Acceptable Success Rate in Patients With Periprosthetic Knee Joint Infection Treated With Debridement, Antibiotics, and Implant Retention.

BACKGROUND: Acute periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) surgery can be treated with debridement, antibiotics, and implant retention (DAIR). However, varying results have been reported in the literature and optimal timing of the procedure is still debated. In this retrospective cohort study, we investigate (a) success rate of DAIR for treating PJI following primary TKA surgery and (b) whether time after primary surgery until DAIR and (c) type of isolated microorganism influence outcome. METHODS: Sixty-seven patients with PJI following primary TKA surgery treated with DAIR were identified. Patients with insufficient data and patients who did not fulfill Musculoskeletal Infection Society PJI criteria were excluded, leaving 58 patients for analysis. Minimum follow-up was 2 years. A DAIR was considered a success if the patient was infection free after 2 years. RESULTS: The overall success rate of PJI treated with DAIR was 84%. Median time until DAIR was 21 days (7-1092). Thirty-four patients (59%) were revised within 28 days, 42 patients (72%) within 42 days, while 10 patients (17%) were revised more than 90 days after primary TKA surgery. The success rates were 85%, 88%, and 60%, respectively. In the patients revised within 90 days, our success rate was 90% (43/48) regardless of the involved microorganism. CONCLUSION: We find DAIR to be a viable and safe treatment option for PJI following primary TKA surgery, when performed early after primary surgery and with the addition of a relevant postrevision antibiotic regime.

Total knee arthroplasty in younger patients evaluated by alternative outcome measures.

In this prospective multicenter study we included subjects younger than 60 years of age and scheduled for primary total knee arthroplasty (TKA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sexual life. Questionnaires including Oxford Knee Score (OKS) and SF-36 were evaluated preoperatively and 3, 6, and 12 months postoperatively. OKS and SF-36 showed significant improvements. However, patient satisfaction and fulfillment of personal expectations did not reflect these scores. Overall, TKA did not affect the patients' socioeconomic status, and overall, patients did not experience impairment of sexual life, but decreased frequency and negative affection of sexual practice should be anticipated. Alternative outcome measurements of TKA surgery not focusing on implants and surgical techniques shed new light on important consequences of arthroplasty surgery.

The epidemiology of Schmorl's nodes and their correlation to radiographic degeneration in 4,151 subjects.

PURPOSE: Schmorl's nodes (SNs) are commonly seen in vertebral imaging of the normal adult population referred for different reasons and are duly noted by the radiologist. However, little is known about their etiology: either SNs are perceived as largely inert developmental or congenital herniations of disc tissue into weak areas of the vertebral end-plates, or they are perceived as a common pathological pathway of different adverse and general factors such as malignancy, trauma, infection, osteoporosis, Paget's disease and so forth. A commonly accepted morphological definition of what precisely constitute SNs does not exist, and consequently prevalences vary wildly in the literature. In the present study of 4,151 standardized lateral radiographs of the lumbar spine in an adult, Caucasian population between 22 and 93 years (median age 63 years, M 1,533, W 2,618). METHODS: We investigated prevalence, distribution and epidemiologic relationships of SNs. RESULTS: SNs occur primarily in the upper part of the lumbar spine, and usually there are multiple lesions in the same individual. We could not establish any significant correlation between SNs and gender, age, BMI, height, weight or occupational exposure for heavy lifting. The overall prevalence was 3.8%. We did not find any significant correlations between SNs and overall degeneration of the lumbar spine. CONCLUSION: We found a prevalence of SNs in the lower end of the spectrum than hitherto reported.

The alignment of the knee joint in relationship to age and osteoarthritis: the Copenhagen Osteoarthritis Study.

INTRODUCTION: The aim of the present study was to describe the changes in the axis of the knee joint in both radiologically osteoarthritic and non-osteoarthritic knees, on the basis of angles measurable in standardized clinical short knee radiographs, in a cross sectional study of an epidemiological cohort. DESIGN: From the third inclusion of the Copenhagen City Heart Study, 4,151 subjects were selected for standardized radiography of the knees. After censuring the inclusion, the resulting cohort was comprised of 3,488 individuals. Images were analyzed for radiological knee joint osteoarthritis (OA) and the anatomical femorotibial axis of the knee joint was measured. RESULTS: The prevalence of knee joint OA in males was 27.9% and 27.5%, for the left and right knees respectively. In females this was 32.8% and 36.4%. The mean knee joint angles were 4.11° in males; and 5.45° in females. A difference of 1.3° was found between the genders. In non-osteoarthritic knees the increase in valgus orientation in relationship to increasing age was found to be 0.03° and 0.04° per year, respectively, for males and females. Likewise, Kellgren and Lawrence found that OA was seen to influence a shift towards varus of 0.55°-0.76° per level of OA. CONCLUSION: Stratification in accordance with morphological severity of OA documented a clear tendency for the axis of the diseased knees to depart from the mean, primarily in the direction of varus. In knees exhibiting no signs of radiographic osteoarthritis we found a significant relationship between increasing age and a shift in the anatomical axis in the direction of valgus.

A new algorithm for hip fracture surgery. Reoperation rate reduced from 18 % to 12 % in 2,000 consecutive patients followed for 1 year.

BACKGROUND AND PURPOSE: Treatment of hip fracture patients is controversial. We implemented a new operative and supervision algorithm (the Hvidovre algorithm) for surgical treatment of all hip fractures, primarily based on own previously published results. METHODS: 2,000 consecutive patients over 50 years of age who were admitted and operated on because of a hip fracture were prospectively included. 1,000 of these patients were included after implementation of the algorithm. Demographic parameters, hospital treatment, and reoperations within the first postoperative year were assessed from patient records. RESULTS: 931 of 1,000 operative procedures were performed according to the algorithm, as compared to only 726 of 1,000 prior to its introduction (p < 0.001). After implementation of the algorithm, junior registrars still performed half of the operations, but unsupervised procedures declined from 192 of 1,000 to 105 of 1,000 (p < 0.001). The rate of reoperations declined from 18% to 12% (p < 0.001 in a multiple Cox regression analysis), with a decline of 24% to 18% for intracapsular fractures and a decline of 13% to 7% for extracapsular fractures. The proportion of bed-days caused by reoperations was reduced from 24% of total hospitalization before the algorithm was introduced to 18% after it was introduced. INTERPRETATION: It is possible to implement an algorithm for treatment of all hip fracture patients in a large teaching hospital. In our case, the Hvidovre algorithm both raised the rate of supervision and reduced the rate of reoperations. The reduced reoperation rate saved many hospital bed-days.

Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year.

BACKGROUND AND PURPOSE: In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fractured lateral femoral walls, where it often led to lack of healing in a maximally telescoped position. We hypothesized that INs would be the superior implant in these specific circumstances. METHODS: We retrospectively examined 311 consecutive patients treated in our department between 2002 and 2008, with either an IN (n = 158) or an SHS (n = 153) mounted on a 4-hole side-plate, for an AO/OTA type 31A1-2 pertrochanteric fracture with a detached greater trochanter. The status of the lesser trochanter was assessed preoperatively and the integrity of the lateral femoral wall, fracture reduction, and position of the implants were assessed postoperatively. Reoperations due to technical failure were recorded for one year postoperatively. RESULTS: Multivariate logistic regression analysis showed that the groups were similar regarding demographic and biomechanical parameters. The lateral femoral wall was more frequently fractured during SHS implantation (42 patients) than in the IN group (9 patients) (p < 0.001). 6 (4%) of the 158 patients operated with IN had to be reoperated, as compared to 22 (14%) in the SHS group of 153 patients (p = 0.001). INTERPRETATION: IN had a lower reoperation rate than SHS in these pertrochanteric hip fractures with a detached greater trochanter. IN left more lateral femoral walls intact.

Case definitions of knee osteoarthritis in 4,151 unselected subjects: relevance for epidemiological studies: the Copenhagen Osteoarthritis Study.

INTRODUCTION: The aims of the present study were threefold: to examine the distribution of knee joint osteoarthritis in a large, standardized radiological study; to examine the relationships between self reported knee pain and radiological OA; and to examine the natural history of radio-morphological change over age in individuals without radiological features of OA. MATERIALS AND METHODS: The Copenhagen Osteoarthritis Study - COS is a substudy of the Copenhagen City Heart Study, a longitudinal regional health survey. From the third inclusion of the CCHS (1992-1994) 4,151 subjects were selected for subsequent standardized radiography of the pelvis, the knees, the hands, the wrists, and the lumbar spine. Images were analyzed and knee joint osteoarthritis (OA) was classified according to the radiographic atlas of Kellgren and Lawrence. Joint space width (JSW) was measured at three sites within both the medial and the lateral compartment. RESULTS: For the entire cohort the prevalence of radiological knee joint OA of all grades was 38.7% for men and 44.2% for women. Age stratification documented increasing knee joint OA both in regard to prevalence and morphological severity. Knee pain was universally correlated to the Kellgren and Lawrence severity of OA. In a subgroup with no features of radiological OA, a significant and linear decline in JSW with increasing age was found. CONCLUSION: We found a clear relationship between self-reported knee pain and radiological osteoarthritis. Pain was proportionally related to the severity of change. We also demonstrated a significant diminishing of joint space width with increasing age in individuals without apparent radiological degeneration.

Cranial acetabular retroversion is common in developmental dysplasia of the hip as assessed by the weight bearing position.

BACKGROUND AND PURPOSE: The appearance of acetabular version differs between the supine and weight bearing positions in developmental dysplasia of the hip. Weight bearing radiographic evaluation has been recommended to ensure the best coherence between symptoms, functional appearance, and hip deformities. Previous prevalence estimates of acetabular retroversion in dysplastic hips have been established in radiographs recorded with the patient supine and with inclusion only if pelvic tilt met standardized criteria. We assessed the prevalence and the extent of acetabular retroversion in dysplastic hip joints in weight bearing pelvic radiographs. PATIENTS AND METHODS: We assessed 95 dysplastic hip joints (54 patients) in weight bearing anteroposterior pelvic radiographs, measuring the acetabular height and the distance from the acetabular roof to the point of crossing of the acetabular rims, if present. RESULTS: Acetabular retroversion was found in 31 of 95 dysplastic hip joints. In 28 of 31 hip joints with retroversion, crossover of the acetabular rims was positioned within the cranial 30% sector. The degree of pelvic tilt differed between retroverted and non-retroverted dysplastic hip joints, though only reaching a statistically significant level in male dysplastic hip joints. INTERPRETATION: We identified cranial acetabular retroversion in one-third of dysplastic hip joints when assessed on weight bearing pelvic radiographs. If assessed on pelvic radiographs obtained with the patient supine, and with inclusion only if the degree of pelvic tilt meets standardized criteria, the prevalence of acetabular retroversion may be underestimated.

Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients.

BACKGROUND AND PURPOSE: Very few studies have focused on patient characteristics that influence length of stay (LOS) in fast-track total hip (THR) and knee arthroplasty (TKR). The aim of this prospective study was to identify patient characteristics associated with LOS and patient satisfaction after total hip and knee replacement surgery. PATIENTS AND METHODS: Between September 2003 and December 2005, 712 consecutive, unselected patients (440 women) with a mean age of 69 (31-91) years were admitted for hip and knee replacement surgery at our specialized fast-track joint replacement unit. Epidemiological, physical, and perioperative parameters were registered and correlated to LOS and patient satisfaction. RESULTS: 92% of the patients were discharged directly to their homes within 5 days, and 41% were discharged within 3 days. Age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization, were all found to influence postoperative outcome in general, and LOS and patient satisfaction in particular. INTERPRETATION: We identified several patient characteristics that influence postoperative outcome, LOS, and patient satisfaction in our series of consecutive fast-track joint replacement patients, enabling further attention to be paid to certain aspects of surgery and rehabilitation.

Low bone mineral density is associated with reduced hip joint space width in women: results from the Copenhagen Osteoarthritis Study.

OBJECTIVE: Since estrogen receptors (ER-alpha/ER-beta) were identified in human chondrocytes, animal and experimental studies have demonstrated the importance of continued estrogen production for the integrity of articular cartilage. However, human epidemiological support of the hypothesis has been inconclusive. The present cross-sectional study investigated the relationship between reduced bone mineral density (BMD), as a surrogate parameter of endogenous estrogen status assessed by digital x-ray radiogrammetry, and reduced minimum hip joint space width (JSW). DESIGN: Standardized hand radiographs of the Copenhagen Osteoarthritis Study cohort of 3,913 adults (1,470 male/2,443 female) with a mean age of 60 years (range, 18-92) were analyzed using X-Posure digital software, version 2.0 (Sectra-Pronosco). The system is operator independent. From 1,200 individual measurements per radiograph, mean BMD was calculated. Minimum hip JSW was assessed on standardized pelvic radiographs. RESULTS: Digital x-ray radiogrammetry BMD decreased in both men and women after the age of 45 years, progressively more so in women. Although minimum hip JSW in men remained relatively unaltered throughout life, a marked decline in female minimum hip JSW after age 45 years was observed. We found moderate but highly significant relationships between reduced BMD and reduced hip JSW in women (P < 0.0001), adjusted for age and dysplastic joint incongruity. CONCLUSION: We believe that the present study supports the hypothetical relationship between reduced estrogen levels and hip JSW reduction in women.

Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation.

BACKGROUND: Reoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture, the position of the implant, and the patient's characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw. METHODS: Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135 degrees sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively. RESULTS: Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001). CONCLUSIONS: A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.

No major effects of preoperative education in patients undergoing hip or knee replacement--a systematic review.

INTRODUCTION: The outcome of total hip (THA) and knee arthroplasty (TKA) may be optimised through preoperative patient education (PPE). It is hypothesised that PPE reduces anxiety, ensures realistic patient expectations and enhances post-operative outcome. The objective was to determine whether the literature supports a positive effect of PPE on post-operative outcomes including anxiety, pain, length of hospital stay (LOS), patient satisfaction, post-operative complications, mobility, and expectations. METHODS: PubMed and Embase searches were performed on 1 October 2014. Randomised studies of preoperative edu-cation (written, verbal and audiovisual) imparted by health professionals to patients were included. RESULTS: A total of twelve studies including 1,567 participants were identified. Six studies involved patients undergoing THA, five studies involved both THA and TKA, and one study TKA only. No convincing evidence in favour of PPE on outcomes regarding pain, LOS, patient satisfaction, post-operative complications, mobility and expectations was found. However, there was evidence for a reduction in preoperative anxiety. CONCLUSION: PPE has not been shown to affect post-operative outcomes - except for a significant reduction in preoperative anxiety. However, this conclusion may be flawed by the general heterogeneity of the pooled studies. Hence, there is a strong need for properly designed randomised and controlled studies that are sufficiently powered, performed in generalised optimised hospital settings including optimised logistics and clinical enhancements that allow for discrimination between outcome parameters.

Alternative outcome measures in young total hip arthroplasty patients: a prospective cohort study.

In this prospective multicentre cohort study we studied subjects younger than 60 years of age scheduled for primary total hip arthroplasty (THA). The study assessed patients' overall satisfaction, fulfillment of preoperative expectations, the effect on socioeconomic parameters, and quality of sex-life. Questionnaires including Oxford Hip Score (OHS) and SF-36 were evaluated preoperatively and 3, 6 and 12 months postoperatively. OHS and SF-36 showed significant improvements (p<0.028, Wilcoxon Signed Rank test). THA did not affect the patients' socioeconomic status. Increased frequency of intercourse or better abilities in intercourse positions were experienced by 18 of 39 females due to reduced pain and increased range of motion. Patients sexually active before THA surgery remained active. These findings constitute important new information to young patients and surgeons during the decision making process.

[The dysplastic hip I. Etiology, epidemiology and diagnosis]. / Den dysplastiske hofte I. Aetiologi, epidemiologi og diagnostik.

Magnetic resonance scanning, computer tomography, and dynamic ultrasound-scans have recently unveiled a broad spectrum of morphological anomalies of the dysplastic hip. The possibility of individualized treatment of late diagnosed and residual dysplasia of the hip in childhood and adulthood has renewed the interest in this orthopaedic topic.

[The dysplastic hip II. Treatment]. / Den dysplastiske hofte II. Behandling.

The possibility of individualized treatment of residual dysplasia of the hip in childhood and adulthood has renewed the interest in this orthopaedic field and new procedures of treatment have been devised. This article reviews current knowledge of the treatment of the dysplastic hip.

Periacetabular osteotomy: sporting, social and sexual activity 9-12 years post surgery.

Hip joint survivorship and functional outcome are traditional outcome measures applied after periacetabular osteotomy (PAO). Younger adults however have greater demands and expectations on the function of their hip joints and these demands are not expressed using traditional outcome assessment tools. The main purpose of this study was to explore alternative functional and quality of life measure after PAO.A cross sectional survey of preserved hip joints following PAO was performed. Fifty-two patients (68 hips), mean age 41 years (range 24-67), returned a questionnaire examining satisfaction, willingness to repeat surgery, quality of life, abilities in social activities, sports and sex-life, pain, limp, and stability of the hip.Median satisfaction was 5 (range 1-5) and 44 of 49 patients were willing to repeat surgery. Significant improvements were seen in quality of life, ability to do sports, participate in social activities and sex-life (p values <0.001) (although sex-life for males (p = 0.102)). Traditional outcomes (pain, stability and limp) showed significant improvements (p<0.001). Lasting improvements in patients' sex life, social life and ability to do sports nine to 12 years following PAO were reported. Such factors are important measures of outcome in a younger adult cohort.

[Arthrosis and arthroplastic surgery influence patients' sex life, depression, and socioeconomy]. / Artrose og alloplastikkirurgi har indflydelse på seksualliv, depression og socioøkonomiske forhold.

Over the past years there has been an increasing number of total hip or total knee arthroplastic operations. Due to demographic changes this tendency will probably continue. The operation frees the patient of disabling pain and stiffness and gives back the mobility to the patient. This systematic review addresses the impact an operation has on the patients' quality of life, economy, sex-life and possibly depression. We have identified relevant articles by search of PubMed MeSH database and a traditional search of PubMed. Furthermore we have evaluated the reference lists for articles of interest.

[Hip arthroscopy]. / Hofteartroskopi.

This review article describes the role of hip arthroscopy and the development of the technique over the past decade. The refinement of this technique has led to the discovery of ''new'' diseases of the hip joint. Recently, femoro-acetabular impingement (FAI) has been proposed as a source of soft tissue dysfunction, motion loss, and early osteoarthritis in the hip. Recognition of FAI is important, as failure to address this underlying pathology may lead to early onset osteoarthritis and subsequent hip replacement. The preliminary results after hip arthroscopy are described.

The prevalence of predisposing deformity in osteoarthritic hip joints.

It is becoming increasingly evident that hip joint deformities may be major contributors to the development of osteoarthritis, and the term 'idiopathic osteoarthritis' may be inappropriate in many cases. Our study cohort was derived from the Copenhagen Osteoarthritis Sub-study, a cross sectional population-based database of 4151 individuals, all of whom had a standard anteroposterior weight-bearing pelvic radiograph taken. Hip joints were classified according to type and degree of deformity. We defined hip osteoarthritis by a minimum joint space width of < or = 2 mm. This cut-off has a significant relationship in both sexes with the clinical presentation. The study cohort which fulfilled these inclusion criteria consisted of 322 females (149 right hips and 173 left hips) and 162 males (77 right hips and 85 left hips) with osteoarthritis. We found an overall prevalence of predisposing hip deformities in females of 62.4% and in males of 78.9%. Minor and major deformities showed the same prevalence. Both sexes had a comparable prevalence of minor and major hip joint deformity, except for pistol grip deformity, which was more prevalent in men. We concluded that 'idiopathic osteoarthritis' is uncommon, and that even minor predisposing deformities are associated with hip osteoarthritis.

Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey.

BACKGROUND: Although the clinical consequences of femoroacetabular impingement have been well described, little is known about the prevalence of the anatomical malformations associated with this condition in the general population, the natural history of the condition, and the risk estimates for the development of osteoarthritis. METHODS: The study material was derived from a cross-sectional population-based radiographic and questionnaire database of 4151 individuals from the Copenhagen Osteoarthritis Substudy cohort between 1991 and 1994. The subjects were primarily white, and all were from the county of Østerbro, Copenhagen, Denmark. The inclusion criteria for this study were met by 1332 men and 2288 women. On the basis of radiographic criteria, the hips were categorized as being without malformations or as having an abnormality consisting of a deep acetabular socket, a pistol grip deformity, or a combination of a deep acetabular socket and a pistol grip deformity. Hip osteoarthritis was defined radiographically as a minimum joint-space width of 0.13). A deep acetabular socket was a significant risk factor for the development of osteoarthritis (risk ratio, 2.4), as was a pistol grip deformity (risk ratio, 2.2). Acetabular dysplasia and the subject's sex were not found to be significant risk factors for the development of hip osteoarthritis (p = 0.053 and p = 0.063, respectively). The prevalence of hip osteoarthritis was 9.5% in men and 11.2% in women. The prevalence of concomitant malformations was 71.0% in men with hip osteoarthritis and 36.6% in women with hip osteoarthritis. CONCLUSIONS: In our study population, a deep acetabular socket and a pistol grip deformity were common radiographic findings and were associated with an increased risk of hip osteoarthritis. The high prevalence of osteoarthritis in association with malformations of the hip joint suggests that an increased focus on early identification of malformations should be considered.