Polyethylene liner dissociation in cementless total hip arthroplasty: Ensuring accurate diagnosis.

BACKGROUND: Uncemented acetabular components are widely used in modern total hip arthroplasty (THA). Modularity has numerous advantages including the ability to use supplementary screw fixation for the shell, and allow to switch from ceramic to polyethylene (PE) bearings and vice versa, and the use of lipped and face-changing liners. OBJECTIVE: Despite these advantages, a problem with modular PE liners is dissociation. This is a rare complication in modern implants. The rate of liner dissociation is reported to be very low between 0.17% and 0.8%. Typical symptoms are sudden onset of groin pain in a previously well-functioning hip joint, followed by grinding or clicking sensations during hip joint motions indicating, that the femoral head is articulating with the metal acetabular shell rather than with the PE liner. Any newly observed noise or squeaking from a THA should undergo radiographic investigation to exclude liner dissociation. CASE PRESENTATION: We present the case of an 88-yearold male patient who developed PE liner dissociation in a cementless THA with a Pinnacle acetabular component six years after the index operation. We recommended revision of the left hip, which was performed two days later. In the interim, the patient was advised to use a pair of crutches. During revision surgery, it was observed that the metal head made contact with the cementless cup shell without damaging it from a macroscopic standpoint. Consequently, a simple exchange of the PE liner was conducted, and a 36 mm metal head was implanted due to scratches on the original head. CONCLUSION: Early diagnosis facilitates a straightforward exchange of the liner along with the head, potentially preserving the osseous integrated cup shell and stem integrity. Routine radiologic follow-up allows to distinguish between PE liner dissociation and severe PE wear.

[Treatment options for coccygodynia]. / Therapieoptionen bei der Coccygodynie.

BACKGROUND: To this day, patients with coccyx problems are the most frequently underestimated patient population in orthopedic practices. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccyx problems remain a tiresome topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis. DIAGNOSTIC: The main symptom of coccygodynia is the pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by the change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx. TREATMENT: After the diagnosis has been made, conservative treatment should first be started with oral NSAIDs, relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltrations with a glucocorticoid and local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indication was correct.

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the "Quality Improvement in Postoperative Pain Management" (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine. MATERIALS AND METHODS: In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management. RESULTS: Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics. CONCLUSION: Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept.

No clinically significant difference in postoperative pain and side effects comparing conventional and enhanced recovery total hip arthroplasty with early mobilization.

INTRODUCTION: Enhanced recovery after surgery (ERAS) leads to less morbidity, faster recovery, and, therefore, shorter hospital stays. The expected increment of primary total hip arthroplasty (THA) in the U.S. highlights the need for sufficient pain management. The favorable use of short-lasting spinal anesthesia enables early mobilization but may lead to increased opioid consumption the first 24 h (h) postoperatively. METHODS: In a retrospective study design, we compared conventional THA with postoperative immobilization for two days (non-ERAS) and enhanced recovery THA with early mobilization (ERAS group). Data assessment took place as part of the "Quality Improvement in Postoperative Pain Treatment project" (QUIPS). Initially, 2161 patients were enrolled, resulting in 630 after performing a matched pair analysis for sex, age, ASA score (American-Society-of-Anesthesiology) and preoperative pain score. Patient-reported pain scores, objectified by a numerical rating scale (NRS), opioid consumption and side effects were evaluated 24 h postoperatively. RESULTS: The ERAS group revealed higher activity-related pain (p = 0.002), accompanied by significantly higher opioid consumption (p < 0.001). Maximum and minimum pain as well as side effects did not show significant differences (p > 0.05). CONCLUSION: This study is the first to analyze pain scores, opioid consumption, and side effects in a matched pair analyses at this early stage and supports the implementation of an ERAS concept for THA. Taking into consideration the early postoperative mobilization, we were not able to detect a difference regarding postoperative pain. Although opioid consumption appeared to be higher in ERAS group, occurrence of side effects ranged among comparable percentages.

[Coccygodynia-An often underestimated clinical picture]. / Kokzygodynie ­ ein häufig unterschätztes Krankheitsbild.

One of the most frequently underestimated symptoms in orthopedic practices is coccygodynia. The clinical picture of coccygodynia was first described in 1859. Nevertheless, discussions about the importance of coccygeal problems remain a controversial topic. All patients have in common that they have gone through a long ordeal with many therapists, examinations and therapeutic approaches without having received a real diagnosis. The main symptom of coccygodynia is pain directly on the lowest segment of the coccyx, which often only occurs when sitting and is intensified by a change in position, usually from a sitting to a standing position. Trauma can only be described as the trigger in 50% of cases. Women are four times more likely to be affected than men. The gold standard for imaging should be viewed from standing and seated dynamic lateral radiographs of the coccyx. After the diagnosis has been made, conservative treatment should first be started with oral nonsteroidal anti-inflammatory drugs (NSAID), relief with a coccyx cushion with a recess and, if necessary, physiotherapy to strengthen or loosen the pelvic floor. Local infiltration with a glucocorticoid and a local anesthetic directly in the painful area are also often promising. If the symptoms persist for more than 6 months, surgical treatment in the sense of removing the coccyx can be discussed with the patient. The literature shows a success rate of 80-90% if the indications are correct.

A clinical decision support system in back pain helps to find the diagnosis: a prospective correlation study.

The aim of this study is to show the concordance of an app-based decision support system and the diagnosis given by spinal surgeons in cases of back pain. 86 patients took part within 2 months. They were seen by spine surgeons in the daily routine and then completed an app-based questionnaire that also led to a diagnosis independently. The results showed a Cramer's V = .711 (p < .001), which can be taken as a strong relation between the tool and the diagnosis of the medical doctor. Besides, in 67.4% of the cases, the diagnosis was concordant. An overestimation of the severity of the diagnosis occurred more often than underestimation (15.1% vs. 7%). The app-based tool is a safe tool to support healthcare professionals in back pain diagnosis.

[Osteoporotic vertebral fractures-From diagnosis to treatment]. / Osteoporotische Wirbelkörperfrakturen ­ Von der Diagnose zur Therapie.

The aim of the present work is an overview of current concepts in the treatment of osteoporotic vertebral fractures, risk factors, clinical presentation and conservative and operative management. Osteoporotic vertebral fractures are a widespread problem, affecting between 700,000 and 1.5 million adults annually in the USA alone. Osteoporotic vertebral fractures can cause severe physical impairment, including back pain, dysfunction, and progressive thoracic kyphosis. Mortality after osteoporotic vertebral fractures is still increased compared to age-matched controls. In the reality of care, advocates of purely conservative therapy as well as advocates of surgical treatment can be found all over the world. In summary, understanding the risk factors, appropriate clinical evaluation and treatment strategies are crucial. When surgery is indicated, balloon kyphoplasty shows significantly better pain reduction and lower mortality compared to nonsurgical treatment.

Pain Course after Total Knee Arthroplasty within a Standardized Pain Management Concept: A Prospective Observational Study.

BACKGROUND: Joint replacement surgeries have been known to be some of the most painful surgical procedures. Therefore, the options for postoperative pain management are of great importance for patients undergoing total knee arthroplasty (TKA). Despite successful surgery, up to 30% of the patients are not satisfied after the operation. The aim of this study is to assess pain development within the first 4 weeks after TKA in order to gain a better understanding and detect possible influencing factors. METHODS: A total of 103 patients were included in this prospective cohort study. Postoperative pain was indicated using a numeric rating scale (NRS). Furthermore, demographic data and perioperative parameters were correlated with the reported postoperative pain. RESULTS: The evaluation of postoperative pain scores showed a constant decrease in the first postoperative week (mean NRS score of 5.8 on day 1 to a mean NRS score of 4.6 on day 8). On day 9, the pain increased again. Thereafter, a continuous decrease in pain intensity from day 10 on was noted (continuous to a mean NRS score of 3.0 on day 29). A significant association was found between postoperative pain intensity and gender, body mass index (BMI), and preoperative leg axis. CONCLUSIONS: The increasing pain score after the first postoperative week is most likely due to more intensive mobilization and physiotherapy in the rehabilitation department. Patients that were female, had a low BMI, and a preoperative valgus leg axis showed a significantly higher postoperative pain scores. Pain management should consider these results in the future to improve patient satisfaction in the postoperative course after TKA.