Antibiotic prophylaxis before tissue biopsy has no effect on culture results in presumed aseptic revision total hip arthroplasty.

Background: Antibiotic prophylaxis (AP) is considered to be the gold standard for revision total hip arthroplasty (R-THA) due to the high incidence of prosthetic joint infection (PJI). To diagnose PJI, intraoperative tissue biopsies for culture are of particular importance. However, antibiotic interference could theoretically lead to less reliable culture results. Currently, there is no consensus on whether AP should be administered before or after tissue biopsy. In this study, we aimed to investigate the effect of AP timing on culture results and PJI rates in presumed aseptic R-THA. Methods: A retrospective single-center cohort study among 490 patients was performed; 61 patients received AP pre-incision, and 429 patients received AP post-biopsy. At least three intraoperative tissues were sampled for each patient and cultured for a minimum of 2 weeks. Minimum follow-up was 6 months. Epidemiological and clinical data (including culture results and incidence of PJI during follow-up) were gathered and analyzed. Results: Positive (4.9 % vs. 5.4 %, p=0.89) and contaminated culture results (23.0 % vs. 22.6 %, p=0.95) were not significantly different between pre-incisional and post-biopsy AP administration. Post-operative PJI incidence during follow-up was 1.6 % and 3.0 %, respectively. This difference was not statistically significant (p=0.54). Conclusion: Pre-incisional AP administration does not yield fewer culture results compared to post-biopsy AP administration. Although statistically not significant, PJI during follow-up was almost twice as high when AP was withheld until after tissue biopsy. Other literature also supports the additional protective benefit of pre-incisional AP. Therefore, we believe pre-incisional AP administration is preferable for presumed aseptic R-THA.

Excellent Long-Term Results of an Austin Moore Hemiarthroplasty After Half a Century: A Case Report.

CASE: We present the unique case of a 73-year-old man who was treated 50 years ago with a hemiarthroplasty (HA) for avascular necrosis after a femoral neck fracture (FNF) of his left hip and who has developed only mild osteoarthritis since and has reported satisfactory clinical and functional outcomes with no acetabular erosion. CONCLUSION: HA for FNFs can provide durable long-term results and can, therefore, be considered as an option in the treatment of FNFs in younger patients. We describe a case with good results after 50 years, which, to our knowledge, is the longest reported follow-up of HA.

Highly Crosslinked Polyethylene Liner Thickness Does Not Influence Survival in Primary Total Hip Arthroplasty After Mean Follow-Up of 13 Years: A Study of 2,565 Hips With a Single Design Liner.

BACKGROUND: Concerns remain that thinner highly crosslinked polyethylene (HXLPE) liners in modern total hip arthroplasty (THA) may lead to premature liner-related failures or revision. The aim of this study was to evaluate the effect of liner thickness on survival and revision rates of HXLPE in primary THA after more than 10 years. METHODS: We retrospectively identified 2,565 primary THAs using HXLPE with a mean follow-up of 13 years (range, 11 to 19). Patients were grouped for each mm of polyethylene thickness. Liner thickness varied from 4.9 to 12.7 mm, with one third measuring less than 6 mm. Primary outcomes were reoperation, all-cause revision, and liner-related revision. RESULTS: The reoperation rate was 7.3%, the all-cause revision rate was 5.6%, and the liner-related revision rate was 0.04%. There was no significant difference in all-cause revision when stratified by liner thickness (P = .286) and liner thickness was not associated with liner-related revision (n = 1). There was a statistically, but not clinically significant difference in mean liner thickness for the cohort that underwent reoperation (7.09 versus 6.89 mm, P = .01) and all-cause revision (7.16 versus 6.89 mm, P = .031). CONCLUSION: In our cohort, liner thickness was not associated with all-cause revision-free survival, and there was no clinically significant difference in liner thickness between those patients who did require a reoperation or all-cause revision, and those who did not. There was only 1 liner-related failure in the entire cohort. Our results indicate that using thinner HXLPE liners to maximize femoral head size in THA is a safe practice that does not lead to increased revision rates or liner failure at a mean 13-year follow-up.

Thin highly cross-linked polyethylene liners combined with large femoral heads in primary total hip arthroplasty show excellent survival and low wear rates at a mean follow-up of 12.8 years.

AIMS: Several short- and mid-term studies have shown minimal liner wear of highly cross-linked polyethylene (HXLPE) in total hip arthroplasty (THA), but the safety of using thinner HXLPE liners to maximize femoral head size remains uncertain. The objective of this study was to analyze clinical survival and radiological wear rates of patients with HXLPE liners, a 36 mm femoral head, and a small acetabular component with a minimum of ten years' follow-up. METHODS: We retrospectively identified 55 patients who underwent primary THA performed at a single centre, using HXLPE liners with 36 mm cobalt-chrome heads in acetabular components with an outer diameter of 52 mm or smaller. Patient demographic details, implant details, death, and all-cause revisions were recorded. Cox regression and Kaplan-Meier survival was used to determine all-cause and liner-specific revision. Of these 55 patients, 22 had a minimum radiological follow-up of seven years and were assessed radiologically for linear and volumetric wear. RESULTS: Overall survival rate for all-cause revision was 94.5% (95% confidence interval (CI) 81.7% to 97.2%) at a mean follow-up of 12.8 years (10.9 to 18.7). Three patients were revised, none for liner wear, fracture, or dissociation. A total of 22 patients were included in the radiological analysis (mean follow-up 9.9 years (7.5 to 13.7)). Mean linear liner wear was 0.085 mm (95% CI -0.086 to 0.257) and the volumetric wear rate was 11.097 mm3/year (95% CI -6.5 to 28.7). CONCLUSION: Using HXLPE liners with 36 mm heads in 52 mm acetabular components or smaller is safe, with excellent survival and low rates of linear and volumetric wear at medium-term follow-up. Patients did not require revision surgery for liner complications such as fracture, dissociation, or wear. Our results suggest that the advantages of using larger heads outweigh the potential risks of using thin HXLPE liners.Cite this article: Bone Joint J 2023;105-B(1):29-34.

Functional outcome of total knee arthroplasty following tibial plateau fractures: a systematic review.

BACKGROUND: Posttraumatic osteoarthritis (PTOA) following a tibial plateau fracture (TPF) is a debilitating disease which often affects a young and active patient population for whom good knee function is essential. Frequently, total knee arthroplasty (TKA) is the only surgical option. The aim of this systematic review was to evaluate functional outcome for TKA in PTOA patients, together with several secondary outcome parameters. METHODS: A systematic review according to the PRISMA guidelines was conducted. Studies were included that reported on patient-reported outcome measures, range of motion or objective functional analysis after TKA because of PTOA following TPF. RESULTS: After analyzing 105 studies, 5 were included for the final review. In total, 162 patients with a TKA for PTOA were included of whom 125 (77%) were managed operatively for their TPF. All studies reported improvements in functional outcome after TKA, with two studies showing no significant differences between PTOA patients and a matched cohort of primary OA patients. Reported complication and re-intervention rates were higher for TKA patients with PTOA. CONCLUSION: The results of this review indicate the TKA for PTOA after a TPF provides satisfactory functional outcome, with results similar to those of matched primary OA patients. TKA should, therefore, be considered a viable treatment option to improve function, but both patients and orthopedic surgeons should be aware of the higher complication rates in this patient population.

Chronic Pseudoaneurysm and Anterior Dislocation After Total Hip Arthroplasty Complicated by Arterial Injury: A Case Report.

CASE: A 64-year-old man presented 18 months after total hip arthroplasty complicated by vascular injury with a history of leg pain, inability to mobilize, and progressive chronic leg edema. It is presumed that there was persistent subtle bleeding over time with pseudoaneurysm formation and prosthetic hip dislocation secondary to the mass effect. CONCLUSION: Physicians should consider pseudoaneurysm as a possible diagnosis when confronted with a large intra-articular mass in the hip after a relatively short follow-up period, particularly in the context of a prior vascular injury at the time of the index procedure.

Patients' perceived walking abilities, daily-life gait behavior and gait quality before and 3 months after total knee arthroplasty.

INTRODUCTION: Functional outcome and patients' daily-life activities after total knee arthroplasty are becoming more important with a younger and more active patient population. In addition to patient-reported outcome measures (PROMs), trunk-based accelerometry has shown to be a promising method for evaluating gait function after total knee arthroplasty. The aim of this study was to evaluate daily-life perceived walking abilities, gait behavior and gait quality before and 3 months after total knee arthroplasty, using PROMs and trunk-based accelerometry. MATERIALS AND METHODS: A cohort of 38 patients completed questionnaires including the Oxford Knee Score and modified Gait Efficacy Scale before and 3 months after primary unilateral total knee arthroplasty. At both time points, they wore a tri-axial accelerometer at the lower back for seven consecutive days and nights. Gait behavior was calculated using gait quantity and walking speed, and multiple gait quality parameters were calculated. RESULTS: Significant improvements were seen after 3 months in the Oxford Knee Score [median (interquartile range) 29 (10) vs 39 (8), p < 0.001] and modified Gait Efficacy Scale [median (interquartile range) 67 (24) vs 79 (25), p = 0.001]. No significant changes were observed in gait behavior (quantity and speed) or gait quality variables. CONCLUSIONS: In contrast to the significant improvements in patients' perception of their walking abilities and PROMs, patients did not show improvements in gait behavior and gait quality. This implies that after 3 months patients' perceived functional abilities after total knee arthroplasty do not necessarily represent their actual daily-life quantity and quality of gait, and that more focus is needed on postoperative rehabilitation to improve gait and functional behavior.

Implant survival in uncemented total hip arthroplasty for displaced intracapsular femoral neck fractures: outcomes of 115 patients in a single center.

INTRODUCTION: There remains disagreement about the use of cemented or uncemented total hip arthroplasty (THA) for patients with a displaced intracapsular femoral neck fracture (FNF). The aim of this study was to assess implant survival, mortality, and postoperative complication rates of uncemented THA for a displaced intracapsular FNF in a single center. PATIENTS AND METHODS: A cohort of 115 patients who received uncemented THAs for a displaced intracapsular FNF was retrospectively examined for implant survival in terms of revision and any reoperation, mortality, and postoperative complications. RESULTS: The one- and five-year implant survival was 99.1% (95% confidence interval (CI) 97.3-100.9) and 97.8% (95% CI 94.7-100.9) for revision and 93.6% (95% CI 88.9-98.3) and 90.0% (95% CI 83.3-96.7) for any reoperation, respectively. Impaired mobility was significantly associated with lower implant survival (p = 0.01). The one, three, and 12 month mortality rates were 2.8% (95% CI 0-5.9), 3.7% (95% CI 0.2-7.2), and 5.6% (95% CI 1.3-9.9), respectively. Postoperative complication rate was 10% with 5% intra-operative fractures. CONCLUSIONS: Contrary to earlier reports of results of uncemented THA for displaced FNF, the results of this study were comparable with those reported in the literature for cemented THA in displaced FNF with respect to implant survival, mortality, and complication rates. This indicates that uncemented THA could be a viable option for these patients. In future, the additional literature with a prospective design is needed to support and reinforce our conclusion.

Gait quality assessed by trunk accelerometry after total knee arthroplasty and its association with patient related outcome measures.

BACKGROUND: With an increasingly younger population and more active patients, assessment of functional outcome is more important than ever in patients undergoing total knee arthroplasty. Accelerometers have been used successfully to objectively evaluate gait quality in other fields. The aim of this study was to assess gait quality with accelerometers before and after surgery, and to assess added value of resulting parameters to patient reported outcome measures scores. METHODS: Sixty-five patients (mean age 65 years (range 41-75)) who underwent primary total knee arthroplasty were evaluated using a tri-axial trunk accelerometer preoperatively and 1 year after surgery. Gait quality parameters derived from the accelerometry data were evaluated in three dimensions at both time points. Factor analysis was performed on all outcome variables and changes from before to 1 year after surgery in the most representative variable for each factor were studied. FINDINGS: Factor analysis identified three separate gait quality factors, with questionnaire and gait quality parameters loading on different factors. Both gait quality factor scores and questionnaire factor scores improved significantly 1 year after surgery. As expected based on the factor analysis, only weak to moderate associations were found between patient reported outcome measures and gait quality before surgery, after surgery and in change scores. INTERPRETATION: The independence of patient reported outcome measures and gait quality parameters measured with trunk accelerometry indicates that gait quality parameters provide additional information on functional outcome after total knee arthroplasty. Providing caretakers with objectively measurable targets using accelerometry could help improve outcome of these patients.

Fast-track total knee arthroplasty improved clinical and functional outcome in the first 7 days after surgery: a randomized controlled pilot study with 5-year follow-up.

INTRODUCTION: Fast-track protocols (FP) are used more and more to optimize results after total knee arthroplasty (TKA). Many studies evaluating FP in TKA concentrate on clinical outcome and medium to long-term results. Since discharge from hospital after TKA is achieved increasingly quicker worldwide using FP in an increasingly younger and active patient population, the effects of FP on functional outcome in the first days after TKA become more important. The purpose of the current study was to compare FP with a regular joint care protocol (RP), with an emphasis on the first 7 days after surgery. MATERIALS AND METHODS: A non-blinded randomized controlled clinical pilot study was performed with 25 patients assigned to a FP group and 25 patients assigned to a RP group. Primary outcome was functional outcome, clinical outcome, pain, and complications for each day in the first week after surgery. Patients were followed up to 5 years after surgery. RESULTS: Significantly lower VAS scores for knee pain, faster Timed-Up and Go test times and more mobility on functional tests were seen on several days in the first week in the FP group compared to the RP group. Few other significant differences were found at 2, 6 weeks, and no significant differences were found at 12 weeks and 1, 2 and 5 years after surgery. CONCLUSIONS: Fast-track protocol for primary TKA showed significantly lower knee pain scores and improved functional outcome in the first 7 days after TKA compared to a regular protocol.

Operative resection is a viable treatment of macrodactyly of the foot caused by lipofibromatous hamartoma: a case study with 5 year follow-up.

UNLABELLED: Lipofibromatous hamartoma (LFH) is a benign tumour of nervous tissue that most commonly involves the median nerve. Only a few cases of LFH in the foot have been described. In these cases growth of bone and other tissue causing macrodactyly, a condition known as macrodystrophia lipomatosa, is often observed. Conservative treatment of LFH is usually preferred because of the potential loss of neurological function after surgery. Here we present a rare case of a 44-year old patient with LFH causing macrodactyly of the second ray of the left foot whose symptoms did not improve after conservative treatment. We describe the diagnostic process and the operative resection that was performed and show the follow-up results 5 years after surgery. All the symptoms experienced by our patient had disappeared. This case demonstrates that operative treatment of LFH in the foot is a viable option in patients with persistent symptoms following conservative treatment. LEVEL OF EVIDENCE: Level V.

Ketogenic diet improves forelimb motor function after spinal cord injury in rodents.

High fat, low carbohydrate ketogenic diets (KD) are validated non-pharmacological treatments for some forms of drug-resistant epilepsy. Ketones reduce neuronal excitation and promote neuroprotection. Here, we investigated the efficacy of KD as a treatment for acute cervical spinal cord injury (SCI) in rats. Starting 4 hours following C5 hemi-contusion injury animals were fed either a standard carbohydrate based diet or a KD formulation with lipid to carbohydrate plus protein ratio of 3:1. The forelimb functional recovery was evaluated for 14 weeks, followed by quantitative histopathology. Post-injury 3:1 KD treatment resulted in increased usage and range of motion of the affected forepaw. Furthermore, KD improved pellet retrieval with recovery of wrist and digit movements. Importantly, after returning to a standard diet after 12 weeks of KD treatment, the improved forelimb function remained stable. Histologically, the spinal cords of KD treated animals displayed smaller lesion areas and more grey matter sparing. In addition, KD treatment increased the number of glucose transporter-1 positive blood vessels in the lesion penumbra and monocarboxylate transporter-1 (MCT1) expression. Pharmacological inhibition of MCTs with 4-CIN (α-cyano-4-hydroxycinnamate) prevented the KD-induced neuroprotection after SCI, In conclusion, post-injury KD effectively promotes functional recovery and is neuroprotective after cervical SCI. These beneficial effects require the function of monocarboxylate transporters responsible for ketone uptake and link the observed neuroprotection directly to the function of ketones, which are known to exert neuroprotection by multiple mechanisms. Our data suggest that current clinical nutritional guidelines, which include relatively high carbohydrate contents, should be revisited.