Better Short-term Outcomes after Total Hip Arthroplasty Compared to Hemiarthroplasty in Active Older Patients with Displaced Intracapsular Femoral Neck Fracture.

BACKGROUND: Hip fractures are a public health problem that disproportionately affects the elderly. Displaced femoral neck fractures were treated historically with hemiarthroplasty, but the use of total hip arthroplasty (THA) is increasing showing superior long-term results. OBJECTIVES: To assess whether THA has superior short-term results compared to bipolar hemiarthroplasty for displaced femoral neck fractures. METHODS: Two groups of active older patients underwent either cementless bipolar hemiarthroplasty or THA for displaced femoral neck fracture. All patients were operated on using the direct lateral approach to the hip joint. Patients were assessed using the Harris Hip Score at hospital discharge and at 6 weeks follow-up. RESULTS: We included 40 patients ages 65-85 years; 18 underwent bipolar hemiarthroplasty and 22 THA. The number of women in each group was similar, as was mean age: 73.1 ± 4.2 years in the hemiarthroplasty group and 71.0 ± 3.7 in THA. Harris Hip Score on hospital discharge was similar in both groups. Walking ability at discharge was better in the THA cohort and they were discharged sooner: 5.2 ± 1.3 vs. 6.4 ± 1.7 days following hemiarthroplasty (P = 0.021). At 6 weeks follow-up, the mean Harris Hip Score was higher in the THA group (78.6 ± 11 vs. 61.5 ± 17 for hemiarthroplasty, P < 0.001). Patients in the THA group walked longer distances, needed less support while walking, and reported less pain. CONCLUSIONS: Better short-term results at hospital discharge and at 6 weeks follow-up after THA contributed to earlier patient independence and shorter hospital stays.

A modified minimally invasive osteotomy for hallux valgus enables reduction of malpositioned sesamoid bones.

BACKGROUND: The current minimally invasive distal metatarsal osteotomy for hallux valgus (HV) is V-shaped, which prevents the correction of the rotational metatarsal head deformity and reduction of the sesamoid bones. We sought to determine the optimal method for sesamoid bone reduction during HV surgery. METHODS: We reviewed the medical records of 53 patients who underwent HV surgery between 2017 and 2019 using one of three techniques: open chevron osteotomy (n = 19), minimally invasive V-shaped osteotomy (n = 18), and a modified straight minimally invasive osteotomy (n = 16). The sesamoid position was graded using the Hardy and Clapham method on weight-bearing radiographs. RESULTS: When compared to open chevron and V-shaped osteotomies, the modified osteotomy resulted in significantly lower postoperative sesamoid position scores (3.74 ± 1.48, 4.61 ± 1.09, and 1.44 ± 0.81, respectively, P < 0.001). Furthermore, the mean change in postoperative sesamoid position score was greater (P < 0.001). CONCLUSION: The modified minimally invasive osteotomy was superior to the other two techniques in correcting HV deformity in all planes, including sesamoid reduction.

Orthopedic-Metabolic Collaborative Management for Osteoporotic Hip Fracture.

OBJECTIVE: Osteoporotic hip fractures are associated with increased morbidity, mortality, and secondary fractures. Although osteoporosis treatment can reduce future fracture risk, patients often do not receive it. We report results of a coordinator-less fracture liaison service in Israel addressing hip fracture patients. The primary endpoint was attending the Metabolic Clinic. Secondary endpoints included vitamin D measurement, calcium and vitamin D recommendations, initiation of osteoporosis treatment, and mortality 1-year post-fracture. METHODS: This prospective study included 219 hip fracture patients who were compared with historical controls. Data on hospitalized patients were collected before and after implementation of a structured protocol for hip fracture patients, led by a multidisciplinary team, without a coordinator. RESULTS: The study included 219 and 218 patients ≥60 years old who were operated on in 2013 and 2012, respectively. Metabolic Clinic visits increased from 6.4 to 40.2% after the intervention ( P<.001). Among 14 patients who attended the Clinic in 2012, 85.7% began osteoporosis therapy; among 88 who attended in 2013, 45.5% were treated at the first visit. Vitamin D measurements and calcium and vitamin D supplementation increased postintervention (0.5-80.1%, P<.001; 30.8-84.7%, P<.001, respectively). Patients receiving osteoporosis medications had lower mortality rates than untreated patients (4.3% vs. 21.8%). CONCLUSION: An Orthopedic-Metabolic team implemented by existing staff without a coordinator can improve osteoporosis care for hip fracture patients. Yet, gaps remain as only 40% had Metabolic Clinic follow-up postintervention, and of these, only half received specific treatment recommendations. Hospitals are encouraged to adopt secondary fracture prevention protocols and continuously improve them to close the gaps between current management and appropriate metabolic assessment and treatment. ABBREVIATIONS: CHS = Clalit Health Services; CI = confidence interval; FLS = fracture liaison service; HMO = health maintenance organization; OR = odds ratio.

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures.

AIM OF THE STUDY: Bleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options. METHOD: We conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation. RESULTS: Three patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention. DISCUSSION: Vascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory. CONCLUSIONS: A vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.

Simultaneous Bilateral Versus Unilateral Total Knee Arthroplasty: A Comparison of 30-Day Readmission Rates and Major Complications.

We queried the National Surgical Quality Improvement Program to compare the rate of 30-day readmissions and major complications between simultaneous bilateral and unilateral total knee arthroplasty (TKA). We identified 1771 patients who underwent simultaneous (same-day) bilateral TKA and matched them to a control group of 6790 patients who underwent unilateral TKA. The simultaneous bilateral TKA patients had longer surgery, were more commonly performed under general anesthesia, had a higher rate of postoperative transfusion, and a greater proportion of patients discharged to rehabilitation facilities. Simultaneous bilateral TKA has a low incidence of major complications and was not associated with more readmissions as compared to unilateral TKA (3.6% versus 3.5% respectively). Nonetheless, the odds of major complications was slightly higher following simultaneous bilateral TKA (OR=1.58).

Value of Early Postoperative Computed Tomography Assessment in Ankle Fractures Defining Joint Congruity and Criticizing the Need for Early Revision Surgery.

Previous investigators have questioned the reliability of plain radiographs in assessing the accuracy of ankle fracture reduction when these were compared with the computed tomography (CT) evaluation in the preoperative setting, in particular, in fractures with syndesmosis injuries or trimalleolar fragments. The role of CT assessment, however, has not been investigated in the early postoperative setting. In the early postoperative setting, reduction still relies most commonly on fluoroscopy and plain radiographs alone. In the present study, we hypothesized that early postoperative CT assessment of ankle fractures with syndesmosic injuries and posterior malleolar fragments can add valuable information about the joint congruity compared with plain radiographs alone and that this information could affect the decisions regarding the need for early revision surgery. A total of 352 consecutive operated ankle fractures were reviewed. Of these, 68 (19%) underwent early postoperative CT assessment and were studied further to identify the causes that prompted revision surgery. Of the 68 cases, despite acceptable reduction found on the plain radiographs, 20 (29%) underwent early (within 1 week) revision surgery after studying the CT scans, which revealed malreduction of the syndesmosis, malreduction of the posterior lip fragment, and intra-articular fragments. We concluded that in ankle fractures involving disruptions of the syndesmosis or posterior malleolar fragments, early postoperative CT assessment could be justified, because it will reveal malreduction and prompt early revision intervention for a substantial proportion of these patients.

The Sterile Elastic Exsanguination Tourniquet vs. the Pneumatic Tourniquet for Total Knee Arthroplasty.

We compared the sterile elastic exsanguination tourniquet and the pneumatic tourniquet for total knee arthroplasty. 145 patients were operated on using a pneumatic tourniquet and 166 with the sterile elastic exsanguination tourniquet. Patients with the sterile elastic exsanguination tourniquet had a smaller decrease in hemoglobin on post-operative days one (P<0.028) and three (P<0.045). The amount of blood collected from drains at 24h was significantly lower in the sterile elastic exsanguination group. A trend towards a higher rate of wound complications within 3months following the operation was found in the pneumatic tourniquet group. The sterile elastic exsanguination tourniquet works at least as good as the pneumatic one.

Anatomic Reconstruction Technique for a Plantar Calcaneonavicular (Spring) Ligament Tear.

Acquired flatfoot deformity in adults is usually due to partial or complete tearing of the posterior tibial tendon, with secondary failure of other structures such as the plantar calcaneonavicular (spring) ligament (SL), which maintain the medial longitudinal arch. In flexible cases, the tibialis posterior can be replaced with the flexor digitorum longus. It is common practice to suture the SL directly in the case of a tear; however, if the tear is complete, suturing directly to the ligament alone will not be possible. Reconstruction of the ligament is needed; however, no validated methods are available to reconstruct this ligament. The operative technique of SL reconstruction described in this report as a part of acquired flatfoot deformity reconstruction consists of augmenting remnants of the spring from the navicularis to the sustentaculum tali and suspending it to the medial malleolus using 2-mm-wide, long-chain polyethylene suture tape. This technique results in the firm anatomic reconstruction of the SL, in addition to "classic" medial arch reconstruction. We recommend SL reconstruction for medial arch reconstruction when the SL is torn.

Use of a spinal cage for creating stable constructs in ankle and subtalar fusion.

In complicated foot surgery with reconstruction of the hindfoot, a gap will sometimes be present between the bones that must be filled and stabilized. Bone grafting with structural bone graft is 1 alternative; however, it can collapse and must be stabilized with screws or a nail. A locking intramedullary nail can be used but could lead to nonunion owing to distraction. Newer nails include a compression device but that can result in shortening. We developed a technique that includes distraction of the fusion area with a spinal cage and then compression of the construct by inserting a compression screw through the cage. We present our experience with this technique.We reviewed the data from 7 patients who had undergone surgery using this technique. The technique included distraction of the fusion area and insertion of a titanium cylindrical spinal cage filled with autologous cancellous bone graft. A cannulated compression screw was then inserted through the cage, creating compression of the fusion area against the cage and achieving stabilization of the fusion area. Postoperatively, a non-weightbearing cast was applied for 3 months, followed by a full weightbearing cast until radiographic fusion was apparent. Complete radiographic union was observed in all 7 patients within 6 to 12 months postoperatively. At the latest follow-up visit, the mean American Orthopaedic Foot and Ankle Society scale score was 54 ± 16 (range 30 to 71) points. The use of a cylindrical titanium cage with a local bone graft and stabilization by distraction and compression provided a stable construct, avoided shortening, and led to good fusion. In addition, donor site complications and unpredictable strength loss and lysis of bone allograft were avoided.

Displaced mid-shaft clavicular fractures: is conservative treatment still preferred?

BACKGROUND: A clavicular fracture accounts for 2.6%-5% of adult fractures. Fractures in the middle-third (OTA 15-B) represent 69%-82% of all clavicular fractures. There is no consensus among orthopedic surgeons regarding treatment for these fractures: many support conservative treatment even for displaced middle-third clavicular fractures, while others choose operative treatment. OBJECTIVES: To assess the attitudes of orthopedic surgeons regarding treatment of displaced mid-shaft clavicular fractures. METHODS: We conducted a survey in which we interviewed orthopedic surgeons from various countries during the 2012 EFORT meeting in Berlin. The questionnaire included an X-ray of a displaced middle-third clavicular fracture, as well as questions regarding the surgeon's proposed treatment plan. RESULTS: A total of 177 orthopedic surgeons completed the questionnaire; 49% preferred operative treatment for a displaced middle-third clavicular fracture. Among the orthopedic trauma specialists, 58% suggested operative treatment, as did 82% of shoulder specialists. Most surgeons preferred a locking plate for fixation. CONCLUSIONS: The treatment approach for a displaced middle-third clavicular fracture seems to be evenly split between conservative and operative approaches. The tendency toward operative treatment was.even more remarkable among orthopedic trauma specialists and shoulder specialists who completed the questionnaire. Most surgeons prefer a locking plate as a fixation system for this type of fracture.

The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures.

PURPOSE: Despite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention. METHODS: A questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus. RESULTS: The cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35 % (62) of participants, whereas 65 % (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79 % (140) suggested operative intervention and only 21 % (37) advocated nonoperative management (p = 0.03). CONCLUSIONS: Most surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.

Using a cervical spine cage to reconstruct malunited fibular fractures.

PURPOSE: Anatomical reduction and fixation of unstable ankle fractures is necessary to prevent post-traumatic arthritis. Malunion of the distal fibula in unstable ankle fractures can lead to late degenerative changes of the ankle. Late reconstruction of the ankle can improve its function and postpone the need for ankle fusion or replacement. METHODS: We discuss three patients who presented with fibular malunion. All developed medial gutter opening, syndesmotic widening, and lateral shift and/or talar tilt. Surgery involved an anteromedial approach to clean the medial gutter, an anterolateral approach to clean the syndesmotic interval, elongation of the fibula by six to eight millimetres and stabilisation with a cervical spine cage and a locked plate. RESULTS: After one year, all patients had radiologically demonstrated reduction of the talus in the mortise. Improved function was recorded at final follow up. The cage provides several advantages over other fixation methods, including osteoconductive properties, avoiding bone graft donor site morbidity, and the range of sizes allows the surgeon to adjust the amount of elongation. CONCLUSIONS: Using spinal cages to treat malunited fibula fractures has several advantages compared to bone graft and good results can be expected.

Imageless computer assisted versus conventional total knee replacement. A Bayesian meta-analysis of 23 comparative studies.

We have undertaken a meta-analysis of the English literature, to assess the component alignment outcomes after imageless computer assisted (CAOS) total knee arthroplasty (TKA) versus conventional TKA. We reviewed 23 publications that met the inclusion criteria. Results were summarised via a Bayesian hierarchical random effects meta-analysis model. Separate analyses were conducted for prospective randomised trials alone, as well as for all randomised and observational studies. In 20 papers (4,199 TKAs) we found a reduction in outliers rate of approximately 80% in limb mechanical axis when operated with the CAOS. For the coronal femoral and tibial implants positions, the analysis included 3,058 TKAs. The analysis for the femoral implant showed a reduction in outliers rate of approximately 87% and for the tibial implant a reduction in outliers rate of approximately 80%. Imageless navigation when performing TKA improves component orientation and postoperative limb alignment. The clinical significance of these findings though has to be proven in the future.

Ribosomal proteins as distinct "passengers" of microvesicles: new semantics in myeloma and mesenchymal stem cells' communication.

Aberrant mesenchymal stem cells (MSCs) in multiple myeloma (MM) bone marrows (BM) promote disease progression and drug resistance. Here, we assayed the protein cargo transported from MM-MSCs to MM cells via microvesicles (MVs) with focus on ribosomal proteins (RPs) and assessment of their influence on translation initiation and design of MM phenotype. Proteomics analysis (mass spectrometry) demonstrated increased levels and repertoire of RPs in MM-MSCs MVs compared to normal donors (ND) counterparts (n = 3-8; P = 9.96E - 08). We limited the RPs load in MM-MSCs MVs (starvation, RSK and XPO1 inhibitions), reapplied the modified MVs to MM cell lines (U266, MM1S), and demonstrated that the RPs are essential to the proliferative effect of MM-MSCs MVs on MM cells (n = 3; P < 0.05). We also observed that inhibition with KPT-185 (XPO1 inhibitor) displayed the most extensive effect on RPs delivery into the MVs (↓80%; P = 3.12E - 05). Using flow cytometry we assessed the expression of select RPs (n = 10) in BM-MSCs cell populations (ND and MM; n ≥ 6 each). This demonstrated a heterogeneous expression of RPs in MM-MSCs with distinct subgroups, a phenomenon absent from ND-MSCs samples. These findings bring to light a new mechanism in which the tumor microenvironment participates in cancer promotion. MVs-mediated horizontal transfer of RPs between niche MSCs and myeloma cells is a systemic way to bestow pro-cancer advantages. This capacity also differentiates normal MSCs from the MM-modified MSCs and may mark their reprogramming. Future studies will be aimed at assessing the clinical and therapeutic potential of the increased RPs levels in MM-MSCs MVs.

23Na and 2H magnetic resonance studies of osteoarthritic and osteoporotic articular cartilage.

In this study, the short component of the (23)Na T(2) (T(2f)) and the (23)Na and (2)H quadrupolar interactions (nu(Q)) were measured in bone-cartilage samples of osteoarthritic (OA) and osteoporotic (OP) patients. (23)Na nu(Q) was found to increase in osteoarthritic articular cartilage relative to controls. Similar results were found in bovine cartilage following proteoglycan (PG) depletion, a condition that prevails in osteoarthritis. (23)Na nu(Q) and 1/T(2f) for articular cartilage obtained from osteoporotic patients were significantly larger than for control and osteoarthritic cartilage. Decalcification of both human and bovine articular cartilage resulted in an increase of (23)Na nu(Q) and 1/T(2f), showing the same trend as the osteoporotic samples. Differences in the ratio of the intensity of the large (2)H splitting to that of the small one in the calcified zone were also observed. In osteoporosis, this ratio was twice as large as that obtained for both control and osteoarthritic samples. The (2)H and (23)Na results can be interpreted as due to sodium ions and water molecules filling the void created by the calcium depletion and to calcium ions being located in close association with the collagen fibers. To the best of our knowledge, this is the first study reporting differences of NMR parameters in cartilage of osteoporotic patients.

Routine early post-operative X-ray following internal fixation of intertrochanteric femoral fractures is unjustified: a quality improvement study.

BACKGROUND: There is no consensus regarding the proper radiographic protocol following closed or open reduction and internal fixation for intertrochanteric femoral fractures. The objective of this study was to assess the role of early postoperative imaging studies when deciding about weight bear limitations and reoperations. METHODS: A prospective cohort study of 100 patients (26 men and 74 women, at a mean age of 79.8 years) treated by closed or open reduction and internal fixation for AO31A fractures was conducted. According to the AO classification, there were 25 cases of 31A1, 54 cases of 31A2, and 21 cases of 31A3. For every patient, the intraoperative fluoroscopy studies were recorded and post-operative radiograms were taken during the first week. Excluded were patients for whom the early X-rays were clinically indicated. The intraoperative AP and axial fluoroscopy studies were compared with the radiograms taken during the first post-operative week. The investigators compared the decisions regarding weight-bearing limitations and the need for re-operation before and after conducting the radiograms. RESULTS: The early post-operative imaging studies did not change weight-bearing limitations nor did they lead to consecutive surgical treatments. CONCLUSIONS: Unless indicated by physical examination, there is no value to routine post-operative radiograms within the first few days after closed reduction and internal fixation of intertrochanteric femoral fractures with regard to weight-bearing limitations and re-operation decisions. TRIAL REGISTRATION: Identifier: NCT02868125 .

Gentamicin extended release from an injectable polymeric implant.

Gentamicin sulfate, a potent antibiotic agent, is currently used for treatment of osteomyelitis mainly by intravenous injection with a long-term indwelling catheter, local implant of antibiotic containing polymethylmethacrylate beads or calcium phosphate (bone cements). Searching for more effective treatments, this study was designed to evaluate biodegradable injectable gelling polymeric devices for the controlled release of gentamicin sulfate in the treatment of invasive bacterial infections. Gentamicin sulfate was incorporated in poly(sebacic-co-ricinoleic-ester-anhydride P(SA-RA)) paste at 10-20% w/w and its release in buffer solution was monitored. The in vitro activity of the formulations was determined against Staphylococcus aureus. A constant release of active gentamicin for over 28 days was found. The stability of the formulation was determined under different storage conditions. The formulations were stable to sterilization by gamma-irradiation and long term storage under freezing. The toxicity of the polymer and the formulations with gentamicin was examined by subcutaneous injection to rats. Four weeks after implantation, histopathological examination of the tissues surrounding the implant showed no inflammation. A preliminary study revealed positive effect of gentamicin containing P(SA-RA) on established osteomyelitis in a rat model. In conclusion this study suggests that poly(sebacic-co-ricinoleic-ester-anhydride) 3:7 loaded with 10%-20% gentamicin sulfate, might be used as an injectable biodegradable device for in situ treatment of osteomyelitis induced by S. aureus.

Novel reconstruction technique for an isolated plantar calcaneonavicular (SPRING) ligament tear: A 5 case series report.

BACKGROUND: It is usually accepted that acquired flatfoot deformity after injury is usually due to partial or complete tear of the posterior tibial tendon (PTT), with secondary failure of the other structures which maintain the medial longitudinal arch, such as the plantar calcaneo-navicular (SPRING) ligament. It is unusual to find an isolated Spring Ligament (SL) tear, with an intact TP tendon. METHODS: The medial arch reconstruction technique of an isolated SL tear in 5 patients is presented discussed in this paper. In these 5 cases the clinical presentation mimicked PTT dysfunction. The operative regimen consisted of three steps: direct repair of the ligament, primary reconstruction of the SL by using FiberWire® (Arthrex, Inc) and a medial calcaneal osteotomy. RESULTS: American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score improved from 55.8 (range, 34-74) before surgery to 97.6 (range, 91-100) at more than one year follow-up. No recurrence of the flatfoot deformity was observed at 10 years follow-up. CONCLUSION: SL tear should be suspected in cases of clinical presentation of medial arc collapse even when PTT is intact. In such cases of isolated SL tear reconstruction of the torn ligament using the method described is recommended.