Outcomes of primary total hip arthroplasty using 3D image-based custom stems in unselected patients: a systematic review.

To report clinical and radiographic outcomes of primary THA using three-dimensional (3D) image-based custom stems. This systematic review was performed according to PRISMA guidelines and registered with PROSPERO (CRD42020216079). A search was conducted using MEDLINE, Embase and Cochrane. Clinical studies were included if they reported clinical or radiographic outcomes of primary THA using 3D image-based custom stems. Studies were excluded if specific to patients with major hip anatomical deformities, or if not written in English. Fourteen studies were eligible for inclusion (n = 1936 hips). There was considerable heterogeneity in terms of manufacturer, proximal geometry, coating and length of custom stems. Revision rates ranged from 0% to 1% in the short-term, 0% to 20% in the mid-term, and 4% to 10% in the long-term, while complication rates ranged from 3% in the short-term, 0% to 11% in the mid-term and 0% to 4% in the long-term. Post-operative Harris hip scores ranged from 95 to 96 in the short-term, 80 to 99 in the mid-term, and 87 to 94 in the long-term. Radiographic outcomes were reported in eleven studies, although none reported 3D implant sizing or positioning, nor compared planned and postoperative hip architecture. Primary THA using 3D image-based custom stems in unselected patients provides limited but promising clinical and radiographic outcomes. Despite excellent survival, the evidence available in the literature remains insufficient to recommend their routine use. Future studies should specify proximal geometry, length, fixation, material and coating, as well as management of femoral offset and anteversion. The authors propose a classification system to help distinguish between custom stem designs based primarily on their proximal geometry and length.

It is not 'business as usual' for orthopaedic surgeons in May 2020- the Austrian-German-Swiss experience.

PURPOSE: To document the status-quo of orthopaedic health-care services as the COVID-19 pandemic recedes, and to determine the rate of resumption of orthopaedic surgery in the German-speaking countries in May 2020. METHODS: A prospective online survey was sent out to 4234 surgeons of the AGA - Society of Arthroscopy and Joint-Surgery (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA). The survey was created using SurveyMonkey software and consisted of 23 questions relating to the reduction of orthopaedic services at the participating centres and the impact that the pandemic is having on each surgeon. RESULTS: A total of 890 orthopaedic surgeons responded to the online survey. Approximately 90% of them experienced a reduction in their surgical caseload and patient contact. 38.7% stated that their institutions returned to providing diagnostic arthroscopies. 54.5% reported that they went back to performing anterior cruciate ligament reconstructions (ACLR), 62.6% were performing arthroscopic meniscus procedures, and 55.8% had resumed performing shoulder arthroscopy. Only 31.9% of the surgeons were able to perform elective total joint arthroplasty. 60% of the participants stated that they had suffered substantial financial loss due to the pandemic. CONCLUSION: A gradual resumption of orthopaedic health-care services was observed in May 2020. Typical orthopaedic surgical procedures like ACLR, shoulder arthroscopy and elective total joint arthroplasty were reported to be currently performed by 54%, 56% and 32% of surgeons, respectively. Despite signs of improvement, it appears that there is a prolonged curtailment of orthopaedic health-care at present in the middle of Europe.

Outcomes of capsulolabral reconstruction for posterior shoulder instability.

BACKGROUND: Surgical treatment of isolated posterior shoulder instability-a rare and often misdiagnosed condition-is controversial because of poor outcomes. Failure of physical therapy in symptomatic young athletes requires capsulolabral reconstruction or bone block procedures. The goal of this study was to report the outcomes of patients who have undergone surgical capsulolabral reconstruction and to look for risk factors that contribute to failure of this procedure. MATERIAL AND METHOD: We analyzed the outcomes of 101 patients who underwent capsulolabral reconstruction: 83 included retrospectively, 18 included prospectively. The procedures were performed alone or in combination with capsular shift, labral repair, closure of the rotator interval and notch remplissage. The primary endpoint was failure of the procedure, defined as recurrence of the instability and/or pain. We also determined the outcomes based on specific (Walch-Duplay, modified Rowe) and non-specific (Constant, resumption of activities) scores of shoulder instability. RESULTS: The results were satisfactory despite a high failure rate: 35% in the retrospective cohort with 4.8±2.6 years' follow-up and 22% in the prospective cohort with 1.1±0.3 years' follow-up. The various outcome scores improved significantly. Ninety-two percent of patients returned to work and 80% of athletes returned to their pre-injury level of sports. Eighty-five percent of patients were satisfied or very satisfied after the surgery. No risk factors for failure were identified; however, failures were more common in older patients, those who underwent an isolated procedure and those who had unclassified clinical forms. CONCLUSION: Treatment of posterior shoulder instability by capsulolabral reconstruction leads to good clinical outcomes; however, the recurrence rate is high. LEVEL OF EVIDENCE: 4 - retrospective study.

External rotation of the femoral component increases asymmetry of the posterior condyles.

AIMS: The morphometry of the distal femur was largely studied to improve bone-implant fit in total knee arthroplasty (TKA), but little is known about the asymmetry of the posterior condyles. This study aimed to investigate the dimensions of the posterior condyles and the influence of externally rotating the femoral component on potential prosthetic overhang or under-coverage. PATIENTS AND METHODS: We analysed the shape of 110 arthritic knees at the time of primary TKA using pre-operative CT scans. The height and width of each condyle were measured at the posterior femoral cut in neutral position, and in 3º and 5º of external rotation, using both central and medial referencing systems. We compared the morphological characteristics with those of 14 TKA models. RESULTS: In the neutral position, the dimensions of the condyles were nearly equal. Externally rotating the femoral cut by 3º and 5º with 'central referencing' induced width asymmetry > 3 mm in 23 (21%) and 33 (30%) knees respectively, while with 'medial referencing' it induced width asymmetry > 3 mm in 43 (39%) and 75 (68%) knees respectively. The asymmetries induced by rotations were not associated with gender, aetiology or varus-valgus alignment. CONCLUSION: External rotation may amplify the asymmetry between the medial and lateral condyles, and exacerbate prosthetic overhang, particularly in the superolateral zone. 'Central referencing' guides result in less potential prosthetic overhang than 'medial referencing' guides. Cite this article: Bone Joint J 2017;99-B:894-903.

Morphometric analysis of the distal femur in total knee arthroplasty and native knees.

AIMS: Analysis of the morphology of the distal femur, and by extension of the femoral components in total knee arthroplasty (TKA), has largely been related to the aspect ratio, which represents the width of the femur. Little is known about variations in trapezoidicity (i.e. whether the femur is more rectangular or more trapezoidal). This study aimed to quantify additional morphological characteristics of the distal femur and identify anatomical features associated with higher risks of over- or under-sizing of components in TKA. METHODS: We analysed the shape of 114 arthritic knees at the time of primary TKA using the pre-operative CT scans. The aspect ratio and trapezoidicity ratio were quantified, and the post-operative prosthetic overhang was calculated. We compared the morphological characteristics with those of 12 TKA models. RESULTS: There was significant variation in both the aspect ratio and trapezoidicity ratio between individuals. Femoral trapezoidicity was mostly due to an inward curve of the medial cortex. Overhang was correlated with the aspect ratio (with a greater chance of overhang in narrow femurs), trapezoidicity ratio (with a greater chance in trapezoidal femurs), and the tibio-femoral angle (with a greater chance in valgus knees). DISCUSSION: This study shows that rectangular/trapezoidal variability of the distal femur cannot be ignored. Most of the femoral components which were tested appeared to be excessively rectangular when compared with the bony contours of the distal femur. These findings suggest that the design of TKA should be more concerned with matching the trapezoidal/rectangular shape of the native femur. TAKE HOME MESSAGE: The distal femur is considerably more trapezoidal than most femoral components, and therefore, care must be taken to avoid anterior prosthetic overhang in TKA

Do outcomes of outpatient ACL reconstruction vary with graft type?

BACKGROUND: Studies establishing the feasibility of anterior cruciate ligament (ACL) reconstruction as an outpatient procedure in France were usually conducted with hamstring tendon grafts. The objective of this study was to evaluate the outcomes of outpatient ACL reconstruction according to whether the graft was harvested from the hamstring tendons or patellar tendon. HYPOTHESIS: Outpatient ACL reconstruction can be performed using any type of graft. METHODS: A single-centre retrospective study was conducted in consecutive patients older than 16 years who had primary ACL reconstruction using patellar tendon or hamstring tendons, with or without lateral tenodesis. Patients who underwent other procedures on bones or peripheral ligaments and those with a previous history of ACL reconstruction were excluded. The primary evaluation criterion was the occurrence of complications within 45 days after surgery. Secondary evaluation criteria were the visual analogue scale (VAS) for pain during the first 3 postoperative days, patient satisfaction on day 3, and the IKDC and Lysholm clinical scores on day 45. RESULTS: The analysis included 104 knees (one knee per patient). Hamstring tendons were used in 77 (74%) knees and patellar tendon in 27 (26%) knees. In the hamstring group, 2 (2.6%) patients spent the first postoperative night in the hospital and 2 others were re-admitted. No hospitalisations were recorded in the patellar-tendon group. None of the patients required revision surgery within 45 days of the reconstruction procedure. None of the postoperative criteria studied showed statistically significant differences between the two groups. DISCUSSION: ACL reconstruction can be performed on an outpatient basis using any type of graft. The main determinants of successful outpatient ACL reconstruction are a standardised clinical management strategy and an appropriate anaesthesia protocol. LEVEL OF EVIDENCE: Level IV, retrospective study.

Tibial component rotation assessment using CT scan in medial and lateral unicompartmental knee arthroplasty.

BACKGROUND: Rotation of tibial component has not been analysed in literature for unicompartmental knee arthroplasty. The purpose of the study was to determine and compare the rotation of medial and lateral unicompartmental knee arthroplasty (UKA) tibial components. We assumed both components (lateral and medial) were positioned with external rotation. PATIENTS AND METHODS: Eighteen lateral and 19 medial UKA patients were scanned postoperatively in neutral position with computed tomography enabling lower extremity three-dimensional image acquisition from the hip to the ankle. All the patients were operated by three different senior surgeons using the same surgical technique. From the reconstructions we measured the two-dimensional (2D) rotation of the tibial components. RESULTS: The rotation of the tibial component was external (mean 6.5°, SD 5.1°) for the medial UKA and external (mean 7.3°, SD 10.3°) as well for the lateral UKA. The difference was statistically insignificant (P=0.717). DISCUSSION: This study presents the first 2D in vivo analysis accurately determining and comparing medial and lateral UKA component rotation. Despite a wide range of value, we found both components were indeed externally rotated. The variability in implant positioning was observed despite the rigorous performance of an experienced surgeon using routine techniques in patients selected under routine criteria. Further analysis of these patients for satisfaction and implant survivorship in relation to implant rotation may give us an optimal range for the tibial component. If it is found that this ideal range cannot be consistently obtained with current surgical techniques then there may be a case for the use of a navigation system.

Lateral versus medial tibial plateau: morphometric analysis and adaptability with current tibial component design.

The purpose of this study was to analyze the in vivo dimensions of each tibial plateau for planning of unicompartmental knee arthroplasty (UKA), and to compare the morphometric data to the dimensions of nine current designs of UKA tibial components. Thirty-seven knees (31 females and 6 males) operated on with UKA were studied. All patients were examined postoperatively using computed tomography (CT). There were 18 lateral and 19 medial UKAs. On the CT scan, each operated tibial plateau was measured in the transverse plane at the resection level, just below the full polyethylene tibial component. We measured the length of the anteroposterior (AP) cut as well as the maximal mediolateral dimension of the resected plateau (perpendicular to the AP cut). We compared the measurements with nine current UKA systems: Accuris (Smith and Nephew), Advance (Wright Medical), HLS Uni Evolution (Tornier), Miller-Galante and "ZUK" (Zimmer), Oxford and Oxford alpha (Biomet), Preservation (DePuy) and Unix (Stryker). There was good correlation between patient height and mediolateral dimension (r=0.6), and between patient height and area of total tibial plateau (r=0.7). The anteroposterior dimension was greater for the medial plateau (mean 50.8 mm, SD 3.3) than for the lateral plateau (mean 47.2 mm, SD 3.3). This difference was statistically significant (P=0.0016). Some UKA implants are designed with an asymmetric femoral component, but none have an asymmetric tibial component. The present study suggests, however, that the shape of the medial tibial plateau differs from that of the lateral plateau. This difference can lead to mediolateral overhang for medial UKA, if the surgeon aims for optimal anteroposterior coverage.