacetabular osteotomy (PAO) is to delay or prevent osteoarthritic development in dysplastic hips. However, it is unclear whether the surgical goals are achieved and if so in which patients. This information is essential to select appropriate patients for a durable PAO that achieves its goals. QUESTIONS/PURPOSES: We therefore (1) determined hip survival rates; (2) determined how many preserved hips were functionally unsuccessful after PAO; and (3) identified demographic, clinical, and radiographic factors predicting failure after PAO. METHODS: We retrospectively reviewed 316 patients (401 hips) who had PAO between December 1998 and May 2007. We evaluated radiographic parameters of dysplasia and osteoarthritis and obtained WOMAC scores. Through inquiry to the National Registry of Patients, we identified conversions to THA. Risk factors for conversion to THA were assessed. Minimum followup was 4 years (mean, 8 years; range, 4-12 years). RESULTS: The overall Kaplan-Meier hip survival rate was 74.8% at 12.4 years. A WOMAC pain score of 10 or more, suggesting clinical failure, was observed in 13% of preserved hips at last followup. Higher age, preoperative Tönnis grade of 2, incongruent hip, postoperative joint space width of 3 mm or less, and postoperative center-edge angle of less than 30° or more than 40° predicted conversion to THA. CONCLUSIONS: PAO preserved three of four hips with most functioning well at 4- to 12-year followup. When planning surgery, surgeons should attempt to achieve hip congruence and a center-edge angle of between 30° to 40° to improve the durability of PAO. LEVEL OF EVIDENCE: Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Long-term results with the Kudo type 3 total elbow arthroplasty.

From 1992 to 1993, 17 elbows were replaced with the unlinked Kudo type 3 total elbow arthroplasty in 16 patients with arthritic joint destruction. Of these elbows, 8 were available for clinical examination after a mean of 9.5 years. Of the 17 elbow implants, 5 were revised: 2 because of loosening of the ulnar component, 1 because of dislocation, 1 because of a periprosthetic fracture, and 1 because of a late deep infection. At 9.5 years' follow-up, 67.9% of the prostheses had survived, and the mean survival of the implant was 8.7 years (95% confidence interval, 7.5-10 years). In this study, we observed high rates of progressive valgus tilting of the ulnar component. This valgus tilting is of major concern because it provides more stress to a smaller area on the polyethylene. It may, therefore, cause an increased degree of polyethylene wear and, thereby, reduce the final implant survival rate.