Imprecise prediction of implant sizes with preoperative 2D digital templating in total knee arthroplasty.

PURPOSE: To analyze the match between preoperatively determined implant size (2D templating) and intraoperatively used implant size in total knee arthroplasty (TKA). Also examined were the factors that might influence templating accuracy (gender, surgeon experience, obesity, etc.). MATERIALS AND METHODS: The study was retrospective and conducted in a specialized ENDOCERT arthroplasty center. Digital templating was done with the MediCAD software. If the planned and implanted TKA components (both femur and tibia) were the same size, the match was classified "exact." A deviation of ± one size (at the femur or tibia or both) was classified "accurate." A deviation of ± two or more sizes (at the femur or tibia or both) was classified "inaccurate." Obesity, gender, implant type and surgeon experience were investigated for potential influence on templating accuracy. Chi-square tests and Cohen's weighted kappa test were used for statistical analysis. RESULTS: A total of 482 cases [33.6% male, 66.4% female, age 69 ± 11, body mass index (BMI) 30.3 ± 5.8] were included. When the femur and tibia were taken together, exact size match was observed in 34% (95% CI 29.9-38.3%) of cases, accurate size match in 57.5% (95% CI 53-61.8%) and inaccurate size match in 8.5% (95% CI 6.3-11.2%). Inaccurate size match prolonged operative time (p = 0.028). Regarding the factors potentially influencing templating accuracy, only gender had a significant influence, with templating being more accurate in men (p = 0.004). BMI had no influence on accuracy (p = 0.87). No effect on accuracy was observed for implant type and surgeon experience. CONCLUSIONS: The accuracy of 2D size templating in TKA is low, even in a specialized ENDOCERT arthroplasty center. The study findings challenge the usefulness of preoperative 2D size templating and highlight the importance of more reliable templating methods. LEVEL OF EVIDENCE: Level III (retrospective observational study).

Resuming elective hip and knee arthroplasty after the first phase of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates recommendations.

PURPOSE: The Covid-19 pandemic has disrupted health care systems all over the world. Elective surgical procedures have been postponed and/or cancelled. Consensus is, therefore, required related to the factors that need to be in place before elective surgery, including hip and knee replacement surgery, which is restarted. Entirely new pathways and protocols need to be worked out. METHODS: A panel of experts from the European Hip Society and European Knee Association have agreed to a consensus statement on how to reintroduce elective arthroplasty surgery safely. The recommendations are based on the best available evidence and have been validated in a separate survey. RESULTS: The guidelines are based on five themes: modification and/or reorganisation of hospital wards. Restrictions on orthopaedic wards and in operation suite(s). Additional disinfection of the environment. The role of ultra-clean operation theatres. Personal protective equipment enhancement. CONCLUSION: Apart from the following national and local guidance, protocols need to be put in place in the patient pathway for primary arthroplasty to allow for a safe return.

Recommendations for resuming elective hip and knee arthroplasty in the setting of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates Survey of Members.

PURPOSE: The COVID-19 pandemic has disrupted the health care system around the entire globe. A consensus is needed about resuming total hip and knee procedures. The European Hip Society (EHS) and the European Knee Association (EKA) formed a panel of experts that have produced a consensus statement on how the safe re-introduction of elective hip and knee arthroplasty should be undertaken. METHODS: A prospective online survey was done among members of EHS and EKA. The survey consisted of 27 questions. It includes basic information on demographics and details the participant's agreement with each recommendation. The participant could choose among three options (agree, disagree, abstain). Recommendations focussed on pre-operative, peri-operative, and post-operative handling of patients and precautions. RESULTS: A total of 681 arthroplasty surgeons participated in the survey, with 479 fully completing the survey. The participants were from 44 countries and 6 continents. Apart from adhering to National and Local Guidelines, the recommendations concerned how to make elective arthroplasty safe for patients and staff. CONCLUSION: The survey has shown good-to-excellent agreement of the participants with regards to the statements made in the recommendations for the safe return to elective arthroplasty following the first wave of the COVID-19 pandemic.

Osteoid osteoma in the base of the coracoid process of the scapula. Excision by anterior approach: a case report.

Osteoid osteoma in the base of the coracoid process of the scapula is very rare and diagnosis and treatment often is delayed. A lesion in this atypical location may seem surgically unreachable. This report is of a case of osteoid osteoma in the base of coracoid process in a 14-year-old female. The lesion had been diagnosed as a nontumorous condition and overlooked for four years. Computed tomography and magnetic resonance imaging revealed a nidus in the base of the coracoid process. The en bloc excision of the osteoid osteoma was managed by an anterior approach using an osteotomy of the coracoid process. A 12-month follow-up examination revealed no symptoms and computed tomography showed bone healing with no recurrence of the tumor.

Two-stage treatment of chronic staphylococcal orthopaedic implant-related infections using vancomycin impregnated PMMA spacer and rifampin containing antibiotic protocol.

To determine the clinical role of rifampin containing antibiotic combination and modified two-stage exchange arthroplasty with a vancomycin loaded polymethylmethacrylate (PMMA) spacer for the treatment of orthopaedic implant related Staphylococcus epidermidis infections, a prospective study was initiated. A total of 10 patients, with a mean age of 59 years (range: 32 to 78 years) were included in the study. The mean follow up was 23.4 months (range: 16 to 36 months). Six patients had an infected hemiarthroplasty of the hip, three had infected total hip arthroplasty, and one had an infected femoral neck fracture with implant failure and pseudoarthrosis. All had culture-proven Staphylococcus epidermidis infections, six of the isolates were methicillin resistant. Following debridement and implantation of a PMMA spacer, a rifampin-vancomycin antibiotic protocol was initiated until the erythrocyte sedimentation rate and C-reactive protein levels were within normal limits. After reimplantation and discharge from the hospital, oral antibiotics with rifampin-ciprofloxacin were continued for three to six months. At the final follow-up none of the patients had any clinical or laboratory signs of infection. Although this study includes a limited number of patients and relatively short-term follow-up the results indicate that in the presence of orthopaedic implant infection with Staphylococcus epidermidis, modified two-stage exchange arthroplasty using a vancomycin-loaded PMMA spacer and a rifampin-containing antibiotic protocol may be beneficial.

Calcific myonecrosis.

Calcific myonecrosis is a rare and late sequela of compartment syndrome, which becomes symptomatic years after the initial trauma. We diagnosed this condition in a 64-year old man, 42 years after he sustained a shot-gun wound to the right lower leg. Total excision of a peripherally calcified, cystic mass, continuous with the anterior tibial muscle belly resulted in complete resolution of symptoms. Consideration of the diagnosis is warranted in patients with a history of major injury who develop a soft tissue mass in the traumatized compartment. The treatment of choice is marginal excision.

Intra-articular metastatic melanoma of the right knee.

Melanoma can metastasize to almost every organ and tissue. Although bone metastases have been reported frequently, the authors are aware of only a single report of intra-articular synovial metastasis. A case of metastatic melanoma, mimicking degenerative medial meniscal tear of the right knee, is presented. Further examination revealed asymptomatic metastases in the liver, subcutaneous tissue, and left trochanter minor. Arthroscopic examination revealed widespread synovial metastasis and a palliative arthroscopic synovectomy was performed.

Vascularised bone graft applications in upper extremity problems.

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6-78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed.

Treatment of scaphoid nonunions with a vascularized bone graft based on the first dorsal metacarpal artery.

Four patients with chronic nonunion of the scaphoid were treated by a vascularized bone graft based on first dorsal metacarpal artery. The mean duration of the nonunion was 28.5 months (range 12-48 months). There was avascular necrosis in all patients confirmed by magnetic resonance imaging (MRI). None of the patients had previous attempts at surgical reconstruction. Two fractures were localized at the waist one in the distal part and one at the proximal pole. Osseous union of the scaphoid was confirmed by X-ray in all patients in an average of 2.1 months. We recommend this technique for the treatment of established scaphoid pseudoarthrosis with avascular necrosis since it is associated with minimal morbidity and predictable good results.

Unusual causes of scapular clicking. Lymphangioma of the thoracic wall and aneurysmal bone cyst of the scapula.

Scapular clicking with shoulder motion has been described for a variety of conditions. Two unusual cases, a lymphangioma of the thoracic wall in a 42-year-old man and an aneurysmal bone cyst of the scapula in an 8-year-old boy, are presented. The lymphangioma was treated by marginal excision of the lesion and the aneurysmal bone cyst, by excision of the infraspinal portion of the scapula with resolution of symptoms.

Spinal imbalance and decompensation problems in patients treated with Cotrel-Dubousset instrumentation.

The basic principles of current idiopathic scoliosis treatment are three-dimensional correction and rigid fixation. Although it is accepted that Cotrel-Dubousset instrumentation (CDI) meets these goals, there is concern about the potential risk of trunk imbalance and spinal decompensation during the derotation manoeuvre. The results of 45 patients with idiopathic scoliosis treated with CDI between December 1988 and August 1992 were retrospectively analysed. Mean age was 14.3 years and mean follow-up period was 48.6 months. An average correction of 49.6% was achieved in the major curves. The best results were obtained in King type III curves, with a 69.4% correction. Spinal imbalance was evaluated by measuring lateral trunk shift (LT), shift of head (SH) and shift of stable vertebra (SS). Decompensation was measured by the increase in secondary curves. When all curve types were included, the average preoperative LT value of 1.96 vertebral units (VU) was brought down to 0.91 VU postoperatively, achieving a 55.9% correction. Fourteen patients had an SH value of zero preoperatively and remained balanced after instrumentation. Of the 41 remaining patients, 21 achieved an SH value of zero postoperatively. When all cases were included, the average preoperative SH value was 1.0 VU, which was corrected to 0.42 VU with CDI (69% correction). An average correction of SS of 75.5% was obtained, with the mean preoperative value of 0.73 VU being corrected to 0.19 VU. At the last follow-up visit, a secondary curve had formed above the major curve in one patient, and three patients had a junctional kyphosis. Loss of correction in the frontal plane correlated with loss of correction of LT. The rigid and semiflexible lumbar curves had a tendency to progress when they were not instrumented, especially in type II curves. Junctional kyphosis could be prevented when concave laminar claws were used in the thoraco-lumbar region. It was concluded that spinal decompensation and imbalance could be minimized with careful preoperative planning, avoidance of overcorrection and use of long instrumentation in double major curves.

Antibiotic-impregnated plaster of Paris beads. Trials with teicoplanin.

Teicoplanin-impregnated plaster of Paris beads were made and in vitro release properties were studied. Teicoplanin was released in an initial massive dose, with a rapid decline during the first three days, followed by a slowly declining prolonged release up to 30 days. The release tested by diffusion in gelose and high-performance liquid chromatography was found to be 21.4% and 28.2%, respectively, of the amount theoretically present in the beads. Plaster of Paris is a resorbable, nontoxic biomaterial that has already been used to fill dead spaces in bone and deliver antibiotics in the treatment of chronic osteomyelitis. The addition of teicoplanin, a new antistaphylococcal agent with low known bacterial resistance, is a promising alternative. Follow-up tests in vivo, simulating local conditions of the osteomyelitic bone, are necessary to prove efficacy.