The influence of alignment in long-term functional outcome of total knee arthroplasty.

BACKGROUND: This study aimed to analyze long-term survival rate and clinical outcomes of a NexGen LPS knee system. The effect of component alignment parameters on clinical scores and patient satisfaction was also investigated. METHODS: Between June 2002 and January 2010, 204 knees of 152 patients underwent total knee arthroplasty with NexGen LPS-Flex knee system with fix bearings. The mean follow-up was 13.2 (range, 10 to 18 years). The relationship between radiologic and clinical results was investigated with component angles. Outlier angles were determined according to cutoff values of alpha, beta, gamma, and delta angles on the radiographs taken immediately after the operation. Knees were classified based on existing outliers they have as "No Outliers" (Group 1), "Single Outliers" (Group 2), and "Multiple Outliers" (Group 3). RESULTS: Revision surgery was required for ten patients, and the overall survival rate was 95.1% at the last follow-up. "Single Outliers" did not show a clinically significant difference in functional scores compared to the "No Outliers" group. However, KSKS and FJS-12 were significantly lower in "Multiple Outliers" knees (p: 0.039 and 0.019, respectively). CONCLUSION: NexGen LPS-Flex knee system has satisfactory results with 95.1% implant survival in 13.2 years. FJS-12 measurements at the end of the follow-up demonstrate a favourable result of the fixed bearing design. On two plane X-ray evaluations, components malaligned with two or more outliers in the same knee deteriorate patient satisfaction and clinical results.

Proximal Humerus Tumors: Higher-than-Expected Risk of Revision With Constrained Reverse Shoulder Arthroplasty.

BACKGROUND: The treatment of proximal humerus tumors with endoprostheses is associated with a high risk of implant-related surgical complications. Because of extensive soft-tissue resection and muscular detachment during surgery, instability is the most common serious complication. A reverse total shoulder arthroplasty with a highly constrained design is one option to mitigate instability, but few studies have reported the results of this prosthesis for proximal humerus tumor resections. QUESTIONS/PURPOSES: (1) What are the short-term functional results of the constrained reverse total shoulder prosthesis in terms of Musculoskeletal Tumor Society (MSTS), DASH, and Constant-Murley scores and ROM values? (2) What is the frequency of revision, using a competing-risks estimator to assess implant survival, and what were the causes of the revisions that occurred? (3) What proportion of patients experienced dislocations at short-term follow-up? METHODS: Between January 2014 and June 2017, we treated 55 patients with proximal humeral resections and reconstructions for malignant tumors. Of those, 33% (18) of patients were treated with the constrained, reverse total shoulder arthroplasty implant under study here. During that period, no other constrained reverse total shoulder implant was used; however, 13% (seven) of patients were treated with conventional (unconstrained) reverse total shoulder implants, 27% (15) had hemiarthroplasties, 15% (eight) of patients had biologic reconstructions with auto- or allografts and 13% (seven) underwent amputation. During the period in question, our general indications for use of the constrained device under study here were resection of the deltoid muscle/axillary nerve or the deltoid insertion on the humerus due to tumor invasion, or extensive rotator cuff and surrounding soft tissue resection that might result in shoulder instability. During this period, these indications were adhered to consistently. Four of 18 patients treated with the study implant died (three died with the implant intact) and none were lost to follow-up before 2 years, leaving 14 patients (seven women and seven men) for study at a median (range) follow-up of 35 months (25 to 65). Two authors evaluated the clinical and functional status of each patient with ROM (flexion, extension, internal and external rotation, abduction, and adduction) and MSTS, (range 0% to 100%), Constant-Murley (range 0% to 100%), and DASH (range 0 points to 100 points) scores. For the MSTS and Constant-Murley scores, higher percentage scores mean better functional outcome; and for the DASH score, a higher score means more severe disability. Radiographs were obtained at each visit and were used to look for signs of loosening, which we defined as progressive radiolucencies between visits, prosthetic component migration, and fragmentation/fracture of the cement. The Sirveaux classification was used to determine scapular notching. A competing risks analysis with 95% confidence intervals was performed to estimate the cumulative incidence of revision surgery, which we defined as any reoperation in which the implant was removed or changed for any reason, with patient mortality as a competing event. RESULTS: At the most recent follow-up, the median (range) MSTS score was 78% (50 to 90), the DASH score was 20 (8 to 65), and the Constant-Murley score was 53% (26 to 83). The median ROM was 75° in forward flexion (40 to 160), 78° in abduction (30 to 150), 35° in internal rotation (10 to 80), and 33° in external rotation (0 to 55). Postoperatively, two of 14 patients underwent or were supposed to undergo revision surgery, and the cumulative incidence of revision surgery was 18% for both 30 and 48 months (95% CI 2 to 45). During the study period, no patients reported instability, and no dislocations occurred. CONCLUSIONS: Our findings are concerning because the revision risk with this constrained reverse total shoulder implant was higher than has been reported by others for other proximal humerus prostheses. The highly constrained design that helps prevent instability might also transmit increased stresses to the humeral component-bone interface, therefore making it susceptible to loosening. We believe that any other implant with a similar degree of constraint will have the same problem, and changing the indications for patient selection may not solve this issue. These theories need to be tested biomechanically, but our desire is to warn surgeons that while trying to prevent instability, one might trade one complication (instability) for another: aseptic loosening. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Long-term results of reconstruction with pelvic allografts after wide resection of pelvic sarcomas.

Reconstruction after the resection of a pelvic tumor is a challenging procedure in orthopedic oncology. The main advantage of allograft reconstruction is restoration of the bony architecture of the complex pelvic region. However, high complication rates such as infection and allograft resorption had been reported in the literature. In this study, we aimed to retrospectively review nine patients treated with pelvic resection and structural pelvic allograft reconstruction. Functional results, complications, and survival of the patients and the allografts were evaluated. At a mean follow-up of 79 months, three patients were dead. Major complications were detected in eight of the nine patients. Infection (four of the nine patients) and allograft resorption (three of the nine patients) were the most common causes of failure. The cumulative survival of the patients was 66.7 percent at 70 months. However, allograft survival was only 26.7 percent at 60 months. Mean MSTS score was 69. In conclusion, we suggest that other reconstruction options should be preferred after pelvic resections because of the high complication rates associated with massive allograft reconstruction.

Low dose vancomycin-loaded spacers for two-stage revision knee arthroplasty: High success, low toxicity.

BACKGROUND: Two-stage revision arthroplasty is a widely used treatment method for infected knee arthroplasty. Loading high doses of antibiotics to spacer during the first stage is standard practice. However, there are reported systemic side effects attributed to antibiotic-loaded spacers. The aim of our study is to investigate the success rate and systemic toxicity following the first stage revision knee arthroplasty with low-dose vancomycin-loaded spacers. METHOD: We included patients with infected knee arthroplasty eligible for two-stage revision arthroplasty from 2001 to 2020. One gram of vancomycin is added per pack of bone cement. Spacers were handmade in the operating theatre. Following the first stage, pre-operative and postoperative culture results, infection parameters, kidney and liver function tests, and functional scores were analyzed. Kaplan-Meier survival analysis was done to determine the success rate. RESULTS: Fifty patients with a mean follow-up of 48 months (24-108) were included in the study. A five-year survival analysis showed an 88.5% success rate. Fourteen percent of the patients had acute kidney injury with creatinine levels between 1.12-2.80 mg/dl, and 8% had a mild drug-induced liver injury with elevated serum ALT levels between 223-540 U/L and total bilirubin levels between 0.59-1.23 mg/dl. None of the patients required dialysis. All of the systemic side effects were reversible. CONCLUSION: Our results have suggested that low dose antibiotic-loaded spacers are comparable to the studies with high dose antibiotic loaded spacers regarding infection eradication and survival rates. They are less likely to cause severe systemic side effects. Therefore we suggest low dose antibiotic-loaded spacers should be considered when treating patients with vancomycin sensitive Staphylococcal species and culture negative infected knee arthroplasty.

Postoperative bleeding adversely affects total knee arthroplasty outcomes in hemophilia.

BACKGROUND: Hemophilic arthropathy can result in severe degenerative arthritis and functional limitations in the knees of relatively young patients. Total knee arthroplasty (TKA) provides pain relief and gain of function in advanced-stage hemophilic arthropathy cases. However, little is known about the long-term effects of early major postoperative bleeding (MPOB) in people with hemophilia (PWH). The aim of this study was to evaluate the effects of early MPOB on the final functional outcome, complications, and implant survival of TKA in a single-center hemophilia cohort. METHOD: PWH who underwent TKA between 1998 and 2019 in a single center were reviewed. Demographic data, clinical data, and radiographic images were evaluated. Hospital for Special Surgery (HSS), Knee Society Score (KSS), and Knee Society Function Score (KSS-F) scores were used to determine function. Patients with early bleeding complications (wound dehiscence, ecchymosis, hemarthrosis, hematoma formation, prolonged or recurrent bleeding attacks) were defined as the bleeding group. Patients who did not experience these complications were assigned to the control group. The bleeding group was compared with controls. Survival of the primary arthroplasty was analyzed by Kaplan-Meier curves. RESULTS: Forty-five TKAs in 29 patients were included in the study. TKA led to an increase in the mean range of motion from 46.08° to 84.59° (P < 0.01). HSS scores increased from 48.33 preoperatively to 82.67 postoperatively (P < 0.01). There were improvements in both KSS and KSS-F scores from 34.22 and 53.3 preoperatively to 82.00 and 84.63 (P < 0.01), respectively. Ten patients (10 TKAs) (34%) experienced major bleeding during the postoperative period. Six of these patients had moderate hemophilia, and four had severe hemophilia. Three of these patients had hemarthroses (10.2%), one patient had a hematoma (3.4%), one patient had hemorrhagic bullae formation (3.4%), and five had excessive/prolonged bleeding from the wound (17%). The bleeding group (34%) had significantly worse HSS (63.78 vs 92.75, P < 0.001), KSS (61.78 vs 93.25, P < 0.001), and KSS-F (60.71 vs 96.25, P = 0.005) scores compared with controls. Preoperative and postoperative flexion contractures were positively correlated (+0.33, P = 0.003). One of the patients with postoperative hemarthrosis also had an accompanying transient common peroneal nerve palsy, and one patient (3.4%) had a periprosthetic fracture. Three knees (6.6%), two of whom were in the bleeding group, developed periprosthetic infections. Four knees (8.8%) in three patients underwent revision surgery, and two knees (4.4%) ended up in arthrodeses. Kaplan-Meier analysis revealed a mean survival duration of 17.04 years for the bleeding group and 22.15 years for the control group (P = 0.83). Survival rates were 80.0% for the bleeding group and 96.4% for the control group (P = 0.83). CONCLUSIONS: In this study, MPOB after TKA in PWH was common and led to significantly worse function. MPOB after TKA in PWH was associated with a higher rate of complications and lower survival rates, although the differences were not statistically significant. Efforts must be made to avoid MPOB after TKA in PWH.

Dislocation after total hip arthroplasty: does head size really matter?

INTRODUCTION: Recent advances in polyethylene and ceramic technologies has allowed us to use larger sized heads without compromising the wear properties of a total hip arthroplasty (THA). 1 benefit of this change has been proposed to be a lower incidence of dislocation. METHODS: We retrospectively evaluated the dislocation rate in 913 THAs performed using the same standardised surgical technique employed by a single team of surgeons at our institution between 1995 and 2015. Patients were assigned to 2 groups: small (⩽28 mm), large diameter heads (⩾36 mm and larger). The cup position was measured and plotted to determine its status according to the Lewinnek's safe zone (15° ± 10° for anteversion, 40° ± 10° for inclination). RESULTS: 16 of the 472 small heads dislocated (3.4%) while 5 of the 441 in large head group (1.1%) (p = 0.04). In all of the large head patients that dislocated the cup position was in the safe range of Lewinnek. However, in the large head group only 64.5% of the cups were in the safe zone. CONCLUSIONS: By changing the head size to 36 mm, we were able to decrease the dislocation rate significantly. Errors of cup positioning according to Lewinnek became oblivious when using large heads. In our opinion, using large heads in THA makes a difference in terms of dislocation.

The effect of the COVID-19 pandemic on orthopedic surgeries in a tertiary referral center.

OBJECTIVES: The aim of this study is to investigate the effect of the novel coronavirus-2019 (COVID-19) pandemic on the operational trends in the orthopedic surgery department of a tertiary referral center. PATIENTS AND METHODS: A total of 305 orthopedic surgical procedures in 245 patients (136 males, 109 females; mean age: 34±26.6 years; range, 0 to 91 years) between March 16th and June 27th, 2020 were retrospectively analyzed. The same period of the year before including 860 procedures in 783 patients (364 males, 419 females; mean age: 33.6±25.8 years; range, 0 to 95 years) was also reviewed as a pre-pandemic control group. Patient demographics, surgical indications, COVID-19 polymerase chain reaction (PCR) test status, method of anesthesia, surgical subspecialties (trauma, sports, etc.), trauma mechanisms, and surgical priorities were evaluated. The pandemic and the pre-pandemic periods were compared. RESULTS: The rate of elective surgeries decreased compared to the previous year, and priority C type surgeries had the highest frequency (42.5%). Orthopedic trauma was the leading subspecialty with 91 (29.8%) cases and had a higher share, compared to the pre-pandemic period (17.0%). Hip fractures (18.7%) were the most common cause of trauma surgery, and simple falls (42.3%) composed the largest group of trauma mechanisms, which was similar to the pre-pandemic period (hip fractures, 13.6%; simple falls, 42.5%). The distribution of surgical urgency levels and subspecialties differed significantly between the pre-pandemic and pandemic periods (p<0.001). Post-hoc analysis of subspecialty distribution revealed a significant decrease in arthroplasty (p=0.002) and hand surgery (p<0.001), and a significant increase in trauma (p<0.001) and the "other" category (p<0.001). CONCLUSION: Our experience in a tertiary referral center illustrated a shift toward performing emergent and urgent surgeries, when the severity of the outbreak increased. Prioritizing surgical urgencies during the outbreak changed the orthopedic surgery practice with an emphasis on trauma and oncology surgeries. Hip fractures were the most common cause of trauma surgery, and simple falls composed the largest group of trauma mechanisms.

Titanium cage reconstruction of acetabular defects in revision hip arthroplasty results in favourable outcomes: up to 17 years follow-up.

INTRODUCTION: Titanium cages are valuable implant solutions in management of severe acetabular defects during total hip revisions. We aimed to report clinical and radiological results of our cases in which we used titanium cages for reconstruction of acetabular defects. METHODS: Patients underwent titanium cage reconstruction and bone grafting for their acetabular defects with minimum 2 year-follow-up are included to the study. Analysis of patient records, modified Hospital for Special Surgery hip score and radiological examinations on plain X-rays were evaluated. Acetabular defects are classified according to Paprosky's classification.Kaplan Meier survival analysis is performed. RESULTS: Fifty-six hips of 54 patients (2 bilateral) aged between 29-79 (mean 57 years ) are followed up for 7.06 years ±3.72 (2-17 years).Five patients required revision surgeries at a mean of 2.6±2.2 years. Kaplan Meier's analysis revealed a survival rate of 91,5 % and mean revision free duration was 15,66±0,56 years.HSS scores of the patients before revision surgery yielded a mean score of 27,9 ± 4,9 (14-38). HSS scores at final follow up showed a significant improvement at a mean score of 45,9 ± 7 (28-56) differences were statistically significant, p<0,001). DISCUSSION: Titanium cages are successful for restoring bone stock in severe acetabular defects. It is critical to pay attention on meticulous bone grafting of the presented defects and obtain good hip mechanics during cage insertion. Mechanical reasons are the leading cause of failure in long term but restoration of the bone stock and improvement in defect severity were regularly observed even in failed cages.

Titanium mesh cage as an alternative reconstruction method for epiphyseal-sparing tumour resections in children.

In this study, we introduced an alternative reconstruction option for epiphysis-sparing tumour resection in children. Eight patients with a malignant tumour in the diaphysis or metaphysis-diaphysis junction of a long bone underwent epiphysis-sparing intercalary resection. Reconstruction was performed using a titanium mesh cage filled with impacted cancellous bone allograft and autograft. A plate and screws were used to supplement the fixation. At the last follow-up, union was achieved in seven patients. Limb-length discrepancy occurred in three patients. Functional scores revealed a good functional outcome. This technique may be an alternative method for epiphyseal-sparing tumour resections in children.

An unusual pattern of arthritis in a child with Kawasaki syndrome.

Arthritis is reported in one-third of cases with Kawasaki syndrome. It may have an early or a late onset form. We present a 15-month-old-girl who had been referred with complaints of pain and swelling in her left shoulder. Physical examination revealed bulbar conjunctival injection, erythematous lips and pharynx, strawberry tongue, erythematous rash, edema and erythema of the left shoulder, left knee, right elbow and right wrist, and moderate distress in the left shoulder and left hip. She was diagnosed with Kawasaki syndrome, and intravenous immunoglobulin infusion (IVIG) 2 g/kg and aspirin (100 mg/kg/day) were instituted. The patient had two additional episodes of arthritis involving the hip joint on the 8th day, and the shoulder and metacarpophalangeal (MCP) and interphalangeal (IP) joints of her right hand on the 15th day. Turbid material was aspirated in both instances; Gram and Wright's staining of this material showed many leukocytes but no bacteria. A second dose of IVIG (1 g/kg) was given. At the end of the third week all extremities were painless, with a normal range of motion. Arthritis in our patient was the presenting sign, having a 'septic arthritis mimicking' and 'biphasic' pattern. Although the patient presented with severe and recurrent arthritis, which is significantly correlated with severe multisystem disease and the presence or development of coronary artery aneurysm, the response to IVIG was excellent.

Two-staged revision with custom made prosthesis in septic failure of massive allograft reconstruction after type II-III pelvic resection.

Reconstruction of defects occurring during periacetabular resections of pelvic tumors is required particularly in young and functionally active persons. Allograft reconstruction provides good functional outcomes in restoration of normal pelvic anatomy. A 24-year-old male patient was reconstructed with an allograft-prosthesis composite after periacetabular resection due to pelvic chondrosarcoma. After four years, a two-staged revision with a custom-made pelvic prosthesis was performed due to septic failure. Successful radiographic and functional outcomes were achieved at two-year follow-up. In conclusion, we suggest a two-staged revision with a custom-made pelvic prosthesis as a satisfactory option in case of septic failure of allograft reconstruction after periacetabular resection.

Gait analysis in adults with severe hip dysplasia before and after total hip arthroplasty.

Anatomical reconstruction of high riding hips by total hip arthroplasty (THA) and subtrochanteric shortening osteotomy aims to normalise gait pattern and improve functional hip scores. We present the medium-term clinical results of a group of patients with high riding dislocated hips in whom a cementless THA and subtrochanteric shortening osteotomy had been performed. We compared them with their preoperative status, with patients who had undergone a cementless THA for primary osteoarthritis, and also with a group of healthy gender and age-matched controls. Prospective computerized, three-dimensional gait analyses were performed in 8 female patients with uni-/ or bilateral severe developmental dysplasia of the hip (Group I). Gait analysis was performed preoperatively and at a mean of 12.5 months postoperatively. A group of 8 individuals who received cementless hip replacement for primary osteoarthritis (Group II), and a control group of 8 able-bodied individuals (Group III) were recruited for comparison. Patients in Group I improved and approached the values of Group II. However both were behind Group III. Limb length discrepancy was reduced from a mean of 4.3 cm (range, 1 - 8 cm) to a mean of 0.8 cm (range, 0 - 2 cm) at the latest follow-up. Pain was reliably relieved and activities of daily living were improved in patients with high riding developmental dysplasia of the hip, but they were still behind the normal population average. Nevertheless, the results can be as satisfactory as those in patients who undergo a THA for primary osteoarthritis.

Distraction osteogenesis (callotasis) for pelvic closure in bladder exstrophy.

The success of urogenital reconstruction in bladder exstrophy is dependent on how successfully the pelvic ring can be closed. In patients with this disorder, the pubic bones are short and separated. A two-component plate-rod combination was designed to widen the pelvic ring using distraction osteogenesis (callotasis). After a middiagonal iliac osteotomy, two components of the implant are connected with two bolts passing through the iliac bone. After 10 days, the rods outside the skin are approximated gradually. When the pubic bones get close, they are fixed by heavy nonabsorbable sutures. The current study included 14 patients who were operated on between 1990 and 1996. The mean followup was 6 years. No neurologic or vascular complications developed. Successful tension-free closure of the abdominal wall was achieved in all but one patient. Urogenital reconstruction was done in the second stage. In all but one patient, the bladder was closed in one stage of urogenital reconstruction. In one patient (7%), a deep infection developed for which the patient needed early implant removal resulting in failure of the urogenital reconstruction. The described method addresses the pathoanatomy of the pelvic ring. The diameter of the pelvic ring can be widened and the pubic bones can be approximated without a significant increase in tension.