The impact of femoral bone quality on cementless total hip pre-operative templating.

INTRODUCTION: Accurate templating is an integral part of pre-operative planning for total hip arthroplasty (THA). Templating of cementless implant accuracy has been average. The aim of this study was to assess the impact of Dorr femoral classification on the accuracy of pre-operative digital templating. PATIENTS AND METHODS: This was a retrospective study of cementless THA pre-operative planning using one implant design. A total of 210 primary THA were reviewed. A total of 102 cementless THAs matched the exclusion and inclusion criteria, using one implant combination, were analyzed by an orthopaedic resident and a fellowship trained arthroplasty surgeon. Each x-ray was evaluated and assigned a femoral Dorr classification. Accuracy of templating was determined by comparing the templated size with the actual implant size both for the femoral and acetabular components. RESULT: Out of the 102 cases, exact templating size was achieved in 35.3% for the acetabulum, 25.5% for the femur, and only in 9.8% for both components. Reasonable templating, ± one of the actual size, was achieved in 78.4% for the acetabulum, 74.5% for the femur, and 60.8% for both components. Use of Dorr femoral type classification did not result in better templating accuracy. CONCLUSION: Pre-operative hip cementless templating using digital x-rays with double marker method do not improve accuracy compared to other methods available for templating. Accounting for bone quality using the Dorr femoral classification did not improve accuracy.

Total Knee Arthroplasty for Valgus Deformity via a Lateral Approach: Clinical Results, Comparison to Medial Approach, and Review of Recent Literature.

BACKGROUND: Total knee arthroplasty (TKA) for valgus deformity is a challenge. The standard medial parapatellar approach may not be universally useful for this. We have adopted the lateral approach to valgus knees. Here we describe our experience with this approach, present early results, and compare them to the medial approach. METHODS: Our institutional registry was queried for all patients with valgus deformity who underwent a TKA via a lateral approach between 2013 and 2016. The registry was also queried for patients with valgus deformity who underwent a TKA through a medial approach in previous years and this data was compared to the study group. RESULTS: Seventy-nine valgus knees in 72 patients were operated through a lateral approach. Deformity was corrected by 10.8°, from 16.2° to 5.4° (P < .001). Patellar tilt improved from -2.3° to 0.3° (P = .037). Seven implants (9%) were constrained. Mean operating time was 87 minutes (range 53-137). Twenty-five knees in 23 patients were operated via the medial approach. Deformity was corrected by 7.3°, from 13.2° to 5.9° (P < .001). Mean operating time was 137 minutes (range 90-230). Constrained implants were used in 16% of cases. The lateral approach allowed better correction of valgus deformity (10.8 vs 7.3, P = .03) and shorter operative times (87 vs 137 minutes, P < .001). CONCLUSION: A lateral approach TKA for valgus deformity improves knee alignment and patellar tilt. Compared to the medial approach, it allows better correction of the deformity, shorter operating times, and perhaps less use of constrained implants.

Informal (Hallway) medical consultation in orthopedics-is it as common as it seems?

INTRODUCTION: Informal (hallway) medical consultation is an integral part of the physician's work. As musculoskeletal complaints are very common, orthopedic surgeons stand in the frontline of this practice. Many of these consultations are poorly, if at all, documented, thus imposing a potential medical danger to the patient and a medicolegal danger to the surgeon. We conducted this first study to examine whether this practice is common among the orthopedic surgeons in university hospital. METHODS: In this prospective study, a 2-month record of informal consultations was kept. Six orthopedic surgeons-two joint reconstruction surgeons, one spine surgeon, two arthroscopy and sports medicine surgeons, and a shoulder surgeon participated. They recorded the details of the consulter, whether the consultation was for himself or somebody else, the major complaint, and whether it was a second opinion. All patients were advised to go to the formal orthopedic consultation and no advice or treatment was given. At the end of 2 months, each surgeon was asked to evaluate the percentage of cases he had failed to report. RESULTS: During the 2-month period, 158 people asked for informal (hallway) consultations. 11 of them (7%) were physicians, 114 (72%) were other hospital personnel, 26 (17%) were unrelated to hospital, and 6 (4%) were treated patients' relatives. 93 (59%) of consultations were about the consulter himself and the rest were about a relative or a friend. 41 (26%) were requests for a second opinion. The estimated percentage of not reported cases was 10-40%; when the number of consultations was corrected for these figures, it reached 208 consultations in 2 months. DISCUSSION: In this prospective study, six participating surgeons recorded 158 informal consultation requests in 2 months. If a correction is performed, it averages 0.6 consultations a day for a surgeon (or, if only workdays are counted-0.8 consultations a day). Orthopedic surgeons should be aware of this frequent habit and send these patients to a formal consultation.

Long Term Results of Liner Polyethylene Cementation Technique in Revision for Peri-acetabular Osteolysis.

Patients with peri-acetabular osteolysis around a well fixed cementless acetabular component may be treated with liner exchange. When the locking mechanism is unreliable or unavailable, cementing the liner into the fixed acetabular component is a feasible option. The purpose of this study was to evaluate the clinical and radiographic long term results of this technique. Forty hip revisions with liner cementation in 37 patients were performed. The minimum follow up was 10 years. Modified Harris Hip Score and recent x rays were reviewed. Four hips were re-revised. Two patients were diagnosed with exacerbation of osteolysis but refused revision. Dislocation rate was relatively high (16%). Liner cementation technique in revision hip surgery is useful in patients with a well fixed metal backed acetabular component.

Effect of severe aortic stenosis on the outcome in elderly patients undergoing repair of hip fracture.

BACKGROUND: The perioperative assessment and management of elderly patients with hip fracture and significant aortic stenosis (AS) is an increasingly common clinical problem with little data available to guide perioperative management. OBJECTIVES: It was the aim of this study to examine the incidence of perioperative events in an elderly population of patients with severe AS undergoing repair of hip fracture as compared with controls without severe AS. METHODS: Patients over the age of 70 with an echocardiographic diagnosis of severe AS defined as an aortic valve area

A Practical Tool for Surveillance of Surgical-Site Infections: A 5-Year Experience in Orthopedic Surgeries.

Continuous surveillance of surgical-site infection (SSI) is labor intensive. We developed a semiautomatic surveillance system partly assisted by surgeons. Most patients who developed postdischarge SSI were readmitted, which allowed us to limit postdischarge surveillance to this group. This procedure significantly reduced workload while maintaining high sensitivity and specificity for SSI diagnosis. Infect Control Hosp Epidemiol 2017;38:610-613.

A short plate compression screw with diagonal bolts--a biomechanical evaluation performed experimentally and by numerical computation.

INTRODUCTION: Decreasing the length of the side plate of the dynamic hip screw would theoretically allow a smaller surgical incision, a shorter surgical time, decreased operative blood loss and minimal periosteal stripping. A new design of a very short plate dynamic hip screw based on two diagonal screws has been developed. Our study compares the new design and the four-hole side plate in respect to mechanical properties and bio-mechanical outcomes utilizing the Finite Element Analysis method. METHODS: Four pairs of fresh frozen cadaveric femora were extracted from male corpses aged 25-43 years (mean 34.8). One femur of each pair was fixated by means of the new system and the other by means of the conventional design. Mechanical loading was applied to all four pairs. The decline which occurred during the periodical loadings and the breakage loads of fixated bones were measured. Mechanical performance and probability of failure was assessed by conducting a mathematical analysis using the finite element method. FINDINGS: The average deflection under excessive cyclic loading was 33% higher in the bones fixated with the very short plate-dynamic hip screw device than in those fixated with the conventional dynamic hip screw. The average load failure during the collapse-loading test was 3120N for the very short plate-dynamic hip screw as compared to 4160N for the regular device. Mechanical testing did not provide decisive results regarding failure. The mathematical analysis performed indicated that the maximal stress in the very short plate-dynamic hip screw reached values 3-4-fold higher than in the regular dynamic hip screw. INTERPRETATION: Although the new design offers a minimally invasive approach to subtrochanteric femur fracture fixation, it was found to have insufficient biomechanical performance resulting in high probability of mechanical failure. The authors believe that the finite element method may have the potential to serve as an additional clinical tool for performing surgical preplanning and assist in decision making.

Navigation-assisted minimally invasive two-incision total hip arthoplasty.

Flouroscopy-based navigation can increase accuracy in two-incision minimally invasive THA, a novel technique develop for promoting fast recovery.

Revision total knee arthroplasty.

BACKGROUND: Revision total knee arthroplasties are performed with increasing frequency due to the increasing numbers of primary arthroplasties. OBJECTIVES: To retrospectively analyze 71 patients who underwent 78 revision total knee arthroplasties during the years 1991 to 1999 METHODS: We evaluated the revised knees using the Knee Society Clinical Rating System after an average follow-up period of 3 years and 9 months (2-10 years). The indications for revision included pain and instability, deep infection of the joint, complaints linked to the patella, or post-trauma to the operated knee. RESULTS: The average knee score (evaluation of the knee joint itself) calculated after the revision was 74.5. The results on the knee score were excellent (> 85) in 48% of patients and poor (< 60) in 22%. The functional results (patient's ability to walk and climb stairs) were only 48.3. CONCLUSION: Although the revision of total knee replacements is known to be problematic, most patients show good results on knee examination, and reasonable functional results given the factors involved.

Avascular necrosis and related complications following healed osteoporotic intertrochanteric fractures.

BACKGROUND: Femoral hip fractures are a common occurrence in the elderly. Of the various fracture patterns, intertrochanteric injuries have the lowest rate of complications. Case reports of ensuing subcapital fracture have all been linked to incorrect placement of fixation devices or to osteomyelitis, white cases of avascular necrosis have only been reported rarely in the literature and are considered to occur at the rare rate of 0.8%. OBJECTIVES: To check the incidence and outcome of AVN in intertrochanteric hip fractures. METHODS AND RESULTS: In a retrospective analysis of patients who had surgical treatment for intertrochanteric fractures. 10 patients (0.5%) underwent dynamic hip screw fixation for intertrochanteric fractures and subsequently developed painful AVN as their primary presentation. Three of these patients were also found to have subcapital fractures. On revision of the primary fixation no fault was found with nail placement. CONCLUSIONS: The reported rate of AVN may be understated since many patients have limiting factors that prevent them from consulting a physician when in pain, and one-third of these patients die within 2 years. Therefore, we suggest that hip pain following fixation of an intertrochanteric fracture should prompt the clinician to consider the rare possibility of AVN or subcapital fracture.

Improving compliance to osteoporosis workup and treatment in postmenopausal patients after a distal radius fracture.

OBJECTIVE: Distal radius fracture (DRF) in postmenopausal women is often the first clinical sign of osteoporosis (OP). Despite the availability of effective treatments, only a minority of patients who sustain a fragility fracture are tested for OP. The purpose of this study was to examine whether a simple intervention by the hospital staff increases rates of OP workup. MATERIALS AND METHODS: We conducted a prospective randomized clinical trial. Ninety nine patients after DRF were randomized to two groups. Both groups were contacted after their fracture and were asked to answer a questionnaire and were informed about the possible relationship between DRF and OP. In the intervention group, patients were sent an explanatory pamphlet and a letter to their primary care physician. An additional survey was conducted to establish whether the intervention improved the number of patients who undergo OP workup. RESULTS: The intervention increased the proportion of patients who turned to their primary care physician from 22.9% to 68.6%, and increased the proportion of patients undergoing OP workup from 14.3% to 40% (p < 0.001). CONCLUSION: Women with DRF who receive an explanation about possible OP implications and are sent explanatory materials are more likely to undergo OP workup.

Set7/9 impacts COL2A1 expression through binding and repression of SirT1 histone deacetylation.

Type II collagen is a key cartilaginous extracellular protein required for normal endochondral development and cartilage homeostasis. COL2A1 gene expression is positively regulated by the NAD-dependent protein deacetylase Sirtuin 1 (SirT1), through its ability to bind chromatin regions of the COL2A1 promoter and enhancer. Although SirT1/Sox9 binding on the enhancer site of COL2A1 was previously demonstrated, little is known about its functional role on the gene promoter site. Here, we examined the mechanism by which promoter-associated SirT1 governs COL2A1 expression. Human chondrocytes were encapsulated in three-dimensional (3D) alginate beads where they exhibited upregulated COL2A1 mRNA expression and increased levels of SirT1 occupancy on the promoter and enhancer regions, when compared to monolayer controls. Chromatin immunoprecipitation (ChIP) analyses of 3D cultures showed augmented levels of the DNA-binding transcription factor SP1, and the histone methyltransferase Set7/9, on the COL2A1 promoter site. ChIP reChIP assays revealed that SirT1 and Set7/9 form a protein complex on the COL2A1 promoter region of 3D-cultured chondrocytes, which also demonstrated elevated trimethylated lysine 4 on histone 3 (3MeH3K4), a hallmark of Set7/9 methyltransferase activity. Advanced passaging of chondrocytes yielded a decrease in 3MeH3K4 and Set7/9 levels on the COL2A1 promoter and reduced COL2A1 expression, suggesting that the SirT1/Set7/9 complex is preferentially formed on the COL2A1 promoter and required for gene activation. Interestingly, despite SirT1 occupancy, its deacetylation targets (ie, H3K9/14 and H4K16) were found acetylated on the COL2A1 promoter of 3D-cultured chondrocytes. A possible explanation for this phenotype is the enrichment of the histone acetyltransferases P300 and GCN5 on the COL2A1 promoter of3 D-cultured chondrocytes. Our study indicates that Set7/9 prevents the histone deacetylase activity of SirT1, potentiating euchromatin formation on the promoter site of COL2A1 and resulting in morphology-dependent COL2A1 gene transactivation.

A simple intervention for improving the implementation rate of a recommended osteoporosis treatment after hip fracture.

OBJECTIVE: Osteoporosis is often under-treated, and hip fracture is frequently its first manifestation. Hospitalization for a hip fracture is an opportunity to initiate osteoporosis treatment. The aim of this study was to investigate whether a simple intervention improves the implementation rate of a recommended osteoporosis treatment. METHODS: One hundred elderly patients admitted with low-impact hip fracture were given a 10 minute explanation about osteoporosis and its treatment during their postoperative hospital stay. In addition, the patients received an explanatory brochure and a letter to their primary care physician that included an article on fracture rate reduction with osteoporosis treatment. Implementation of therapy was assessed by a telephone survey 3 and 6 months postoperatively. The patients who had not received treatment at 3 months were given a repeated explanation. The historical control group was comprised of 100 hip fracture patients with similar demographic characteristics, who were operated on and discharged with the standard care recommendations for osteoporosis prevention. RESULTS: At the 3 month follow-up, the therapy rate in both groups was similar (19%). Fifty-eight percent of the patients in the study group had no recollection of the intervention. However, after a repeated explanation, at the 6 month follow-up, 39% of the intervention group had received drug therapy for fracture prevention (P<.001). CONCLUSION: A simple intervention enlisting the patients' help to involve their primary care physician can increase treatment rates for osteoporosis following a hip fracture. During the immediate postoperative period, the patients and their families have difficulty implementing the recommendations. Therefore, repeated communications are recommended.

Bipolar hip hemiarthroplasty in a patient with an above knee amputation: a case report.

The treatment of an above knee amputee who has sustained a fracture of femoral neck is a challenge for both the orthopaedic surgeon and the rehabilitation team. We present a case of such a patient and discuss different difficulties in his treatment.

Polyethylene liner cementation technique in asymptomatic versus symptomatic osteolysis.

Osteolysis around a cementless acetabular component can lead to severe bone loss. This study examined whether osteolysis should be treated while still asymptomatic. Thirty-seven liner cementation revisions were performed in 34 patients. Mean patient age was 61 years, and mean time elapsed after index surgery was 85 months (range, 36-168 months). Patients were evaluated by Harris Hip Score (HHS), and mean follow-up was 5 years (range, 43-82 months). Average HHS was 87 with a pain component of 39. In asymptomatic patients, both the HHS and the pain score were significantly higher: 95 and 43, respectively (P<.01). One patient with extensive bone loss had a fracture of the acetabulum and underwent revision at another institution. Revision of the polyethylene liner and cementation of a new one is a useful technique in patients with a stable acetabular shell. This is especially true for asymptomatic patients with osteolysis and thus should be performed early; however, high dislocation rate is still a concern.

Sciatic nerve palsy due to hematoma after thrombolysis therapy for acute pulmonary embolism after total hip arthroplasty.

Sciatic nerve paralysis as a complication of bleeding due to hip surgery is a rare entity. The use of thrombolysis and full-dose heparin administration for the treatment of massive pulmonary embolism increase the risk for developing major bleeding. Prompt recognition and intervention in this condition are warranted. A case of sciatic nerve palsy due to expanding thigh hematoma as a complication of thrombolytic therapy for pulmonary embolism after total hip arthroplasty is presented with a literature review. Although rare, this complication should be promptly recognized and immediate decompression should take place because of the favorable results of the early treatment.