Total Hip Replacement in Developmental Hip Dysplasia: A Narrative Review.

The reconstruction of the hip joint in patients suffering from developmental hip dysplasia (DDH) is a demanding procedure and presents many challenges to the reconstructive surgeon. Higher rates of mechanical complications are present in this group of patients. The results of cemented and uncemented implants used in DDH patients are very promising, according to recent outcomes. However, the surgeon has to be aware of several complications, in order to establish an uneventful surgical management of DDH. The specific article investigates the technical challenges and clinical results of total hip arthroplasty in patients with DDH.

Wet Lab-Based Cataract Surgery Training Curriculum for the PGY 2/PGY 3 Ophthalmology Resident.

Introduction: Studies have shown that structured cataract surgery training curricula are beneficial for resident surgeons-in-training, yet nearly one-third of US training programs do not have one, and public dissemination of said curricula are lacking. Methods: We created a microsurgical simulation center and accompanying structured training curriculum. Weekly lectures focused on the steps of cataract surgery, variations on technique, and complications. Each didactic was followed by a 1.5- to 2-hour time block with faculty supervision in the wet lab. Finally, to demonstrate proficiency, residents submitted a recorded video illustrating their competency within 1 week of the lecture. We reviewed videos and provided written feedback via a standardized form. Curriculum effectiveness was evaluated through formative feedback on the course itself and complication rates for resident-performed cataract surgery before and after implementation of the curriculum. Results: The course was implemented in 4 consecutive academic years, allowing time for nine junior residents to participate in the course at least once before operating as a senior. The incidence of posterior capsule tears for senior residents decreased from 3.07% in the 4 years preceding curriculum implementation to 1.13% for the senior residents who completed the course at least once as juniors (p = .0571). Supervised wet lab sessions and submitted videos allowed faculty to identify surgically struggling residents early. Discussion: Implementation of a cataract surgery training curriculum for junior ophthalmology residents provides a safe and effective environment to practice surgical techniques. Such a curriculum may decrease the complication rates of beginner surgeons.

Comparison of graft survival following penetrating keratoplasty and Descemet's stripping endothelial keratoplasty in eyes with a glaucoma drainage device.

PURPOSE: To compare corneal graft survival rates after penetrating keratoplasty (PK) and Descemet's stripping endothelial keratoplasty (DSEK) in patients with a glaucoma drainage device (GDD) or medically managed glaucoma. METHODS: A retrospective chart review was conducted on consecutive patients who underwent primary PK or primary DSEK. Inclusion criteria consisted of eyes with a diagnosis of glaucoma prior to corneal transplantation and a minimum of 6 months of follow-up. Graft failure was defined as an edematous cornea with failure to maintain deturgescence lasting beyond a period of 1 month of intense steroid therapy or vascularization and scarring resulting in irreversible loss of central graft clarity. Corneal graft survival was calculated using Kaplan-Meier survival analysis. Patients were divided into four groups: GDD-PK, GDD-DSEK, medical-PK and medical-DSEK. RESULTS: Fifty-six eyes of 56 patients were identified as meeting inclusion criteria. Among eyes with a GDD, there was no difference in the proportion of failures between PK grafts (48%) and DSEK grafts (50%) (p = 0.90). Failure occurred earlier in DSEK recipients compared to PK recipients, 5.82 ± 6.77 months versus 14.40 ± 7.70 months, respectively (p = 0.04). A Kaplan-Meier analysis did not identify a difference between the four groups with respect to graft failure (p = 0.52). CONCLUSION: There is no significant difference in graft survival rates between medically and surgically treated glaucoma patients for either PK or DSEK grafts. In patients with GDD, graft failure occurs earlier in DSEK compared to PK.

Practice patterns of cataract surgeons at academic medical centers for the management of inadequate capsule support for intracapsular or sulcus intraocular lens placement during cataract surgery.

PURPOSE: To determine practice patterns with regard to intraocular lens (IOL) placement during cataract surgery when there is inadequate capsule support for intracapsular or sulcus IOL placement. SETTING: Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA. DESIGN: Cross-sectional study of anonymous survey results. METHODS: An online survey was e-mailed to the coordinators of all Accreditation Council for Graduate Medical Education-accredited ophthalmology residency programs with a request to forward to all faculty who perform cataract surgery. RESULTS: Sixty-seven (57.2%) of 117 confirmed survey recipients participated. Thirty-six (62.1%) said they felt comfortable placing scleral-fixated posterior chamber IOLs (PC IOLs) independently. Faced with inadequate capsule support, 58.6% would place a primary anterior chamber IOL (AC IOL), 29.3% would place a primary scleral-fixated PC IOL, and 5.3% would leave the patient aphakic for secondary scleral-fixated PC IOL placement. Surgeons not comfortable placing scleral-fixated PC IOLs were most likely to choose primary AC IOLs (77.3%). Surgeons comfortable placing scleral-fixated PC IOLs were more evenly divided between primary AC IOLs (47.2%) and scleral-fixated PC IOLs (41.7%). Among surgeons who favored primary scleral-fixated PC IOLs, 63.7% cited a decreased risk for long-term complications as their reason for IOL choice; 50.0% of surgeons who favored primary AC IOLs cited avoidance of a second surgery. CONCLUSIONS: In general, primary AC IOL placement was preferred in the setting of inadequate capsule support, although less so among surgeons who were comfortable placing scleral-fixated PC IOLs. Lack of comfort with scleral-fixated PC IOL placement suggests a potential unmet training need in residency and fellowship programs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of primary graft survival following penetrating keratoplasty and Descemet's stripping endothelial keratoplasty in eyes with prior trabeculectomy.

PURPOSE: To compare corneal graft survival rate after primary Descemet's stripping endothelial keratoplasty (DSEK) and primary penetrating keratoplasty (PK) in patients with prior trabeculectomy or medically managed glaucoma. METHODS: A retrospective chart review was conducted on consecutive patients who underwent DSEK or PK. Inclusion criteria consisted of eyes with a diagnosis of glaucoma prior to corneal transplantation and ≥ 6 months of follow-up. Graft failure was defined as an oedematous cornea with failure to maintain deturgescence lasting beyond a period of 1 month of intense steroid therapy or vascularisation and scarring resulting in irreversible loss of central graft clarity. Corneal graft survival was calculated using Kaplan-Meier survival analysis. Patients were divided into four groups: trabeculectomy-DSEK, trabeculectomy-PK, medical-DSEK or medical-PK. RESULTS: Fifty eyes (30 DSEK, 20 PK) of 50 patients (mean age 77 ± 10 years) met the enrollment criteria. Mean follow-up was 17.4 ± 14.2 months. A significantly higher proportion of the DSEK grafts (50%) compared with PK grafts (10%) failed at last follow-up (p = 0.005). Kaplan-Meier analysis identified a significant difference between the groups with respect to time to graft failure (p = 0.006). Patients with trabeculectomy who underwent DSEK had earlier graft failures than all other groups (p ≤ 0.035), but there were no differences between the medical-DSEK, medical-PK and trabeculectomy-PK groups (all p > 0.35). CONCLUSIONS: Eyes with prior glaucoma showed higher rates of DSEK graft failure compared with PK. Patients with prior trabeculectomy demonstrated higher and earlier corneal graft failure rates with DSEK than with PK.

Individual patient data meta-analysis of organ failure in acute pancreatitis: protocol of the PANCREA II study.

CONTEXT: Organ failure is a major determinant of mortality in patients with acute pancreatitis. These patients usually require admission to high dependency or intensive care units and consume considerable health care resources. Given a low incidence rate of organ failure and a lack of large non-interventional studies in the field of acute pancreatitis, the characteristics of organ failure that influence outcomes of patients with acute pancreatitis remain largely unknown. Therefore, the Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA) aims to conduct a meta-analysis of individual patient data from prospective non-interventional studies to determine the influence of timing, duration, sequence, and combination of different organ failures on mortality in patients with acute pancreatitis. METHODS: Pancreatologists currently active with acute pancreatitis clinical research will be invited to contribute. To be eligible for inclusion patients will have to meet the criteria of acute pancreatitis, develop at least one organ failure during the first week of hospitalization, and not be enrolled into an intervention study. Raw data will then be collated and checked. Individual patient data analysis based on a logistic regression model with adjustment for confounding variables will be done. For all analyses, corresponding 95% confidence intervals and P values will be reported. CONCLUSION: This collaborative individual patient data meta-analysis will answer important clinical questions regarding patients with acute pancreatitis that develop organ failure. Information derived from this study will be used to optimize routine clinical management and improve care strategies. It can also help validate outcome definitions, allow comparability of results and form a more accurate basis for patient allocation in further clinical studies.

The use of postoperative slit-lamp optical coherence tomography to predict primary failure in descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine if central donor lenticle thickness as measured by slit-lamp optical coherence tomography (SL OCT; Heidelberg Engineering, Heidelberg, Germany) is predictive of primary donor failure in patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Retrospective cross-sectional study. METHODS: Eighty-four patients who underwent DSAEK surgery by 2 surgeons (D.C.R. and J.A.S.) were enrolled. At each postoperative visit (postoperative day 1, week 1, month 1, and month 2), an SL OCT scan was obtained. Statistical differences in SL OCT measurements of successful and failed DSAEK procedures were measured using the Student t test. A successful DSAEK surgery was defined as having an anatomically attached, clear recipient corneal stroma and donor lenticle compatible with good vision 2 months after surgery. A failed DSAEK surgery was defined as an attached donor lenticle with SL evidence of corneal edema and thickening visible at 2 months or more. RESULTS: Ninety-three eyes of 84 consecutive patients who underwent DSAEK surgery also underwent postoperative SL OCT. After 2 months of follow-up, 82 (88%) procedures were successful and 11 (12%) procedures were failures. The average donor lenticle thickness in successful DSAEK eyes was 314 +/- 128 microm on postoperative day 1 as compared with failed DSAEK eyes, which averaged 532 +/- 259 microm (P = .0013). This was independent regardless of whether the lenticle was attached on the first postoperative visit. Seventy-nine (98%) successful DSAEK eyes had a lenticle thickness of < or = 350 microm at the 1-week visit. All of the failed DSAEK eyes (11 eyes) had a lenticle thickness > or = 350 microm at the 1-week postoperative visit. Statistically significant differences in SL OCT thickness measurements were seen between successful and failed DSAEK cases at all examinations after postoperative week 1. CONCLUSIONS: Corneal thickness measurements made with SL OCT are an important predictor of DSAEK failure in both attached and detached lenticles within the first week of surgery. DSAEK lenticle thickness of 350 microm or less at 1 week had a predictability of success of more than 98%.

High levels of synovial fluid osteoprotegerin (OPG) and increased serum ratio of receptor activator of nuclear factor-kappa B ligand (RANKL) to OPG correlate with disease severity in patients with primary knee osteoarthritis.

OBJECTIVE: Evaluation of serum and synovial fluid OPG and sRANKL in 37 patients with primary knee osteoarthritis. DESIGN AND METHOD: OPG and sRANKL were measured using ELISA. RESULTS: OPG, sRANKL and sRANKL/OPG were increased in osteoarthritis patients' serum. Synovial OPG was higher than serum OPG, while sRANKL/OPG was higher in the serum; both correlated with disease severity. DISCUSSION: RANKL/OPG pathway is implicated in the pathogenesis of knee osteoarthritis being a suitable target for therapeutic intervention.

Arthroscopic ACL reconstruction with Delta plasty: an innovative approach with hamstrings' transfer and double tibial tunnel.

We propose a new technique, with double bundle, double tibial tunnels with a bridge between them, using the hamstrings as auto-grafts, retaining either their central or peripheral attachment. A prospective series of 41 patients underwent primary reconstruction of the anterior cruciate ligament by one surgeon, arthroscopically and electronically assisted; 37 were men and 4 were women with a mean age of 24.7 years. The mean follow-up was 19.05 (12-30) months. Normal function and joint stability was achieved. The patients returned to full occupational activities within 3-6 months after the operation. The function of hamstrings was not disturbed. Two patients have sustained a new injury without rupture of the grafts. The Noulis-Lachman test was negative in 35 knees. Positive Pivot shift, post-operatively, was present in 15.45% of patients. The IKDC score was 84.55. In the proposed ACL reconstruction technique, the two tendons are transferred and used as grafts, with gracillis and semitendinosus retaining their distal and central attachment, respectively; the former superimposed upon the latter while entering the femoral tunnel. The tibial tunnels leave a bone bridge ranging between 12 and 15 mm within the footprints of ACL. The two bundles are tensioned, each at different angle. This configuration imitates both the anatomy and the function of ACL and controls not only the anterior translation, but also the rotatory stability. With this innovative technique, the final outcome is improved, thus being closer to normal, as evidenced from previous experiments and the present prospective series.

Estimation of radiation doses to patients and surgeons from various fluoroscopically guided orthopaedic surgeries.

In this study, a mathematical method was used to estimate the entrance surface dose (ESD) to the patient and the scattered dose (Ds) to the operating surgeon during various fluoroscopically guided surgical orthopaedic procedures. For 204 patients, the procedure type, the fluoroscopy time and the highest tube potential and current values observed during fluoroscopy were recorded. For the most often performed procedures (intramedullary nailing of peritrochanteric fractures, open reduction and internal fixation of malleolar fractures and intramedullary nailing of diaphyseal fractures of the femur), the respective mean fluoroscopy times were 3.2, 1.5 and 6.3 min while the estimated mean ESDs were 183, 21 and 331 mGy, respectively. The estimated Ds rates for the hands, chest, thyroid, eyes, gonads and legs of the operating surgeon were on average to 0.103, 0.023, 0.013, 0.012, 0.066 and 0.045 mGy min(-1), respectively, and compare well with the literature. The mathematical estimation of doses cannot replace actual measurements; however, it can be used for a preliminary assessment of the radiation dose levels during various surgical procedures, so that the operator, the surgeon and the rest of the medical staff involved could be aware of the associated radiation risk and the radiation protection measures required.

Comparison of fixation methods of double-bundle double-tibial tunnel ACL reconstruction and double-bundle single-tunnel technique.

An experimental study was conducted in order to evaluate biomechanical methods of single-bundle reconstruction in ACL and compare it with a new double-bundle double-tibial tunnel technique. Twenty-four porcine cadaver knees, divided into 4 groups of 6 knees each and 48 proper extensors of the fourth toe tendons, were used for the fixation techniques. In groups A and B, a double-bundle technique with a single femoral and tibial tunnel was used, fixed to a femoral and tibial post with screws and with buttons, respectively. In groups C and D, a double-bundle technique (technique Delta) with two separate tibial tunnels was used, fixed to a femoral and tibial post with screws and with buttons, respectively. A material testing system (Instron) was used for anteriorly translating the tibia until failure. The femoral and tibial post as a fixation method is superior to the conventional buttons technique. The more anatomical double-bundle reconstruction technique provided significantly higher structural properties and smaller loss of fixation compared with the single-bundle reconstruction technique. The comparison of the two techniques gave superior results to the femoral and tibial screws over the buttons. The double-bundle technique attempts to restore the anterior stability of the knee joint.

ACL reconstruction with semitendinosus tendon autograft without detachment of its tibial insertion: a histologic study in a rabbit model.

The purpose of this study was to evaluate the histologic changes that occur between 3 and 12 weeks in an intra-articular, semitendinosus autograft, which was harvested without detachment of its tibial insertion and was placed through tibial and femoral drill holes, in a rabbit model. About 30 New Zealand white rabbits underwent ACL replacement using a semitendinosus tendon autograft. The normal ACL was transected at its femoral and tibial insertions. The tendon graft was harvested without detachment of its tibial insertion and its free end was secured with sutures. The graft was then passed through one tibial and one femoral tunnel and secured at the lateral femoral condyle. All animals were divided into three groups and were killed at 3, 6 and 12 weeks after surgery. Nine more animals underwent ACL reconstruction using a free semitendinosus tendon autograft. These animals were used as controls. The intra-articular portion of the graft and the interface between the bone tunnel and the graft was evaluated postoperatively for gross morphology and histological appearance. Results of this study showed that in a rabbit model the semitendinosus tendon autograft retained its viability when harvested without detachment of its peripheral insertion. On contrary, at the control group, necrosis of the graft was observed 3 weeks after surgery and progressively revascularization and maturation occurred 6 and 12 weeks after surgery. Retaining the tibial insertion of the semitendinosus autograft seems to preserves its viability and bypasses the stages of avascular necrosis and revascularization that occurs with the use of a free tendon autograft.

ACL reconstruction and the implication of its tibial attachment for stability of the joint: anthropometric and biomechanical study.

The planar topography of the anterior cruciate ligament (ACL) insertion was investigated and correlated to the use of the double-bundle/double tibial tunnel ACL reconstruction technique within the ACL tibial insertion area. The anteroposterior and mediolateral length of the tibial ACL attachment and the distances of the tibial insertion area from the anterior and posterior tibial borders were measured and the stability of the joint was tested using the double-bundle/double tibial tunnel ACL reconstruction technique. The anteroposterior length, 19.54 mm in men and 17.36 mm in women, of the ACL insertion, averaged approximately 40% of the total intercondylar anteroposterior dimension of the plateau. This broad distribution of insertion fibres ensures ligament tension and hence joint stability. The reported anteroposterior broad insertion of ACL fibres to the tibia is not sufficiently reproduced by the use of one or more bundles having a common tibial tunnel for the ACL reconstruction. In our view, this might be better achieved with two different bundles, with separate tunnels, and independent tensioning in different knee angles. This technique might achieve better results in human knee stability as opposed to other reported techniques.

Cementless LCS rotating-platform knee arthroplasty in patients over 60 years without patella replacement: a mid-term clinical-outcome study.

BACKGROUND: The aim of this prospective paper is to present the results of a cementless LCS rotating-platform artificial knee design without resurfacing of the patella in patients over 60 years of age. MATERIAL/METHODS: In this prospective series, 234 patients were included with 251 knees. The LCS rotating-platform uncemented design was used in all cases, without replacement of the patella. Thirty-four patients were men and 200 were women. Two hundred three patients were suffering from osteoarthrosis (10 bilateral) and 31 patients (7 bilateral) from rheumatoid arthritis. Seventeen patients had a bilateral procedure. Prophylactic antibiotics and anticoagulants were also instituted to all patients. RESULTS: Forty-nine patients developed deep vein thrombosis and responded well to the applied conservative treatment. Overall results in the first 251 cementless cases at 2 to 9.8 years' follow-up (average: 5.7 years) were good to excellent in 94.4%, fair in 4.7%, and poor in 0.7%. Radiographs of the knees showed good bonding and no signs of radiolucency. The average clinical and functional Knee Society Ratings were 21.07 points and 30.95 points, respectively, preoperatively and 87.95 points and 78.56 points, respectively, at the final follow-up evaluation. CONCLUSIONS: With an average follow-up of 5.7 years, uncemented LCS rotating-platform knee joint arthroplasty without replacing the patella in patients over 60 years old was found to perform well, with encouraging clinical and radiological results and a survival rate of 98.1%.

Photoelastic study of the internal and contact stresses on the knee joint before and after osteotomy.

INTRODUCTION: The treatment of knee osteoarthrosis represents a difficult task. Osteotomy is one of the treatment regimes which, in earlier times, was the only surgical procedure giving reliable mid-term results. The improvement was attributed either to the changing of the acting forces or to the so-called biological factor. The use of a photoelastic model allows the observation of the direction of the significant contact and internal stresses at every point in a single plane. MATERIALS AND METHODS: In the present study, we investigated the stress-strain situation of the knee joints in models made from 1 cm thick Araldite plates. These models reproduce tracings from anteroposterior X-ray views of monopodal loading of human knee joints. The models represent: normal knee joints, normal varus or valgus knee joint, knee joints suffering osteoarthrosis in varus or valgus, and knee joints suffering osteoarthrosis, following corrective osteotomies. The models were first loaded along the longitudinal axis with the leg in full extension, with 70 kg (body weight) and then with 140 kg, representing double the normal body weight. RESULTS: The application of longitudinal force on a normal knee joint, in full extension, results in symmetrical arrangement of trajectories in the condyles. Loading of the leg in varus or valgus produces shifting of stresses towards the inclination side. Increased contact stresses are always greater in the tibial condyles. The concentration of strain is directed towards the cortices of the loaded area. In a knee joint with osteoarthrosis, deviation of the trajectories in the condyles towards the inclination of the leg axis is observed. Also, increased contact stresses appear in the articular surfaces, on the inclination side. Isoclinics have meeting points on the loaded cortices. Supracondylar femoral osteotomy, or high tibial osteotomy, restores the axis of the leg, redistributes internal stresses (strain) in the condyles, corrects the trajectorial lines, and redistributes contact stresses in the articular surfaces towards the normal values. CONCLUSION: Correction of the femorotibial axis results in redistribution of the isochromatics, isoclinics, trajectorial lines and contact stresses. The values of the above parameters are corrected and remain closer to these of the normal knee, but in no case does the correction of all the above factors attain normal values. The change of direction of the main stresses following osteotomies towards those of the normal knee probably represents the biomechanical explanation of the way the osteotomy relieves pain and improves function.