Chondrocytes supplemented to bone graft-containing scaffolds expedite cranial defect repair.

Critical maxillofacial bone fractures do not heal spontaneously, thus, often there is a need to facilitate repair via surgical intervention. Gold standard approaches, include the use of autologous bone graft, or devices supplemented with osteogenic growth factors and bone substitutes. This research aimed to employ a critical size calvaria defect model, to determine if the addition of chondrocytes to collagen-containing bone graft substitute, may expedite bone repair. As such, using a critical size rat calvaria defect, we implanted a collagen scaffold containing bone graft substitute (i.e., Bone graft scaffold, BG) or BG supplemented with costal chondrocytes (cBG). The rats were subjected to live CT imaging at 1, 6, 9, and 12 weeks following the surgical procedure and sacrificed for microCT imaging of the defect site. Moreover, serum markers and histological evaluation were assessed to determine osseous tissue regeneration and turnover. Live CT and microCT indicated cBG implants displayed expedited bone repair vs, BG alone, already at 6 weeks post defect induction. cBG also displayed a shorter distance between the defect edges and greater mineral apposition distance compared to BG. Summerizing, the data support the addition of chondrocytes to bone substitute, accelerates the formation of new bone within a critical size defect.

How resources affect management of periprosthetic fractures of the distal femur: perspectives from Israel, South Sudan, and South Africa.

Periprosthetic fractures of the distal femur have significant morbidity in both total hip and total knee arthroplasty (THA and TKA, respectively). The incidence of these fractures is growing, with the predominant mechanism of injury being a fall from a standing height and therefore considered fragility fractures. In many countries, improved public funding and a flourishing private health care sector, when coupled with increased life expectancy, translates to more older patients receiving both TKA and THA and therefore an increased prevalence of periprosthetic fractures and their associated complications. These fractures may occur below a long stem THA, above a TKA, or between the two (so-called "interprosthetic fracture"). We will outline fracture classification, risk factors, diagnosis, and treatment options, highlighting perspectives on treating these fractures in Israel, South Africa, and South Sudan. These countries represent differing access to resources, varied comorbidity factors, and differing health care systems. The points of difference and the points of similarity will be considered.

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.

Serum Metal Ions in Contemporary Monoblock and Modular Dual Mobility Articulations.

BACKGROUND: Questions exist about the release of cobalt and chromium ions from dual mobility (DM) cups. Modular implants, with potential backside wear between the cobalt-chromium liner and titanium cup, are of particular concern. This study compares the metal ion profile of patients with contemporary monoblock and modular DM articulations from two commonly used designs. METHODS: Cobalt and chromium serum levels were measured one year after surgery in a prospective cohort of patients undergoing total hip arthroplasty with a DM construct. Ion levels were detected above 1 µg/L. Clinical and surgical data were correlated with the ion levels for analysis. RESULTS: Overall, 29% of the patients had levels above 1 µg/L of either ion. More patients with modular cups had detectable ions than patients with monoblock cups (39% vs 20%, P = .05). Cobalt was more commonly detected in the monoblock group, and chromium was more commonly detected in the modular group (P = .05). There were no differences in the actual ion levels between the groups (1.35 µg/L vs 1.64 µg/L, P = .44, for cobalt and 1.35 µg/L vs 1.31 µg/L, P = .77, for chromium). No patient underwent revision during the follow-up period. CONCLUSIONS: We found similar cobalt and chromium levels in patients with monoblock and modular DM cups. More patients in the modular group had detectable ions. Cobalt was more frequently detected in the monoblock group. These results suggest that both implants are performing well in the short term, but further follow-up is needed to determine whether the differences found are of clinical significance.

Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review.

BACKGROUND: Although preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty. METHODS: Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020. RESULTS: After applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates. CONCLUSION: There is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI. LEVEL OF EVIDENCE: Level III, systematic review.

Muscle activity while ambulating on stairs and slopes: A comparison between individuals scheduled and not scheduled for knee arthroplasty and healthy controls.

OBJECTIVE: To examine muscle activity patterns of the lower limbs while ascending and descending stairs and slope in adults with knee Osteoarthritis (knee-OA), who were scheduled or not scheduled for Total Knee Replacement (TKR) and healthy controls. METHODS: This cross-sectional study included three groups: knee-OA subjects scheduled for TKR (TKR group; N = 15) and not scheduled for TKR (NTKR group; N = 15) and age-matched controls (N = 11). Outcome measures included: joint range of motion (ROM), Timed Up and Go (TUG), joint pain levels, and functional disability (Oxford) score. Also, durations of muscle activity (rectus femoris, semitendinosus, medial gastrocnemius, bilaterally, and soleus, and tibialis anterior of the OA limb) were recorded while the subjects ascended and descended stairs and a level surface. RESULTS: Both knee-OA groups had significantly higher Oxford scores and bilateral knee pain levels compared to the control group. The TKR group had higher TUG score compared to the NTKR group. The activation duration of the Tibialis Anterior of the OA limb while ascending and descending stairs and slope were higher in the TKR group compared to the NTKR group. No differences in muscle activity durations were found when comparing the OA limb to contralateral limb. CONCLUSION: The muscle activity strategies differentiated between individuals scheduled and not scheduled for TKR. The longer duration of muscle activity of Tibialis Anterior muscle in the TKR group compared to the NTKR group suggest that customized prehabilitation program is required for these groups.

Serum metal ion levels in modular dual mobility acetabular components: A systematic review.

BACKGROUND: Dual mobility (DM) constructs effectively reduce the risk of dislocation in revision and high risk primary total hip arthroplasty. However, modular DM designs require the use of a cobalt-chrome liner against a titanium cup which may induce corrosion, metal ions release, and associated biologic response. The purpose of this systematic review study was to collect all reported cases of serum metal ions after DM in the literature and ask the following questions: 1) what is the overall rate of significantly elevated Cobalt and Chromium metal ions and how do these levels change over time? 2) Does femoral head material composition influence serum metal ion levels? and 3) were there any atypical lymphocytic associated lesions after modular DM that required revision surgery? METHODS: A systematic review was performed according to PRISMA guidelines. In addition to patient demographics, information specific to the performance of the DM implant were recorded including: cobalt and chromium serum ion levels and all reported timepoints, the material composition of the femoral head, all revision and reoperations and any failure related to corrosion of the DM bearing. A significant elevation in cobalt or chromium was defined as >1.0 or >1.6 mcg/L. RESULTS: 248 modular DM THAs were analyzed. The cumulative mean cobalt and chromium levels for all included studies was 0.47mcg/L and 0.53mcg/L, respectively. At final follow-up 13 patients (5.2%) had elevated cobalt ion levels and 4 patients (1.6%) had elevated chromium ion levels. Femoral head material composition trended towards but did not significantly increase serum ion levels. Ceramic heads had elevated cobalt and chromium ions in 4/135 (3%) of patients compared to metal heads which had elevated cobalt ions in 9/113 (8%) and elevated chromium ions in 0/113 (0%), (p = 0.09). There were no reoperations or revisions for metal related reactions at final follow-up (mean 27.4 months). CONCLUSION: In this systematic review including 248 modular DM THAs, elevated serum cobalt ions were present in 5.2% of patients at a mean follow-up of 27.4 months. While a trend towards increased Cobalt serum ions with the use of cobalt chrome femoral heads, femoral head composition was not significantly associated with increased serum metal ion levels. At final follow-up, metal ion levels appear to decrease in the majority of patients between 1 and 2 years and no patient was revised for metal ion related complications. Continued serum metal ion surveillance is recommended to ensure the safety of DM constructs in THA with longer term follow-up.

Reconstruction options and outcomes for acetabular bone loss in revision hip arthroplasty.

Revision total hip arthroplasty in the setting of acetabular bone loss is a challenging procedure and requires a solid understanding of current acetabular reconstruction options. Despite major developments in the field of revision hip surgery in recent decades, reconstruction of acetabular defects remains a major problem in order to achieve primary stability and durable fixation without sacrificing additional bone stock. Although there are several ways to classify acetabular bone defects, the Paprosky classification system is the most commonly used to describe the defects and guide treatment strategy. An understanding of the bone defects associated with detailed pre-operative assessment and planning are essential elements in order to achieve satisfactory outcomes. Multiple acetabular reconstructive options are currently available including impaction bone grafting with metal mesh, reinforcement rings and antiprotrusio cage, structural allografts, cementless hemispherical cups, extra-large "jumbo cups", oblong cups, modular porous metal augments, cup-cage constructs, custom- made triflange cups, and acetabular distraction. To date, debate continues as to which technique is most effective due to the lack of long-term studies of modern reconstruction systems. Further long-term studies are necessary to assess the longevity of the different implants. The purpose of this study was to review the current literature and provide a comprehensive understanding of the available reconstruction options with their clinical outcomes.

Surgical implications of the hip-spine relationship in total hip arthroplasty.

Total hip arthroplasty (THA) is considered the most successful orthopedic surgical procedure of the last century with excellent survivorship up to 20-years. However, instability remains a major issue representing the most common reason for revision after THA. Hip-spine relationship has gained progressive interest between arthroplasty surgeons and its understanding is crucial in order to identify high-risk patients for postoperative dislocation. Spinal deformity and abnormal spinopelvic mobility have been associated with increased risk for instability, dislocation and revision THA. Preoperative workup begins with standing anteroposterior pelvis x-ray and lateral spinopelvic radiographs in the standing and sitting position. Hip-spine stiffness needs to be addressed before THA in consideration of adapting the preoperative planning to the patient's characteristics. Acetabular component should be implanted with different anteversion and inclination angles according to the pattern of hip-spine motion in order to reduce the risk of impingement and consequent dislocation. Different algorithmic approaches have been proposed in case of concomitant hip-spine disease and in case of altered sagittal balance and pelvic mobility. The aim of this review is to investigate and clarify the hip-spine relationships and evaluate the impact on modern total hip arthroplasty.

Kinematics following gait perturbation in adults with knee osteoarthritis: Scheduled versus not scheduled for knee arthroplasty.

OBJECTIVE: To compare recovery kinematics following trip-simulated perturbation during gait between three groups: adults without knee Osteoarthritis (OA) and adults with OA, scheduled and not scheduled for Total Knee Replacement (TKR). METHODS: People with OA scheduled for TKR (TKR group; N = 19) and not scheduled (NTKR group; N = 17) were age-matched with People without OA (N = 19). Outcome measures included: joint range of motion (ROM), Timed Up and Go (TUG), joint pain levels, Oxford score, Instrumental Activities of Daily Living Questionnaire, and the Activities-specific Balance Confidence Scale. Also, spatiotemporal gait parameters and joint kinematics were recorded during perturbed and unperturbed gait. The perturbed gait data were normalized by unperturbed gait data. RESULTS: There were no differences between the two OA groups in the four questionnaire scores and joint ROM. The TUG score of the TKR group was higher than that of the NTKR group. There were no statistically significant between-group differences in the normalized spatiotemporal parameters. The OA groups showed statistically significant lower anterior pelvic tilt ranges and higher maximal hip adduction of the contralateral limb compared to the Non-OA group. When the contralateral limb was perturbed, the TKR group showed significantly lower pelvic rotation range compared to the NTKR and Non-OA groups. When the OA limb was perturbed, the maximal hip flexion of the injured limb was significantly lower and the maximal knee flexion higher in the OA groups compared with the Non-OA group. CONCLUSION: The recovery strategy from trip-simulated perturbation of individuals with OA differs from that of individuals without OA. This may emphasize the importance of devising a treatment plan that focuses on improving balance and reactions to gait perturbation.

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.

Osteonecrosis of the Femoral Head and Hip Arthritis in an Adolescent Following an Isolated Fracture of the Greater Trochanter: A Case Report and Review of the Literature.

CASE: A healthy adolescent sustained an isolated fracture of the greater trochanter after falling from a height. He was treated nonoperatively. After 10 weeks of improvement, the pain recurred, and osteonecrosis of the femoral head was diagnosed. Core decompression and a bone-marrow injection were performed. Transient relief was achieved, followed by deterioration to end-stage hip arthritis. CONCLUSION: To our knowledge, 19 other cases of isolated fractures of the greater trochanter in adolescents have been reported since 1905. All high-energy injuries (10 cases) progressed to osteonecrosis, independent of the intervention; none of the low-energy cases progressed to osteonecrosis. We advocate vigilance and early magnetic resonance imaging for these injuries to detect and treat osteonecrosis in its early stages.

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged.

BACKGROUND: Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population. STUDY DESIGN: retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27-60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores. RESULTS: All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome. CONCLUSION: Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.

Computerized navigation for length and rotation control in femoral fractures: a preliminary clinical study.

OBJECTIVE: Operative treatment of femoral fractures yields a predictably high union rate, but residual malrotation and leg length discrepancy remain a clinically significant problem. The aim of this study was to determine the safety and efficacy of using computerized navigation in controlling the length and rotation in femoral fracture surgery. DESIGN: Prospective consecutive case series of 16 skeletally mature patients with femoral fractures undergoing surgical fixation; 14 were fixed with intramedullary nails and 2 with plates. SETTING: An Academic Level I trauma center. INTERVENTION: Computerized navigation was used to determine the length and rotation of the operated extremity as compared with the intact healthy contralateral side. MAIN OUTCOME MEASURE: All patients underwent postoperative computed tomography scanogram for determining the length and rotation. RESULTS: All fractures healed. Mean rotational difference between the treated and nontreated sides was 3.45 degrees (range, 0-7.7 degrees). Mean length difference between the 2 extremities as calculated by the computed tomography scan was 5.83 mm (range, 0-13 mm). Additional operative time required for computerized navigation was measured in 2 of the cases and totaled ∼30-35 min/case. CONCLUSION: Computerized navigation was accurate and precise at restoring femoral length and rotation during femoral fracture fixation when the intact contralateral femur was used for reference. Further, large-scale randomized studies are required. Additionally, improvements aimed at decreasing operative time and improving user interface of these systems are recommended. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of the levels of evidence.