Salami-Tactics: when is it time for a major cut after multiple minor amputations?

INTRODUCTION: Repetitive minor amputations carry the concomitant risks of multiple surgical procedures, major amputations have physical and economical major drawbacks. The aim of this study was to evaluate whether there is a distinct number of minor amputations predicting a major amputation in the same leg and to determine risk factors for major amputation in multiple minor amputations. MATERIALS AND METHODS: A retrospective chart review including 429 patients with 534 index minor amputations between 07/1984 and 06/2019 was conducted. Patient demographics and clinical data including number and level of re-amputations were extracted from medical records and statistically analyzed. RESULTS: 290 legs (54.3%) had one or multiple re-amputations after index minor amputation. 89 (16.7%) legs needed major amputation during follow up. Major amputation was performed at a mean of 32.5 (range 0 - 275.2) months after index minor amputation. No particular re-amputation demonstrated statistically significant elevated odds ratio (a.) to be a major amputation compared to the preceding amputation and (b.) to lead to a major amputation at any point during follow up. Stepwise multivariate Cox regression analysis revealed minor re-amputation within 90 days (HR 3.8, 95% CI 2.0-7.3, p <0.001) as the only risk factor for major amputation if at least one re-amputation had to be performed. CONCLUSIONS: There is no distinct number of prior minor amputations in one leg that would justify a major amputation on its own. If a re-amputation has to be done, the timepoint needs to be considered as re-amputations within 90 days carry a fourfold risk for major amputation. LEVEL OF EVIDENCE: Retrospective comparative study (Level III).

Registration based assessment of femoral torsion for rotational osteotomies based on the contralateral anatomy.

BACKGROUND: Computer-assisted techniques for surgical treatment of femoral deformities have become increasingly important. In state-of-the-art 3D deformity assessments, the contralateral side is used as template for correction as it commonly represents normal anatomy. Contributing to this, an iterative closest point (ICP) algorithm is used for registration. However, the anatomical sections of the femur with idiosyncratic features, which allow for a consistent deformity assessment with ICP algorithms being unknown. Furthermore, if there is a side-to-side difference, this is not considered in error quantification. The aim of this study was to analyze the influence and value of the different sections of the femur in 3D assessment of femoral deformities based on the contralateral anatomy. MATERIAL AND METHODS: 3D triangular surface models were created from CT of 100 paired femurs (50 cadavers) without pathological anatomy. The femurs were divided into sections of eponymous anatomy of a predefined percentage of the whole femoral length. A surface registration algorithm was applied to superimpose the ipsilateral on the contralateral side. We evaluated 3D femoral contralateral registration (FCR) errors, defined as difference in 3D rotation of the respective femoral section before and after registration to the contralateral side. To compare this method, we quantified the landmark-based femoral torsion (LB FT). This was defined as the intra-individual difference in overall femoral torsion using with a landmark-based method. RESULTS: Contralateral rotational deviation ranged from 0° to 9.3° of the assessed femoral sections, depending on the section. Among the sections, the FCR error using the proximal diaphyseal area for registration was larger than any other sectional error. A combination of the lesser trochanter and the proximal diaphyseal area showed the smallest error. The LB FT error was significantly larger than any sectional error (p < 0.001). CONCLUSION: We demonstrated that if the contralateral femur is used as reconstruction template, the built-in errors with the registration-based approach are smaller than the intraindividual difference of the femoral torsion between both sides. The errors are depending on the section and their idiosyncratic features used for registration. For rotational osteotomies a combination of the lesser trochanter and the proximal diaphyseal area sections seems to allow for a reconstruction with a minimal error.

Clinical results of conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

BACKGROUND: Acromial and scapular spine fractures are common complications after reverse total shoulder arthroplasty (RTSA). There is limited information on the treatment outcome of these fractures. Therefore, the purpose of this study was to compare the clinical outcome of operative and conservative treatment of patients with acromial or scapular spine fractures. METHODS: A total of 1146 RTSAs were performed in our institution between 1999 and 2016. In 23 patients (2%), we identified an acromial fracture, and in 7 cases (0.6%), a scapular spine fracture in the postoperative course. Of those patients, 7 patients (23%) were treated with open reduction and internal fixation and 23 (77%) were treated conservatively. We compared the outcome of operative vs. conservative treatment assessing the Constant score (CS), range of motion, and subjective shoulder value (SSV). Fractures were classified by the system of Crosby. Radiographic assessment consisted of measuring the healing rate, time to heal, and the displacement of the acromion before and immediately after the fracture as well as after treatment. RESULTS: There were no statistically significant differences between operative and conservative treatment. The mean preoperative CS in the operative group was 32 points and improved to 45 points after surgery, whereas it was 35 points in the conservative group and improved to 61 points at the final follow-up. The mean SSV improved from 20 to 50 points in the operative group and from 22 to 58 points in the conservative group. Mean active flexion changed from 59° to 75°, mean abduction from 68° to 67°, and external rotation from 25° to 13° in the operative group and from 75° to 91°, 67° to 92°, and 28° to 24° in the conservative group. CONCLUSIONS: In our study, operative treatment was not superior to conservative treatment, neither for CS, SSV, or range of motion. Both treatment forms, however, resulted in inferior results to those previously reported for RTSA without postoperative acromion fractures. Before better surgical methods have been developed, conservative treatment of acromial fractures may be the better treatment option for acromial fractures after RTSA.

Consistency of 3D femoral torsion measurement from MRI compared to CT gold standard.

BACKGROUND: Several hip and knee pathologies are associated with aberrant femoral torsion. Diagnostic workup includes computed tomography (CT) and magnetic resonance imaging (MRI). For three-dimensional (3D) analysis of complex deformities it would be desirable to measure femoral torsion from MRI data to avoid ionizing radiation of CT in a young patient population. 3D measurement of femoral torsion from MRI has not yet been compared to measurements from CT images. We hypothesize that agreement will exist between MRI and CT 3D measurements of femoral torsion. METHODS: CT and MRI data from 29 hips of 15 patients with routine diagnostic workup for suspected femoroacetabular impingement (FAI) were used to generate 3D bone models. 3D measurement of femoral torsion was performed by two independent readers using the method of Kim et al. which is validated for CT. Inter-modalitiy and inter-reader intraclass correlation coefficients (ICC) were calculated. RESULTS: Between MRI and CT 3D measurements an ICC of 0.950 (0.898; 0.976) (reader 1) respectively 0.950 (0.897; 0.976) (Reader 2) was found. The ICC (95% CI) expressing the inter-reader reliability for both modalities was 0.945 (0.886; 0.973) for MRI and 0.957 (0.910; 0.979) for CT, respectively. Mean difference between CT and MRI measurement was 0.42° (MRI - CT, SD: 2.77°, p = 0.253). CONCLUSIONS: There was consistency between 3D measurements of femoral torsion between computer rendered MRI images compared to measurements with the "gold standard" of CT images. ICC for inter-modality and inter-reader consistency indicate excellent reliability. Accurate, reliable and reproducible 3D measurement of femoral torsion is possible from MRI images.

FAI morphology increases the risk for osteoarthritis in young people with a minimum follow-up of 25 years.

INTRODUCTION: The mechanical conflict in symptomatic femoroacetabular impingement can lead to early osteoarthritis. However, radiographic impingement morphology is often seen in asymptomatic individuals. Long-term observation regarding the risk of developing osteoarthritis in these individuals is lacking. Our study addressed the following questions: Does femoroacetabular impingement morphology increase the risk for development of osteoarthritis after at least 25 years? If yes, which radiographic parameter is the most predictive? Does the level of activity influence the risk for development of osteoarthritis? Are PROM influenced by the grade of osteoarthritis in this population? METHODS: We investigated 51 (32 male, 19 female) patients for whom AP pelvis and Dunn view radiographs were available with a minimum follow-up of 25 years. Alpha angle in AP pelvis and Dunn view radiographs, femoral torsion in Dunn view, lateral center edge angle, cross-over sign, posterior wall sign and prominence of ischial spine sign in AP pelvis radiographs were determined. On the follow-up radiographs, osteoarthritis was graded. Tegner Score for the time of the index radiograph was evaluated. Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index were assessed at latest follow-up. RESULTS: The mean follow-up was 43 years (range 25-58). Cam impingement morphology showed to increase the risk for development of osteoarthritis: Alpha angles of ≥ 55° on AP pelvis and Dunn view radiographs were associated risk factors and showed an OR of 1.05 (p = 0.002) and 1.10 (p = 0.001), respectively. Abnormal femoral torsion and acetabular retroversion were not risk factors for osteoarthritis. Tegner Score at index presentation, HHS and WOMAC Score did not correlate with the grade of osteoarthritis. CONCLUSION: This study showed that cam impingement morphology in young patients raises the risk for development of hip osteoarthritis by 5-10% in a long-term follow-up with a minimum of 25 years, thus its contribution was small.

Occult periprosthetic fractures of the acetabulum in THA using an elliptic cup design have no adverse impact on outcome.

Occult periprosthetic fractures have been defined as a fracture only visible on postoperative CT scans but not on postoperative plain radiography after an uneventful surgery without intraoperative fracture. The fracture rate for hemispherical and peripheral self-locking cups has been described as 8.4%. We retrospectively analyzed postoperative CT scans after primary THA to clear the question whether such occult periprosthetic fractures of the acetabulum require particular treatment strategy. Between 2014 and 2018 we identified 115 CT scans of 114 patients after primary cementless THA with elliptical cups using a direct anterior approach. The CT scans were obtained as part of other investigations. Localization of the fracture, patients demographics, clinical (WOMAC, Harris Hip Score) and radiological outcome were analyzed. Fracture and non-Fracture group were compared with regard to demographics and short-term outcome after 1 year. Four occult fractures (3.5%) were identified. Three fractures involved the posterior wall. All patients had an uneventful routine postoperative rehabilitation. Patients with occult fractures showed similar post- operative HHS and WOMAC scores at 3 (HHS p = 0.576, WOMAC p = 0.128) and 12 (HHS p = 0.479, WOMAC p = 0.588) months. There were no cup loosening nor radiolucent lines at latest follow-up (mean FU 22 months, range 12-34 months). Clinical and radiological short-term outcome was not impaired by the occurrence of an occult periprosthetic fracture of the acetabulum. The incidental detection of an occult periprosthetic fracture of the acetabulum does not seem to oblige the surgeon to adapt the postoperative regime.

Uncemented Total Hip Arthroplasty Through the Direct Anterior Approach: Analysis of a Consecutive Series of 275 Hips With a Minimum Follow-Up of 10 Years.

BACKGROUND: The purpose of this study was to document complications, outcomes, and 10-year survivorship of primary total hip arthroplasty (THA) using a direct anterior approach with an uncemented, straight, hydroxyapatite-coated stem and an uncemented cup. METHODS: A retrospective, consecutive series of 275 primary THAs through a direct anterior approach with traction table using Medacta Versafit cup and Quadra-H stem with a minimum of 10-year follow-up was identified. The cumulative 10-year survival of the implants was estimated using Kaplan-Meier estimator. All complications, reoperations, and failures were analyzed. Subjective and clinical outcomes (Subjective Hip Value, Western Ontario and McMaster Universities Osteoarthritis Index, and Harris Hip Score) were measured. RESULTS: Of 256 patients (275 hips, 143 men and 113 women) with a mean age of 63 (range, 24-85) years, 48 (19%) patients (52 hips) deceased not related to the surgery after a mean time 49 months (range, 3-118) postoperatively. At >10-year follow-up, 9 THAs were revised. The overall implant survival rate was 96.8% (95% confidence interval, 94.4-98.7) at 10 years. One cup and 1 stem were revised because of aseptic loosening. At the last follow-up, the median Subjective Hip Value was 90% (range, 20-100), the Western Ontario and McMaster Universities Osteoarthritis Index score reached a median of 0.2 points (range, 0-6.3), and the median Harris Hip Score points was 99 (range, 29-100). CONCLUSION: Primary THA through an anterior minimal invasive approach with the mentioned implants showed low revision rates and good to excellent clinical outcome after at least 10 years.

Is the contralateral tibia a reliable template for reconstruction: a three-dimensional anatomy cadaveric study.

PURPOSE: The contralateral anatomy is regularly used as a reconstruction template for corrective osteotomies of several deformities and pathological conditions. However, there is lack of evidence that the intra-individual differences between both tibiae are sufficiently small to use the contralateral tibia as a 3D reconstruction template for complex osteotomies. The aim of this study was to evaluate the intra-individual side differences of the tibia in length, torsion, angulation, and translation using 3D measurement techniques. METHODS: 3D surface models of both tibiae were created from computed tomography data of 51 cadavers. The (mirrored) models of the right tibiae were divided into two halves at the centre of the shaft. Thereafter, the proximal and distal segments were aligned to the left (contralateral) tibia in an automated fashion. The relative 3D transformation between both aligned segments was measured to quantify the side difference in 6° of freedom (3D translation vector, 3 angles of rotation). RESULTS: The mean side difference in tibia length was 2.1 mm (SD 1.3 mm; range 0.2-5.9 mm). The mean side difference in torsion was 4.9° (SD 4.1°; range 0.2°-17.6°). The mean side difference in the coronal and sagittal planes was 1.1° (SD 0.9°; range 0.0°-4.6°) and 1.0° (SD 0.8°; range 0.1°-2.9°), respectively. CONCLUSION: The present study confirms small side differences in torsion between the left and right tibia, while the side differences in the coronal and sagittal plane are probably negligible. The contralateral tibia seems to be a reliable reconstruction template for the 3D preoperative planning of complex corrective osteotomies of the tibia. However, torsional differences should be interpreted with caution, as a single cut-off value of a clinically relevant torsional side difference cannot be defined. The presented results are relevant to surgeons considering the contralateral tibia as a 3D reconstruction template for corrective osteotomies of the tibia. LEVEL OF EVIDENCE: Basic science.

Natural History of Degenerative Hip Abductor Tendon Lesions.

BACKGROUND: The best treatment of degenerative hip abductor tendon lesions remains largely unknown, as the natural course of the disease has not yet been reported. The aim of the present study was to investigate the natural history of symptomatic degenerative hip abductor lesions. HYPOTHESIS: Nonoperatively treated hip abductor lesions progress over time, resulting in refractory hip pain and low functional outcomes. STUDY DESIGN: Case series (prognosis); Level of evidence, 4. METHODS: Consecutive patients with greater trochanteric pain syndrome and degenerative changes on magnetic resonance imaging (MRI) of the symptomatic hip were included. Bilateral hip MRI scans and a clinical examination were performed at a minimum follow-up of 36 months to study the type and location of hip abductor lesion. Progression of a lesion was defined as a more severe lesion as compared with the initial MRI results or if the lesion extended to another, initially not involved, trochanteric facet. The muscle's fatty infiltration (FI) was also described. RESULTS: From 106 patients identified, 58 patients (64 hips) aged 66 ± 14 years (mean ± SD) agreed to return to the clinic for follow-up MRI and met the inclusion criteria. At a mean 71-month follow-up, an overall 34% (22/64) of lesions had progressed over time: from trochanteric bursitis to tendinopathy (9/64, 14%) or partial tear (5/64, 8%), from tendinopathy to partial tear (4/64, 6%), from a partial to complete tear (3/64, 4.5%), and with 1 complete tear (1/64, 1.5%) extending to another trochanteric facet. Interestingly, 90% of partial tears remained stable or transformed into a scar. Although patients with a progressive lesion experienced more trochanteric pain (visual analog scale, 4.6 vs 2.8; P = .001), the functional outcomes were comparable with patients with a stable lesion. The majority of hips with a partial tear (64%) demonstrated a progression of gluteus minimus FI from a median grade of 1 to 2, whereas only 1 hip (3%) progressed from grade 2 to 3. Only 3 hips (9%) with a partial tear had a progression of gluteus medius FI, which did not differ significantly from the contralateral unaffected side. CONCLUSION: Nonoperative treatment might be a valid long-term option for degenerative hip abductor lesions, especially for partial tears, which demonstrated a low risk of clinically relevant progression or muscle FI and similar clinical outcomes to those reported in the literature for operatively treated hip abductor tendon lesions.

Biomechanical and Clinical Evaluation of the Optimal Arm Position After Rotator Cuff Surgery With an Adjustable Abduction Brace.

Abduction braces are used with the intention of relieving tension on the supraspinatus, thereby protecting an operative repair. It is not known, however, whether patients wearing a brace do deposit the weight of the arm on the brace effectively or actively stabilize the arm despite the brace. It is further unknown what position of the arm is most effective to relax the shoulder and is considered most comfortable. Twenty-two patients who had undergone an arthroscopic supraspinatus repair were postoperatively fitted with a standard abduction brace equipped with a torque sensor to measure the weight of the arm on the brace on the first and second postoperative days. The most comfortable arm position, tear size, and degenerative muscular changes on magnetic resonance imaging were assessed. Most patients (15 vs 5) preferred a low angle of abduction with the brace in the scapular rather than the true frontal plane irrespective of tear location or size. While loads applied to the brace were slightly higher at high abduction angles (70° and 90°) under regional anesthesia (day 1), they were significantly higher at low abduction angles (30° and 50°) with the arm fully awake (day 2). The most comfortable brace position-which is at low angles of abduction (30° to 50°) in the scapular plane-is associated with the highest load transfer to the brace in the unanesthetized arm. The authors therefore conclude that if an abduction brace is used, it should be fitted in the scapular plane with an abduction angle between 30° and 50°. [Orthopedics. 2021;44(1):e1-e6.].

Acromial Fractures Following Reverse Total Shoulder Arthroplasty: A Cohort Controlled Analysis.

Fractures of the acromion can develop after reverse total shoulder arthroplasty (RTSA). This study sought to identify risk factors for acromial fractures in patients with RTSA. A total of 1146 RTSAs were performed at the authors' institution between 1999 and 2016. In 21 patients (1.8%), the authors identified an acromial fracture during the postoperative course. These patients were compared with a matched cohort of 84 patients who had not developed an acromial fracture postoperatively. As an indicator of changes in pre- to postoperative deltoid loading, the authors created an angle called the "delta angle." There was an elevated risk for acromial fractures with lower lateralization of the humerus from pre- to postoperatively (4.1±7.1 mm vs 8.4±6.1 mm; P=.006), lower preoperative anteroposterior acromial slope (117.3°±11.2° vs 121.7°±17.0°; P=.044), and higher glenoid inclination (beta angle, 72.0°±5.5° vs 76.5°±6.8°; P=.005). Pre- to postoperative changes in the beta angle (9.2°±8.0° vs 4.4°±9.4°; P=.022) and the delta angle (29.4°±8.1° vs 19.5°±9.7°; P<.001) were larger in the fracture group. In addition, diagnosed and treated osteoporosis appeared to be a risk factor for acromial fractures (33% vs 13%; P=.047). The delta angle after RTSA seems to correlate with the risk of developing an acromial fracture. Patients with a high glenoid inclination and/or osteoporosis should be informed that they are at risk. Further, surgeons should be aware that lower distalization together with greater medialization of the center of rotation was associated with more acromial fractures in this study. [Orthopedics. 2020; 43(1):15-22.].

Long-term Results of the Open Latarjet Procedure for Recurrent Anterior Shoulder Instability in Patients Older Than 40 Years.

BACKGROUND: Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy. PURPOSE: To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up. RESULTS: No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly (P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) (P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning (P < .001) and older age at surgery (r = 0.58; P < .001). CONCLUSION: The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.

Susceptibility-weighted imaging of the brain: does gadolinium administration matter?

OBJECTIVE: Susceptibility-weighted MR imaging (SWI) is usually obtained without administration of intravenous gadolinium (Gd). However, it is occasionally necessary to perform SWI after Gd is injected. The effects of Gd on SWI have not been systematically examined. The aim of this prospective study was to investigate whether performing SWI after Gd would influence the diagnostic image quality, parenchymal signal and vascular enhancement. An additional aim is to suggest potential future applications for Gd-enhanced SWI. METHODS: SWI was performed in 31 subjects before and after Gd administration. 17 cases were examined in a 1.5T scanner and the remaining 14 were scanned at 3T. The pre- and post-Gd images were analysed for signal changes in the cerebral grey matter (GM), white matter (WM) as well as for enhancement in the superficial and deep venous system. The visibility of the veins was graded on subtraction maps. RESULTS: The Gd-enhanced images showed no image quality degradation and no significant signal intensity change in the GM and WM as compared to the pre-Gd images (p>0.05). After Gd-administration significant enhancement of the venous sinuses was noticed (p<0.005), while the deep and cortical veins were poorly enhanced as confirmed by the calculated subtraction maps. The results showed no significant difference at variable MRI field strengths. CONCLUSION: It is possible to perform SWI after Gd injection without information loss or signal change in the parenchyma. The most significant difference is the enhancement of the cerebral venous sinuses. Potential future applications are discussed.