Double-center observational study of minimally invasive sacroiliac joint fusion for sacroiliac joint dysfunction: one-year results.

BACKGROUND: For a substantial part of patients with chronic low back pain, the origin is located in the sacroiliac joint (SIJ). Minimally invasive sacroiliac joint fusion (MISJF) is increasingly being implemented as a treatment option in SIJ dysfunction. Despite remaining controversy, evidence continues to increase. This study evaluates the clinical results and safety of MISJF in a double-center consecutive case series in patients with SIJ dysfunction over a one-year observation period. METHODS: SIJ complaints were diagnosed after history taking, physical examination and least a 50% reduction of SIJ pain 30-60 min following image-guided injection. Primary outcome measures were patient reported outcome measurements (PROMs), consisting of Visual Analogue Scale (VAS) pain score and EuroQol 5-dimensions 3-levels (EQ-5D-3L). Patients' perspectives on the effects of surgery were collected through questionnaires. Secondary outcome measures were implant positioning and (serious) adverse events ((S)AE's). RESULTS: A total of 29 patients were included. In 44.8% of patients, SIJ dysfunction was of postpartum origin. The mean VAS-pain score improved from 7.83 (± 1.71) to 4.97 (± 2.63) postoperatively (p < 0.001). EQ-5D-3L score improved from 0.266 (± 0.129) to 0.499 (± 0.260) postoperatively (p < 0.001). Opioid consumption decreased from 44.8 to 24.1% postoperatively (p = 0.026). In 13.7% of patients, an (S)AE occurred. CONCLUSION: MISJF appears to be an effective and safe procedure in this cohort. Statistically significant and clinically relevant improvements in pain and quality of life were observed one-year postoperatively. Future studies should focus on the long-term outcomes to further evaluate the safety and effectiveness of MISJF.

Infection mimicking skin condition: pyoderma gangrenosum.

The a priori risk of infection is high when a patient presents with an ulcerative skin condition and elevated inflammatory parameters. If the ulceration is progressive despite adequate antibiotic therapy and tissue cultures are negative, pyoderma gangrenosum should be considered as the diagnosis. This rare infection mimicking skin condition can develop and worsen due to surgery. In this paper, we report two cases that illustrate the importance of making this clinical diagnosis in a timely manner in order to avoid unnecessary surgical interventions and worsening of the clinical picture.

Study protocol for a randomised controlled trial on the effect of local analgesia for pain relief after minimal invasive sacroiliac joint fusion: the ARTEMIS study.

INTRODUCTION: Chronic lower back pain is a common report in the general population. A dysfunctional sacroiliac joint (SIJ) is estimated to be responsible for one in five patients with lower back pain. Minimally invasive sacroiliac joint fusion (MISJF) is a surgical procedure to treat SIJ dysfunction. During the procedure, the SIJ is stabilised by implants inserted percutaneously under fluoroscopy guidance. Postoperatively, patients often report a lot of pain, which contributes to patients taking high doses of painkillers (opioids for example,) and preventing early mobilisation. In several orthopaedic procedures, intraoperative infiltration of the wound bed results in decreased consumption of analgesics, earlier mobilisation and shorter hospitalisation time. The aim of this study is to investigate the effectiveness of intraoperative SIJ infiltration with analgesia in reducing postoperative pain after MISJF. METHODS AND ANALYSIS: We will perform a two-centre, prospective, double-blind, randomised controlled trial to determine whether SIJ infiltration with 1.5-5 cc bupivacaine 0.50% is superior to 1.5-5 cc placebo (NaCl 0.9%) in reducing postoperative pain in patients after MISJF, and to determine whether bupivacaine significantly reduces opioid use in the direct postoperative period. Patients will be randomised with 1:1 allocation for either bupivacaine (intervention) or placebo SIJ infiltration. Postoperative pain will be measured by the Visual Analogue Scale pain score at entry and exit recovery, 2, 4, 6, 24 and 48 hours postoperatively. ETHICS AND DISSEMINATION: This is the first trial that investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% in reducing postoperative pain after MISJF. If intraoperative SIJ infiltration with bupivacaine 0.50% proves to be effective, this might have important clinical implications, such as postoperative analgesics (opioids for example,) consumption, earlier mobilisation and potentially shorter hospitalisation time. TRIAL REGISTRATION NUMBER: NL9151.

Bilateral massive osteolysis of uncertain origin after total knee arthroplasty: A case report and review of literature.

INTRODUCTION AND IMPORTANCE: Periprosthetic osteolysis (PPOL) is a common complication after total knee arthroplasty (TKA) and is most commonly caused by wear-induced particles. CASE PRESENTATION: We report an unusual case of massive bilateral PPOL in the posterior flanges of the femur and patellae 4 years after bilateral uncemented TKA without patellar resurfacing in a 71-year old female. Bilateral staged revision surgery including polyethylene exchange and allograft morselized bone impaction was performed to treat the osteolytic lesions. There were no signs of implant malalignment, polyethylene wear or component loosening. CLINICAL DISCUSSION: Several factors are associated with an increased risk on PPOL (e.g. polyethylene sterilization method, patient age, male gender). Surgical intervention in the context of massive PPOL should include replacement of a potential particle generator (most often polyethylene), correction of potential malalignment, treatment of bone defects and assessment of implant anchorage. CONCLUSION: This report highlights the available evidence on clinical presentation, associated risk factors and preferred treatment strategy of massive osteolytic lesions after TKA according to available evidence.

Knee Joint Distraction as Treatment for Osteoarthritis Results in Clinical and Structural Benefit: A Systematic Review and Meta-Analysis of the Limited Number of Studies and Patients Available.

OBJECTIVE: Knee joint distraction (KJD) is a joint-preserving osteoarthritis treatment that may postpone a total knee arthroplasty (TKA) in younger patients. This systematic review and meta-analysis evaluates short- and long-term clinical benefit and tissue structure changes after KJD. DESIGN: MEDLINE, EMBASE, and Web of Science were searched for eligible clinical studies evaluating at least one of the primary parameters: WOMAC, VAS-pain, KOOS, EQ5D, radiographic joint space width or MRI cartilage thickness after KJD. Random effects models were applied on all outcome parameters and outcomes were compared with control groups found in the included studies. RESULTS: Eleven articles reporting on 7 different KJD cohorts with in total 127 patients and 5 control groups with multiple follow-up moments were included, of which 2 were randomized controlled trials. Significant improvements in all primary parameters were found and benefit lasted up to at least 9 years. Overall, outcomes were comparable with control groups, including high tibial osteotomy, although TKA showed better clinical response. CONCLUSIONS: Current, still limited, evidence shows KJD causes clear benefit in clinical and structural parameters, both short- and long-term. Longer follow-up with more patients is necessary, to validate outcome and to potentially improve patient selection for this intensive treatment. Thus far, for younger knee osteoarthritis patients, KJD may be an option to consider.

Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis.

PURPOSE: Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation. METHODS: A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). OUTCOMES: Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis. RESULTS: Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD. CONCLUSIONS: There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

Case report: Painless chronic liner dissociation of a total hip arthroplasty.

BACKGROUND: Dislocation or liner dissociation of a total hip prosthesis usually results in pain and discomfort. Although several reports describe chronic dislocation and its treatment, chronic liner dissociation is an unreported complication. CASE DESCRIPTION: We report an unrecognized dissociation and displacement of the liner of a total hip prosthesis after revision THA. The patient had virtually no pain or functional restrictions. The patient's only complaint was pain on the contralateral side, associated with a leg-length discrepancy. Since the patient had no complaints relative to the liner dissociation we elected not to pursue further treatment. The contralateral pain was treated successfully with a shoe lift. LITERATURE REVIEW: Chronic dislocation of a THA is a rare complication and we found reports of only seven cases in the literature. We found no reports of chronic liner dissociation. CLINICAL RELEVANCE: Orthopaedic surgeons should be aware of the possibility of this rare complication. Our case and the literature suggest treatment can be nonsurgical or surgical.