The use of dual mobility cups in revision total hip arthroplasty for failed large head metal-on-metal bearings.

PURPOSE: Revision of failed large head metal-on-metal (MoM) total hip arthroplasty (THA) is a challenging procedure particularly to reconstruct acetabular bone defect due to osteolysis and to achieve hip stability due to soft tissue damages, both potentially caused by adverse reaction to metal debris (ARMD). This study aimed to evaluate the outcome of dual mobility cup (DMC) constructs in revision THA for failed large head MoM bearings with a special attention to the occurrence of dislocation or re-revision. METHODS: Between 2015 and 2019, 57 patients (64 THAs, 41 men, mean age = 65 ± 10 years) underwent revision for MoM THA with the use of DMC were prospectively included in our total joint registry. Mean time to revision was 11 ± 2.5 years. The causes for revision were adverse reaction to metal debris (ARMD) in 49 THAs (76%), painful hip with elevated blood cobalt-chromium ions in seven (11%), and acetabular aseptic loosening in eight (13%). The revision was complete in 22 THAs (34%) and acetabular only in 42 (66%). Clinical and radiographic outcomes, complications, and re-revisions were evaluated at most recent follow-up. RESULTS: At mean follow-up of six ± 1.5 years, the pre- to postoperative Harris Hip Score improved from 74 ± 19 to 92 ± 4 (p = 0.004). Complications occurred in 11 cases (17%): five dislocations (8%), three periprosthetic infections (5%), two aseptic loosening of the acetabular component (3%), and two periprosthetic fractures (3%). Re-revision was required in six cases (9%). CONCLUSION: The use of DMC is a reliable option to prevent instability and ensure a stable acetabular reconstruction in revision THA for failed large head MoM bearings. However, dislocation after revision remains a concern, particularly in cases of severe soft tissue damage related to ARMD.

Direct Cementation of Dual Mobility Cups Into the Bony Acetabulum in Primary Total Hip Arthroplasty: Clinical and Radiographic Outcomes at a Minimum 5-Year Follow-Up.

BACKGROUND: Cemented dual mobility cups (DMCs) are commonly used in combination with acetabular reinforcement devices. Indeed, according to literature, direct cementation of metal-backed acetabular components into the bony acetabulum remains controversial as this technique is potentially associated with increased rates of aseptic loosening. Therefore, this study aimed to evaluate the clinical and radiographic outcomes of DMC cemented into the bony acetabulum in primary total hip arthroplasty (THA). METHODS: A total of 49 THA (48 patients, mean age 78 years [range, 51 to 91]) performed with direct cementation of a DMC into the bony acetabulum were prospectively included in our total joint registry and retrospectively reviewed. The clinical outcome was assessed using the Harris hip score (HHS). The radiographic outcome included measurement of component positioning and occurrence and progression of demarcation around the cemented DMC. Complications were reported with a particular attention to cemented fixation failure and aseptic loosening. RESULTS: At a 7-year mean follow-up (range, 5 to 8), the pre-to postoperative HHS improved from 47 (range, 30 to 58) to 92 points (range, 80 to 98) (P < .01). Nonprogressive and focalized demarcations were observed in 7 THA (14%). Importantly, no progressive demarcation or DMC aseptic loosening was observed. CONCLUSION: Direct cementation of DMC into the bony acetabulum ensured a stable fixation with no progressive demarcation or aseptic loosening at midterm follow-up. Therefore, this technique can be selectively considered in primary THA, especially in elderly or frail patients to avoid potential mechanical failure of press-fit fixation due to altered bone quality or additional morbidity related to the use of acetabular reinforcement devices.

Polyethylene wear of dual mobility cups: a comparative analysis based on patient-specific finite element modeling.

PURPOSE: Concerns remain about potential increased wear with dual mobility cups related to the multiple articulations involved in this specific design of implant. This finite element analysis study aimed to compare polyethylene (PE) wear between dual mobility cup and conventional acetabular component, and between the use of conventional ultra-high molecular weight PE (UHMWPE) and highly cross-linked PE (XPLE). METHODS: Patient-specific finite element modeling was developed for 15 patients undergoing primary total hip arthroplasty (THA). Five acetabular components were 3D modeled and compared in THA constructs replicating existing implants: a dual mobility cup with a 22.2-mm-diameter femoral head against UHMWPE or XLPE (DM22PE or DM22XL), a conventional cup with a 22.2-mm-diameter femoral head against UHMWPE (SD22PE) and a conventional cup with a 32-mm-diameter femoral head against UHMWPE or XLPE (SD32PE or SD32XL). RESULTS: DM22PE produced 4.6 times and 5.1 times more volumetric wear than SD32XL and DM22XL (p < 0.0001, Cohen's d = 6.97 and 7.11; respectively). However, even if significant, the differences in volumetric wear between DM22XL and SD32XL as well as between DM22PE and SD22PE or SD32PE were small according to their effect size (p < 0.0001, Cohen's |d|= 0.48 to 0.65) and could be therefore considered as clinically negligible. CONCLUSION: When using XLPE instead of UHMWPE, dual mobility cup with a 22.2-mm-diameter femoral head produced a similar amount of volumetric wear than conventional acetabular component with a 32-mm-diameter femoral head against XLPE. Therefore, XLPE is advocated in dual mobility cup to improve its wear performance.

[Partial knee arthroplasty - Which parameters to consider for the correct indication and to achieve an optimal result?] / Prothèse unicompartimentale du genou - Quels paramètres considérer pour poser la bonne indication et obtenir un résultat optimal ?

Unicompartmental knee arthroplasty (UKA) is considered an excellent alternative to total knee arthroplasty (TKA) in the treatment of unicompartmental femoro-tibial degeneration with superior functional scores, reduced morbidity and fewer complications. However, revision rates are higher, mainly during the early postoperative period. Failures are attributed to incorrect indications, surgical technical errors and to the low threshold to revision. Several clinical and radiological parameters have to be considered for a correct indication. A high surgical volume is mandatory to assure optimal outcome and survivorship.

La prothèse unicompartimentale du genou (PUC) est considérée comme une excellente alternative à la prothèse totale du genou (PTG) dans le traitement de l'arthrose monocompartimentale avec des scores fonctionnels supérieurs, une morbidité réduite et des taux de complications plus faibles. Cependant, les taux de révision sont plus élevés et se produisent principalement durant la période postopératoire précoce. Ils sont attribués à des indications incorrectes, à des erreurs chirurgicales et au fait que le seuil de révision est plus bas que pour une PTG. Plusieurs paramètres cliniques et radiologiques doivent être pris en considération afin de poser la bonne indication. Un volume chirurgical suffisant est nécessaire pour obtenir un résultat optimal et une survie prolongée de la PUC.

Total knee arthroplasty improves the quality-adjusted life years in patients who exceeded their estimated life expectancy.

PURPOSE: Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis though its risk-benefit ratio in elderly patients remains debated. This study aimed to evaluate the functional outcome, rates of complication and mortality, and quality-adjusted life years (QALY) in patients who exceeded their estimated life expectancy. METHODS: Ninety-seven TKA implanted in 86 patients who exceeded their estimated life expectancy at the time of TKA were prospectively included in our institutional joint registry and retrospectively analyzed. At latest follow-up, the functional outcome with the Knee Society Score (KSS), rates of complication and mortality, and QALY with utility value of EuroQol-5D score were evaluated. RESULTS: At a mean follow-up of three ± one years, the pre- to post-operative KSS improved significantly (p < 0.01). The rates of surgical and major medical complications related to TKA were 3% and 10%, respectively. The re-operation rate with readmission was 3% while no TKA was revised. The 30-day and one year mortality was 1% and 3%, respectively. The pre- to one year post-operative QALY improved significantly (p < 0.01). The cumulative QALY five years after TKA was four years. Assuming that these patients did not undergo TKA, their cumulative QALY at five years would have been only two years. CONCLUSION: TKA is an effective procedure for the treatment of end-stage osteoarthritis in patients who exceeded their estimated life expectancy. TKA provided significant improvement in function and quality of life without adversely affecting overall morbidity and mortality. Therefore, TKA should not be contra-indicated in elderly patients based on their advanced age alone.

Comparison of the long-term cause of failure and survivorship of four hundred and twenty seven metal-on-metal hip arthroplasties: resurfacing versus large head total hip arthroplasty.

INTRODUCTION: Comparison of mid- to long-term cause of failure and survivorship of metal-on-metal (MoM) resurfacing hip arthroplasty (RHA) and large head total hip arthroplasty (THA) remains sparse. This study aimed to identify and compare the cause of failure and survivorship of MoM RHA and THA at a minimum ten year follow-up. METHODS: Four hundred twenty-seven MoM hip arthroplasties (286 THA and 141 RHA) were retrospectively analyzed at a mean follow-up of 13 ± three years. Causes of failure were reported as MoM specific (i.e., adverse reaction to metal debris (ARMD) and painful hip with ion elevation) or MoM non-specific (i.e., fracture, infection, and dislocation). Chromium (Cr) and cobalt (Co) ion levels and Co/Cr ratio were compared. Survivorship was compared according to the cause of failure with revision as the endpoint. RESULTS: The rate of ARMD was significantly higher in THA (OR = 2.9 [95%-CI: 1-7]; p = 0.02). No significant difference was detected in failure rate due to other causes between the two groups (p = 0.2-0.9). Ion levels and Co/Cr ratio were both significantly higher in THA (p < 0.01). Survivorship was significantly lower in THA compared to RHA at ten years [89% (95%-CI: 85%-91%) vs 96% (95%-CI: 91%-98%); p = 0.01] and 15 years [73% (95%-CI: 67%-78%) vs 83% (95%-CI: 73%-90%); p = 0.01]. CONCLUSION: RHA survivorship was significantly higher at any time point. Failure rate due to ARMD was significantly higher in THA while no significant difference in other causes of failure was observed between the two groups. This result emphasizes the role of fretting corrosion at the head-neck junction (i.e., trunnionosis) with significantly higher ion levels and Co/Cr ratio dissociation in THA.

Cementation of a Dual Mobility Cup Into an Existing Well-Fixed Metal Shell: A Reliable Option to Manage Wear-Related Recurrent Dislocation in Patients With High Surgical Risk.

BACKGROUND: During revision total hip arthroplasty (THA), the "double-socket" technique has been proposed as a straightforward solution in order to reduce the overall perioperative morbidity in patients with high surgical risk. However, the option of cementing a dual mobility cup into an existing well-fixed metal shell was sparsely reported. Therefore, this study aimed to evaluate the outcome of a "double-socket" technique performed with a cemented dual mobility cup in revision THA for late instability. METHODS: Twenty-eight revision THAs (28 patients) were performed for wear-related recurrent dislocation using a "double-socket" technique with a cemented dual mobility cup and retrospectively reviewed. The age at revision averaged 82 years (range 74-93). According to the American Society of Anesthesiologists (ASA) physical status classification, 12 patients (43%) were ASA II and 16 patients (57%) were ASA III before revision. RESULTS: At a mean follow-up of 3.5 years (range 2-5), the mean preoperative to postoperative functional outcome improved significantly (P < .01). The mean operative time was 107 minutes (range 75-140). The mean intraoperative bleeding was 200 mL (range 110-420). No postoperative complication, reoperation, or re-revision was reported. Importantly, no dislocation, dissociation of the cemented dual mobility cup construct, or aseptic loosening of the retained metal shell was observed. CONCLUSION: The "double-socket" technique with a dual mobility cup cemented into an existing well-fixed and well-positioned metal shell ensured a straightforward and blood-sparing revision technique that was efficient to restore stability and provide a secure acetabular construct in frail patients with high surgical risk and/or older than their natural life expectancy.

Could a Simple Screening Procedure Identify Patients With Early Cognitive Impairment? Implications for the Treatment of Geriatric Femoral Neck Fractures.

BACKGROUND: Current evidence suggests that cognitive capacities in patients who sustain a femoral neck fracture (FNF) correlate to patient outcome. We hypothesized that a simple selection procedure with 2 questions: "Can you perform your groceries independently?" and "Can you prepare your daily medications unassisted?", which imply a certain level of physical and cognitive function, could identify patients with early cognitive impairment and as a result influence the outcome of hip arthroplasty following an FNF. METHODS: At our clinic, the selection procedure was introduced in 2012 to simplify decision-making in geriatric FNF. At the time of surgery, patients received a total hip arthroplasty (THA) when able to perform their grocery shopping and prepare their daily medications unassisted (n = 100); otherwise, a hemiarthroplasty (HA) was performed (n = 100). Postoperative complications and mortality were assessed retrospectively. Second, we prospectively investigated whether patients' inability to perform groceries or prepare medications was associated with the presence of early cognitive impairment, tested with the Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery. RESULTS: The screening questions showed almost perfect agreement (k = 0.8; sensitivity/specificity: 82%/95%) to early cognitive impairment. The 30-day mortality for THA and HA patients was 2% and 4%, respectively. The 1-year and 5-year survivorship for the THA group was 95% and 87% and for the HA group 63% and 8%, respectively. Complication rates were comparable. CONCLUSION: The results might suggest that 2 simple screening questions could help in the decision-making of the appropriate surgical treatment in elderly patients suffering from a displaced FNF.

Is revision total hip arthroplasty through the direct anterior approach feasible?

BACKGROUND: To date, only limited literature exists regarding revision of total hip arthroplasty (THA) through the direct anterior approach (DAA). However, as the popularity of the DAA for primary surgery is increasing, surgeons will be confronted with the challenge of performing revision surgery through the DAA. The aim of this study was to review the potential of the DAA in the revision setting and to report the clinical results, radiologic outcomes and complication rates of 63 patients undergoing revision THA through the DAA. METHODS: From 01/2009 to 08/2017, 63 patients underwent revision THA through the DAA. Depending on the performed procedure, patients were separated into 4 groups: liner and head exchange (21 patients), revision of the acetabular cup (26 patients), revision of the femoral stem (13 patients) or revision of both components (3 patients). Postoperative complications as well as the clinical and radiological outcome were assessed retrospectively. RESULTS: At a mean follow-up of 18 months, the overall complication and re-operation rates were 14.3% and 12.7%, respectively. Specifically, the complication and re-operation rates were 14.2% and 9.5% after liner and head exchange, 15.4% after revision of the acetabular cup, 15.3% after revision of the femoral stem and 0% after revision of both components. The mean postoperative HHS at 1 year postoperatively was 91 (range 74-100). CONCLUSION: The DAA offers appropriate exposure for exchange of mobile liners and acetabular cup revision. In selected cases with appropriate stem design, femoral stem revision through the DAA is feasible. However, surgeons should be aware of the technical difficulties related to femoral revision and be prepared to extend the approach distally or perform a trochanteric osteotomy.

Migration analysis of a metaphyseal-anchored short femoral stem in cementless THA and factors affecting the stem subsidence.

BACKGROUND: Early femoral stem subsidence following a cementless THA is correlated with aseptic loosening of the femoral component. The short femoral stems allow bone sparing and implantation through a minimally invasive approach; however, due to their metaphyseal anchoring, they might demonstrate different subsidence pattern than the conventional stems. METHODS: In this prospective single-center study, a total of 68 consecutive patients with an average age of 63 years, and a minimum follow-up of 5 years following a cementless THA with a metaphyseal-anchored short femoral stem were included. The femoral stem subsidence was evaluated using "Ein Bild Roentgen Analyse" (EBRA). RESULTS: Average stem migration was 0.96 +/- 0.76 mm at 3 months, 1.71 +/- 1.26 mm at 24 months, and 2.04+/- 1.42 mm at last follow-up 60 months postoperative. The only factor that affected migration was a stem size of 6 or more (r2 = 5.74; p = 0.039). Subdivision analysis revealed, that only in females migration appeared to be affected by stem size irrespective of weight but not in men (female stem size of 6 or more vs. less (Difference = - 1.48 mm, R2 = 37.5; p = 0.001). Migration did not have an impact on clinical outcome measures. CONCLUSIONS: The examined metaphyseal-anchored short femoral stem showed the highest subsidence within the first 3 months postoperative, the implant began to stabilize at about 24 months but continued to slowly migrate with average total subsidence of 2.04 mm at 5 years following the THA. The amount of stem subsidence was not associated with worse clinical outcomes such as HHS, patient satisfaction, or pain.

Accuracy of tibial cuts with patient-specific instrumentation is not influenced by the surgeon's level of experience.

PURPOSE: It was hypothesized that surgeon's experience as well as bone density play a significant role in achieving accurate cuts with patient-specific instrumentation (PSI). The aim of this study was to compare the accuracy of the tibial cuts in different bone densities made by a highly experienced orthopedic surgeon on one hand and a less experienced orthopedic surgeon on the other. METHODS: Tibial models from three different sawbone densities were developed for this study. Each surgeon performed 21 cuts. A coordinate measuring machine was used to analyse the cuts. The K-Cohen test was performed to evaluate the results. The analyzed parameters were guide positioning and deviation from the guide cut to the tibial cut, including varus/valgus angle, the tibial slope, cut height, planarity (mm2), and rugosity (mm). RESULTS: There was a significant difference in the positioning of the tibial cut guide between the two surgeons for the tibial slope (p < 0.05), while no difference was observed for the varus/valgus angle (n.s.) and the cut height (n.s.). No significant difference in the tibial cut was observed between the surgeons for the tibial slope angle (n.s.), varus/valgus angle (n.s.), planarity (n.s.), and rugosity (n.s.). In the different bone types, no significant difference was observed for the tibial slope (n.s.) and varus/valgus angle (n.s.), while planarity and rugosity showed significant differences (p < 0.05). Our study showed no significant difference in the tibial cuts for the tibial slope, varus/valgus angle, planarity, and rugosity between the two surgeons. CONCLUSIONS: In the present study, it could be demonstrated that accuracy of the cuts is ensured by PSI not depending on the surgeon's experience and the bone mineral density. This speaks to its clinical significance: PSI might be suited for less experienced surgeons to reduce outliers in total knee arthroplasty (TKA).

The Role of Total Hip Arthroplasty Through the Direct Anterior Approach in Femoral Neck Fracture and Factors Affecting the Outcome.

BACKGROUND: Femoral neck fractures (FNFs) are a significant cause of mortality and disability among the elderly population. Total hip arthroplasty (THA) is the preferred treating method in active, cognitively intact patients. The direct anterior approach (DAA) has suggested a lower dislocation risk and a significant reduction in postoperative pain and recovery time in elective THA. This study aimed to compare clinical outcomes, perioperative complications, and mortality of THA through the DAA between FNF and elective cases. METHODS: Patients with displaced FNF (n = 150) who received THA through the DAA were matched for gender, age, body mass index, and American Society for Anesthesiologists score with electively treated patients (n = 150). The perioperative complications, clinical and radiologic outcomes, as well as mortality were compared between groups, retrospectively. RESULTS: FNF patients had an increased blood loss, operation duration, hospital stay, and mortality but similar surgery-related complication rates compared to their elective counterparts. The mortality was, however, lower than that reported in the literature. Age, American Society for Anesthesiologists score, and time-to-operation affected the duration of hospital stay and mortality. Less experienced surgeons did not have increased surgery-related complications, but longer operation time and higher blood loss compared to experienced surgeons. CONCLUSION: THA through the DAA might be a credible and safe option for patients presenting an FNF, with excellent functional outcomes, less surgery-related complications, and lower short-term and long-term mortality than those reported in the literature. Early intervention and perioperative stabilization of the patients with FNF could potentially increase the survival rate.

A novel preoperative scoring system for the indication of unicompartmental knee arthroplasty, as predictor of clinical outcome and satisfaction.

INTRODUCTION: Proper patient selection is a crucial factor for the outcome of the unicompartmental knee arthroplasty (UKA). However, there is still not a clear consensus on which patients could benefit the utmost from a UKA. The purpose of this prospective study was to introduce a novel, preoperative, predictive score (Unicompartmental Indication Score, UIS) to aid proper patient selection in UKA. MATERIALS AND METHODS: A total of 152 patients with an average age of 68 years and a mean follow-up of 27 months were evaluated preoperatively with the UIS and postoperative at every follow-up. Correlation analysis was applied to identify potential relationships between the UIS, functional outcomes, pain relief, patient satisfaction, and range of motion. The ROC analysis was used to identify the best cutoff value of the UIS, which would have predicted an optimal outcome following UKA. RESULTS: The majority of the patients (91%) were satisfied with the operation, with 61% reporting excellent and 30% good satisfaction. The UIS was positively correlated to the postoperative Knee Society Score (KSS) for both pain (r = 0.26, p < 0.001) and function (r = 0.31, p < 0.001). The UIS was also positively correlated to the patient satisfaction (p = 0.46, p < 0.001) and maximum postoperative flexion (r = 0.25, p < 0.001). The ROC analysis provided an ideal cutoff for UIS at 25 points (sensitivity: 75%, sensibility: 93%, area under the curve: 86%). At a mean follow-up of 27 months (range 24-37), we observed three revisions in 152 consecutive UKA with a mean UIS of 27 points (range 20-30). CONCLUSIONS: The newly introduced UIS score might be a reliable preoperative scoring system to predict patients with excellent satisfaction, functional outcome, pain relief and possibly implant survivorship following UKA, and therefore, could help the proper patient selection and decision-making in UKA. LEVEL-OF-EVIDENCE: Prospective study, II.

[Modified Lemaire Procedure: Indication, procedure, and clinical results]. / Die modifizierte Lemaire-Technik: Indikation, Eingriff und klinische Ergebnisse.

BACKGROUND: The mechanisms of anterior cruciate ligament (ACR) rupture may include a pivoting mechanism, which is responsible for concomitant lesions of the anterolateral structures. This anterolateral complex is the main stabilizer of tibial internal rotation and therefore accountable for a persisting pivot shift despite technical improvement of ACR reconstruction. For this reason, knee surgeons' interest in addressing anterolateral stabilization in addition to ACR reconstruction has been renewed. STUDIES: Biomechanical and clinical studies have shown promising results so far. The modified, lateral, extra-articular stabilization according to Lemaire as a non-anatomical reconstruction of the anterolateral ligament (ALL) shines with a low morbidity, since no additional tendon harvesting is needed. Besides the potential benefits there are several risks and disadvantages. For example, complete control of the pivot-shift phenomenon is not possible in nearly 8% of cases. In addition, too tight tensioning of the ALL may result in an increase of pressure in the lateral knee compartment. Overall, ALL reconstruction is a hot topic and is heavily discussed in literature. This article provides an overview and brings the modified technique of Lemaire into focus.

[Ankle dislocation without osseous lesions]. / Luxation des oberen Sprunggelenks ohne ossäre Läsion.

Approximately 7-10% of all emergency department patients are diagnosed with distortion of the upper ankle joint. A dislocation of the upper ankle joint without fracture is described in the literature as being very rare. In 33-50% the ankle dislocations are at least first-degree open and associated with a fracture of the tibia, the fibula or the talus. We report the course, treatment and results 12 months after trauma of a posteromedial first-degree open dislocation of the upper ankle joint without fracture. To our knowledge, there is no record of this pathology mentioned in the German language literature.

[The irreducible ankle dislocation: beware of the Bosworth injury]. / Irreponible Luxation des oberen Sprunggelenks: die Bosworth-Verletzung.

A luxation fracture of the ankle characterized by a dislocation of the fibula posterior to the tibial tubercle is defined as a Bosworth injury. The Bosworth fracture is a frequently overlooked complex injury of the ankle joint. Associated injuries such as a pilon fracture and posterior malleolus fracture have rarely been reported. In the case of a closed irreducible ankle fracture dislocation, Bosworth injuries should be considered as a potential cause. This article reports the course, treatment and clinical outcome 12 months after trauma of a Bosworth fracture with associated impaction of the posteromedial pilon and fracture of the posterior malleolus. To date, there are only few reports of comparable injuries in the German language literature.

Total Hip Arthroplasty Improves the Quality-Adjusted Life Years in Patients Who Exceeded the Estimated Life Expectancy.

BACKGROUND: Hip osteoarthritis is a leading cause of functional decline and disability in the elderly. Although patients older than 80 years could significantly benefit from an elective total hip arthroplasty (THA), they pose a significant challenge to both anesthesiologist and arthroplasty surgeon. The purpose of this study was to report the clinical outcomes, complication rate, mortality, and quality-adjusted life year (QALY) of THA in patients who already exceeded the average life expectancy. METHODS: Patients treated with elective THA for debilitating hip osteoarthritis and already exceeded the average life expectancy in Switzerland (n = 100) were included. The complication rate, QALY, and 30-day, 1-year, and midterm mortality were assessed retrospectively. RESULTS: The overall complication rate was 12%. The 30-day and 1-year mortality was 3% and 6%, respectively. The Harris hip score increased significantly from an average of 50 preoperative to 93 points postoperative. Most of the patients (98%) had an improvement in the Harris hip score that was above the threshold for minimally significant change, whereas 75% reported an increase that exceeded the moderate improvement threshold. The average QALY was 4 years. CONCLUSION: THA might be a safe and cost-effective procedure for improving pain, function, and quality of life with low mortality in selected elderly patients who already exceeded the average life expectancy. Hence, the arthroplasty surgeons should not hesitate to operate relatively active, independent, and cognitively intact elderly patients having debilitating hip osteoarthritis based only on the patient's age. Nevertheless, careful patient selection, surgical indications, and aggressive perioperative optimization might be necessary to minimize the risk of preoperative complications.

Is Direct Anterior Approach a Credible Option for Severely Obese Patients Undergoing Total Hip Arthroplasty? A Matched-Control, Retrospective, Clinical Study.

BACKGROUND: Severely obese patients present a significant challenge for arthroplasty surgeons because of their body habitus. Up to date, there is no clear consensus on the safety of the direct anterior approach (DAA) in obese patients undergoing total hip arthroplasty. Therefore, the purpose of the present study was to determine whether DAA is a credible option in severely obese regarding complication rates, clinical outcomes, and component positioning. METHODS: Obese patients with a body mass index ≥ 35 kg/m2 (n = 129) who received total hip arthroplasty with DAA in our institution were matched for gender and age with nonobese patients with body mass index ≤ 25 kg/m2 (n = 125). The postoperative complications and clinical and radiologic outcomes were assessed retrospectively. RESULTS: The results of this study showed an increased risk of reoperation (relative risk: 4.0), mostly due to wound infection and dehiscence, in obese than in nonobese patients. The mean Harris Hip Score increased from 50 and 42 preoperative to 95 and 97 at the 1-year follow-up in obese patients and nonobese patients, respectively. No significant difference was observed regarding the acetabular anteversion, inclination or leg-length discrepancy, and vertical center of rotation. The horizontal center of rotation was slightly medialized (4 mm) in the nonobese compared with the obese patients (1 mm). CONCLUSION: Obese patients had a higher complication and reoperation rate compared with nonobese patients. However, these rates were comparable to the rates of the standard, more extensive approaches presented in the literature. The current data suggest that DAA might be a credible option for obese patients, with excellent functional and radiographic outcomes.

Decompression surgery for lumbar spinal canal stenosis in octogenarians; a single center experience of 121 consecutive patients.

INTRODUCTION: With increasing age, ubiquitous degeneration processes lead to a narrowing of the spinal canal. Degenerative lumbar spinal stenosis (DLSS) causes functional disability and is associated with back and lower extremity pain in older individuals. The goal of this study was to determine if decompression surgery can be performed safely and provide a stable benefit in our octogenarian patient population. METHODS: In this retrospective study, 121 patients over the age of 80 (mean age: 82.7 years SD: 2.4 years) with the diagnosis of central spinal canal stenosis who underwent posterior decompression surgery without fusion for DLSS between January 2006 and August 2013 were followed up from November to December 2013. Peri- and post-operative complications were recorded. Walking distances and visual analogue scale (VAS) scores were determined before surgery and at follow up time (mean follow up time 36 months). Patient's satisfaction with treatment was documented with the overall satisfaction degree scale in Zurich Claudicatio Questionnaire (ZCQ). RESULTS: The peri-operative complication rate was 6.6% with five dural tears, two wound infections and one epidural haematoma. Four patients required revision surgery (three re-decompression and one secondary spondylodesis). Walking distance improved from 147 meters (SD ±110 m) to 340 m (SD ±170 m) p < .001. Pain improved with change of the VAS scores from 7.2 (SD ±1.2) to 4.5 (SD ±1.0), p < .001. The overall satisfaction scale in ZCQ was 2.2 at follow up. CONCLUSION: A minimal surgical intervention, namely decompression, improves walking ability, decreases pain and has marginal potential for complications in patients with DLSS who are over 80 years old.

Does pain relief by CT-guided indirect cervical nerve root injection with local anesthetics and steroids predict pain relief after decompression surgery for cervical nerve root compression?

BACKGROUND: The relationship of pain relief from a recently presented CT-guided indirect cervical nerve root injection with local anesthetics and steroids to surgical decompression as a treatment for single-level cervical radiculopathy is not clear. This retrospective study aimed to compare the immediate and 6-week post-injection effects to the short- and long-term outcomes after surgical decompression, specifically in regard to pain relief. METHODS: Patients (n = 39, age 47 ± 10 years) who had undergone CT-guided indirect injection with local anesthetics and steroids as an initial treatment for single cervical nerve root radiculopathy and who subsequently needed surgical decompression were included retrospectively. Pain levels (VAS scores) were monitored before, immediately after, and 6 weeks after injection (n = 34), as well as 6 weeks (n = 38) and a mean of 25 months (SD ± 12) after surgical decompression (n = 36). Correlation analysis was performed to find potential associations of pain relief after injection and after surgery to investigate the predictive value of post-injection pain relief. RESULTS: There was no correlation between immediate pain relief after injection (-32 ± 27 %) and 6 weeks later (-7 ± 19 %), (r = -0.023, p = 0.900). There was an association by tendency between immediate pain relief after injection and post-surgical pain relief at 6 weeks (-82 ± 27 %), (r = 0.28, p = 0.08). Pain relief at follow-up remained high at -70 ± 21 % and was correlated with the immediate pain amelioration effect of the injection (r = 0.37, p = 0.032). Five out of seven patients who reported no pain relief from injection had a pain relief from surgery in excess of 50 %. CONCLUSIONS: The amount of immediate radiculopathic pain relief after indirect cervical nerve root injection is associated with the amount of pain relief achieved at long-term follow-up after surgical decompression of single-level cervical radiculopathy. Patients can still expect sufficient pain relief from surgery even if they did not respond to the cervical infiltration.