Smoking is not closely related to revision for periprosthetic joint infection after primary total knee and hip arthroplasty.

BACKGROUND: The influence of smoking on the risk of periprosthetic joint infection (PJI) remains unclear. The objective was to explore the impact of smoking on PJI after primary total knee (TKA) and hip (THA) arthroplasty. HYPOTHESIS: Current smoking patients should have an increased risk of PIJ compared with nonsmoking patients. PATIENTS AND METHODS: A prospective registry-based observational cohort study was performed. A total of 4591 patients who underwent primary TKA (3076 patients) or THA (1515) were included. According to the smoking status at the time of arthroplasty, patients were classified as nonsmokers (3031 patients), ex-smokers (688), and smokers (872). Multivariate analysis included smoking status, age, gender, education level, body mass index, American Society of Anesthesiologists class, diagnosis (osteoarthritis, rheumatism), diabetes, chronic obstructive pulmonary disease, perioperative blood transfusion, site of arthroplasty (knee, hip), length of operation, and length of stay. RESULTS: There were PJI after 59 (1.9%) TKA and 27 (1.8%) THA (p=0.840). There were PJI in 47 (1.6%) nonsmokers, 12 (1.7%) ex-smokers, and 17 (1.9%) smokers (p=0.413). There were wound complications (delayed wound healing and superficial wound infection) in 34 (0.7%) nonsmokers, 9 (1.3%) in ex-smokers, and 17 (1.9%) in smokers (p=0.045). In multivariate analysis, only the female gender was a significant predictor of PJI (OR 1.3, 95% CI 1.1-2.4 [p=0.039]). Specifically, the categories of ex-smokers (OR 0.8, 95% CI 0.2-1.7 [p=0.241]) and smokers (OR 1.1, 95% CI 0.6-1.5 [p=0.052]) were not significant predictors. The 4-year arthroplasty survival with PJI as the endpoint was 99.1% (95% CI: 99.0-99.7) for nonsmokers, 99.0% (95% CI: 98.8-99.2) for ex-smokers, and 98.7% (95% CI: 98.2-99.0) for smokers was not significantly different between smoking status groups (p=0.318). DISCUSSION: Smoking was not identified as a significant predictor for PJI following primary TKA or THA. LEVEL OF EVIDENCE: III, prospective cohort study.

Functional Outcome Change Over 10 Years After Primary Total Knee Arthroplasty. A Prospective Longitudinal Cohort Study.

BACKGROUND: To assess any clinically important difference in functional outcome over 10 years after primary total knee arthroplasty (TKA). METHODS: A prospective registry-based observational cohort study including 309 patients older than 60 years who underwent primary TKA. Patients were assessed at 1, 3, 5, 7 and 10 postoperative years with the Knee Society scores (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Clinically important improvement was defined according to the minimal clinically important difference (MCID). Patients were also categorized as type A (unilateral knee osteoarthritis), type B (bilateral knee osteoarthritis) or type C (various sites of osteoarthritis). RESULTS: The mean age at the TKA surgery was 69.2 (SD 7.3) years, 197 (63.7%) were women.Maximum postoperative improvements in functional scores occurred at 3 postoperative years, remained relatively stable up to 5-year. There were significant decreases in all KSS and WOMAC scores at 7-year follow-up (P = .001), remained stable up to 10-year. At 10-year, functional scores were significantly higher than preoperatively (P = .001). Differences between maximum scores at 3-year and those at 10-year were significantly lesser than MCID in all scores (P = .001). In multivariate analysis, type-C patient at TKA surgery was the only significant predictor of unsuccessful KSS score and dissatisfaction at 10-year follow-up. CONCLUSION: Primary TKA provides clinically important improvements in functional and quality of life outcomes over 10-year follow-up compared to preoperatively. Although there were statistically significant declines in KSS and WOMAC scores from 3 to 10 years, the differences were lesser than the MCID.

Patient-Reported Outcomes of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Disc Disease: A Prospective Comparative Cohort Study.

Background: Comparative outcomes of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and traditional open TLIF (O-TLIF) for degenerative lumbar disc disease have been poorly studied. The purpose of this study was to prospectively compare the outcomes between MI-TLIF and O-TLIF for patients with a degenerative disc disease, focusing on the functional capacity of patients in daily life. Methods: A prospective cohort study was performed, comparing 54 patients who underwent O-TLIF and 55 patients who underwent MI-TLIF with a follow-up of 4 years. Clinical evaluation was performed using the Oswestry Disability Index (ODI), 36-item short form survey (SF-36), and a visual analog scale for pain (VAS pain). Radiological evaluation was also performed. Results: At the final follow-up, compared with O-TLIF, MI-TLIF was associated with significantly better intraoperative results, including similar operative time (p = 0.246), lower estimated blood loss (p = 0.001), and shorter hospital stay (p = 0.001). The final ODI score was significantly better in the MI-TLIF group (p = 0.031). The SF-36-physical (p = 0.023) and VAS pain (p = 0.024) scores were significantly better in the MI-TLIF group. There was no significant difference in the fusion rate (p = 0.747). Conclusions: The MI-TLIF technique is an effective and safe procedure for degenerative lumbar disc disease. Compared to traditional O-TLIF, MI-TLIF was associated with less disability and higher quality of life, with a low rate of intraoperative and postoperative complications.

Sesamoid Position Change Over 2 Years After Distal Chevron Osteotomy for Moderate to Severe Hallux Valgus: A Prospective Cohort Study.

BACKGROUND: Sesamoid position change after distal chevron osteotomy for moderate to severe hallux valgus is not well known in the literature. The objective of this study was to determine whether the sesamoid position changed over 2 years after distal chevron osteotomy for moderate to severe hallux valgus. METHODS: Ninety-seven patients who underwent distal chevron osteotomy for moderate to severe hallux valgus were prospectively assessed for 2 years. There were 91 females, and the mean age was 54.9 (SD 10.9) years. The Self-Reported Foot and Ankle Score (SEFAS) was used for functional assessment. Foot pain was assessed by a 0-10 visual analog scale (VAS), and patient satisfaction by a 5-point Likert scale. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), metatarsal head displacement, and sesamoid position by the AOFAS criteria were analyzed. Patients were classified according to the medial sesamoid position on the first postoperative weightbearing radiograph (1º-WB-Xray) into the reduced sesamoid group (66 patients) and nonreduced sesamoid group (31 patients). RESULTS: All patients were assessed preoperatively and postoperatively at 1 month and 2 years. On the 1º-WB-Xray, IMA was significantly lower in the reduced group (P = .038), but HVA (P = .063) and DMAA (P = .246) were not significantly different. At the final follow-up, no patients in the reduced group had sesamoid position change from 1º-WB-Xray, whereas 8 (25.8%) patients in the nonreduced group had change of their sesamoid positions. The SEFAS was not significantly different between groups preoperatively (P = .386) or at 1 month postoperation (P = .064). The final SEFAS, VAS pain, and satisfaction scores were significantly better in the reduced group, although the clinical significance of these changes remains unknown. CONCLUSION: A nonreduced position of the sesamoids obtained in surgery can cause their increased malposition over 2 postoperative years and statistically less functional outcomes. LEVEL OF EVIDENCE: Level II, prospective cohort study.

A relevant number of patients do not increase their engagement in physical, social and leisure activities at the medium-term after total knee arthroplasty: a prospective cohort study.

PURPOSE: The purpose of this study was to investigate the changes in engagement in physical, leisure and social activities in older adults following primary TKA. METHODS: A prospective study of 106 patients with a mean age of 72.6 (SD 7.4) years undergoing primary TKA was performed. Physical, social and leisure activities performed by the patients preoperatively and postoperatively at 3-year were recorded. Activities were selected according to the age, and grouped as passive, moderate and high intensity. The energy spent in each activity was expressed in Metabolic Equivalent of Task (MET) units. Charlson Comorbidity Index, Mini-mental test and Western Ontario and McMaster Universities (WOMAC) scores were also used. Multivariate analysis was used to identify predictors of active patients. RESULTS: Mean WOMAC significantly improved from preoperative (34.8, SD 11.8) to final follow-up (74.4, SD 11.1) (p = 0.001), and the mean energy spent increased from 10.7 (SD 13.6) to 28.2 (SD 16.2) MET-hour weekly (p = 0.001) with a decrease in the passive activities and increase in the moderate activities. However, the participation in high-intensity activities according to age was negligible. Only 65 (61.3%) patients were considered active postoperatively (weekly spending ≥ 40 MET), although the WOMAC scores were not significantly different between active and sedentary patients. Active patients compared with sedentary patients had a significant increase in engagement in physical, social and leisure activities, and a decrease in passive activities. Female gender (p = 0.037), less preoperatively participation in passive activities (p = 0.042), and greater participation in social activities (p = 0.027) were significant predictors of active patients at the final follow-up. CONCLUSION: Overall, most patients increased their activity level postoperatively. However, 38.6% of patients had no increased engagement in moderate physical, social or leisure activities at the medium-term despite improvements in pain and function provided by TKA. LEVEL OF EVIDENCE: II.

No influence of posterior tibial slope change on outcomes after cruciate-retaining total knee arthroplasty: a prospective cohort study.

OBJECTIVE: To investigate whether the functional outcomes were affected by the change in posterior tibial slope (PTS) after using a predetermined PTS for primary cruciate-retaining total knee arthroplasty (CR-TKA). METHODS: Prospective cohort study of 152 patients who underwent primary CR-TKA with a standardized PTS of 5º regardless of the native PTS. Patients were classified postoperatively in two ways. Firstly, according to the PTS change from preoperative to postoperative (increased or decreased PTS group). Secondly, according to the PTS difference between preoperative and postoperative ≤ 4º (group A) and > 4º (group B). The functional outcomes were assessed with the Knee Society Scores (KSS), McMaster Universities Osteoarthritis Index questionnaire (WOMAC), and range of motion (ROM). Preoperative and postoperative PTS were measured on lateral knee radiographs. RESULTS: The minimum follow-up was 5 year. There were no significant differences at the final follow-up in functional outcomes between increased (88 patients) and decreased (64 patients) PTS groups. Likewise, there were no significant differences in functional outcomes between group A (79 patients) and group B (73 patients). In multivariate analysis, the PTS change was not significant predictor for improvement in functional outcome (OR 1.08; 95% CI 0.70-1.40; p = 0.061). CONCLUSION: The PTS change between preoperative and postoperative has no influence on the functional outcomes using a CR-TKA. A standardized PTS regardless of the native is a reliable procedure for primary CR-TKA.

Change in 1-year mortality after hip fracture surgery over the last decade in a European population.

OBJECTIVE: There are scarce data on the mortality after hip fracture surgery for patients treated in the most recent years. The objective of this study was to analyze whether the overall initiatives introduced over the last decade for elderly patients with hip fractures had a positive impact on the 1-year mortality. METHODS: Patients treated during 2010-2012 were compared with patients treated during 2018-2020 for all-cause 1-year mortality. Variables influencing mortality were collected based on the literature, including demographic, comorbidity, cognitive status, and preinjury physical function. Crude mortalities were compared between periods, as well as with the expected mortality in the general population adjusted for age, gender, and year of surgery using the standardized mortality ratio (SMR). A multivariate model was used to identify mortality risk factors. RESULTS: 591 patients older than 65 years were treated during 2010-2012 and 642 patients during 2018-2020. The mean age increased significantly between periods (78.9 vs. 82.6 years, respectively, p = 0.001) in both genders, together with an increase in comorbidity (p = 0.014). The in-hospital mortality risk had no significant difference between periods (2.5 vs. 2.0%, p = 0.339), but the 30-day mortality risk (8.3 vs. 5.5%, p = 0.031) and 1-year mortality risk (16.1 vs. 11.9%, p = 0.023) declined significantly. However, 1-year mortality in 2020 had an excess of 1.33 in SMR. Age older than 80 years, male gender, and Charlson comorbidity index > 2 were significant predictors of 1-year mortality. CONCLUSION: The important evolution achieved in the last decade for the management of patients with hip fracture surgery has led to a significant decline in 1-year mortality, but the 1-year mortality remains significantly higher compared to the general population of similar age and gender.

Similar outcomes of constrained condylar knee and rotating hinge prosthesis in revision surgery for extension instability after primary total knee arthroplasty.

BACKGROUND: Instability is one of the most common reasons for total knee arthroplasty (TKA) failure. Constrained prosthesis can be used for significant ligamentous laxity, but there is not much evidence on the appropriate level of restriction for unstable varus-valgus TKA. The objective of this study was to compare the outcome and survival at a minimum follow-up of five years between rotating hinge knee prosthesis (RHK) and constrained condylar knee prosthesis (CCK) for extension instability following primary TKA. HYPOTHESIS: For symptomatic extension instability after primary TKA, good functional outcomes and survival can be achieved with both designs. MATERIAL AND METHODS: Consecutive patients with unstable primary TKA who underwent revision with either RHK (n=34) or CCK (n=30) were retrospectively compared. Assessments were performed by the Knee Society Scores (KSS), and visual analogue scales (VAS) for pain and patient satisfaction. Radiological evaluation was made. Complications and re-operations were analyzed. RESULTS: Mean post-operative follow-up was 10.3 (range 5-16) years for both groups. At the final follow-up, there was no significant difference between groups in the KSS-knee (p=0.228) or KSS-function (p=0.324) score, VAS-pain (p=0.563), VAS-satisfaction (p=0.780), major complication rate (p=0.194), or TKA survival at 10 years (p=0.091). CONCLUSION: The present study showed comparable good functional outcomes and survival at long-term between RHK and CCK arthroplasties. Both designs can be recommended for revision of total knee arthroplasty with symptomatic extension instability. LEVEL OF EVIDENCE: Level III.

Negative Association of Subclinical Hypothyroidism on Improvement in Patient-Reported Outcomes After Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is to analyze the potential influence of subclinical hypothyroidism (SCH) on improvement in patient-reported outcome measures following primary total knee arthroplasty. METHODS: A prospective, comparative cohort study between 92 SCH and 90 euthyroid patients was performed. Patients were followed up to 5 postoperative years. Patient-reported outcome measure was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. The Knee Society Scores were used for functional evaluation, and 5-point Likert scale for patient satisfaction. The Hospital Anxiety and Depression scale was also used. RESULTS: All outcome scores significantly improved from preoperative to final follow-up in both groups (P = .001). There were no significant differences between groups in Knee Society Scores (P = .057) at the final follow-up, but Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly lower in the SCH group (P = .015). Likewise, the patient satisfaction rate was significant lower in the SCH group (0.010). CONCLUSION: SCH patients have a slower functional recovery than euthyroid patients, and trended toward lower improvements in patient-reported scores. Depression was the most important negative factor. The findings of this study can provide the surgeon with an important information for better counseling the SCH patients.

Similar patient-reported outcomes for hybrid and cemented stem fixation for aseptic tibial revision total knee arthroplasty: a comparison of sequential prospective cohorts.

PURPOSE: The tibial stem fixation in an aseptic revision of total knee arthroplasty is poorly studied and controversial. The objective of this study was to prospectively compare clinical outcomes between hybrid and cemented fixation of the stem in aseptic tibial revision after a minimum follow-up of 5 years. METHODS: Two sequential prospective cohorts of patients who underwent aseptic tibial revision were compared after a minimum follow-up of five years: 31 had both tibial tray and stem cemented (cemented group), and 42 had a hybrid fixation with tibial tray cemented and stem cementless (hybrid group). Clinical assessment was performed by the Knee Society Scores and reduced Western Ontario and McMaster Universities Arthritis Index. Radiological assessment was also performed. RESULTS: There were no significant differences in preoperative data between groups. Postoperatively, no significant differences between groups in clinical scores or complication rate were found. Survival of the TKA revision at 5-year was 94% (95% CI 89-98%) in the cemented group, and 98% (95% CI 92-100%) in the hybrid group (ns). CONCLUSION: Clinical outcomes and implant survival were comparable between hybrid and cemented tibial stem fixation. LEVEL OF EVIDENCE: II.

Influence of sesamoid position after scarf osteotomy for hallux valgus on patient-reported outcome. A prospective cohor study.

BACKGROUND: The objective was to evaluate the influence of the postoperative sesamoid position as measured with conventional radiographs on the patient-reported outcome after scarf osteotomy. The hypothesis was that incomplete reduction of the sesamoid would result in a decreased functional outcome. METHODS: Eighty-two patients who underwent scarf osteotomy for hallux valgus were prospectively assessed for up to two postoperative years. The Self-Reported Foot and Ankle Score (SEFAS) was used to assess the quality of life, and the American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale (AOFAS) for the functional outcome. A visual analogue scale (VAS) assessed pain, and Likert scale for patient satisfaction. Radiologically, hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), and sesamoid position were analyzed. According to the final sesamoid position, patients were classified as normal position (48 patients) and outlier position (34 patients). A power analysis, conventional and logistic regression statistical analysis were performed. RESULTS: At the final follow-up, significant improvements in all clinical scores were observed for both groups (p = 0.001) with no significant difference in AOFAS score (p = 0.413), but SEFAS score (p = 0.023), VAS-pain (p = 0.006), and satisfaction (p = 0.014) were significantly better in the normal group than in the outlier group. There were significant differences between groups in final HVA (p = 0.042) and IMA (p = 0.040). In multivariate analysis, only lower VAS-pain score (OR 0.4, 95% CI 0.2-0.6; p = 0.039) and normal sesamoid position (OR 2.4, 95% CI 1.6-3.2; p = 0.012) were significant predictor of patient satisfaction. CONCLUSION: At two postoperative years, normal sesamoid position as measured on weight-bearing radiographs was associated with lower pain and better patient satisfaction in patients underwent scarf osteotomy for moderate to severe hallux valgus.

A validated outcome categorization of the knee society score for total knee arthroplasty.

PURPOSE: To determine cutoff values for the Knee Society Scores (KSS) indicative of a categorical scale of medium-term outcomes. METHODS: One hundred and fifty-five patients who underwent primary cruciate-retaining TKA with a patellar button for osteoarthritis at a single-centre were assessed prospectively by the KSS and short-form Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) simultaneously at the 3-year follow-up. A validated categorization of the WOMAC score was used as a standard. The area under the curve (AUC) of receiver-operating characteristic (ROC) was used to assess the discriminative analysis accuracy of the, and the Youden index estimated the optimal cutoff point. RESULTS: For the KSS-knee score, the cutoff for an excellent outcome was 90.3 (AUC 0.75, 95% CI 0.71-0.78), 76.6 (AUC 76.6, 95% CI 0.70-076) for good, 64.8 (AUC 0.76, 95% CI 0.72-0.79) for fair, and < 64.8 (AUC 0.69, 95% CI 0.67-0.73) for poor. For the KSS-function score, the cutoff values were 85.2 (AUC 0.71, 95% CI 0.69-0.75), 73.1 (AUC 0.72, 95% CI, 0.70-0.76), 55.7 (AUC 0.70, 95% CI 0.71-0.74), and < 55.7 (AUC 0.68, 95% CI 0.66-0.72), respectively. CONCLUSION: A KSS-knee score ≥ of 90 was considered an excellent outcome, 77 good, 65 fair, and < 65 poor. For the KSS-function, those values are 85, 73, 56 and < 56, respectively. The treatment outcome's judgement may be clearer for the surgeon concerning a particular patient when using cutoff values for the scoring system employed, such as those determined in the present study. LEVEL OF EVIDENCE: II.

Similar outcomes and satisfaction after transtibial versus transportal femoral drilling for anterior cruciate ligament reconstruction in young adult recreational athletes.

PURPOSE: Controversy continues regarding whether the transtibial (TT) and transportal (TP) methods for anterior cruciate ligament (ACL) reconstruction provide similar or different outcomes, and the evidence on patient satisfaction is very limited. The objective of this study was to compare functional outcomes and patient satisfaction in young adult recreational athletes who underwent arthroscopic hamstring ACL reconstruction using either the TT or the TP femoral tunnel drilling method. METHODS: A nonrandomized prospective study was designed to compare the outcomes of arthroscopic hamstring ACL reconstruction using TT or TP method. Functional outcome was assessed with the Lyshom score, and patient satisfaction with a 5-point Likert scale. Knee stability was measured with the KT-1000 arthrometer. RESULTS: 42 patients in the TT group and 41 in TP group, with age ranged 18-40 years, were compared with a mean follow-up of 42 (range 24-60) months. There were no significant differences between groups in the Lysholm score (n.s.), sport return rate (n.s.) or patient satisfaction with the surgery (n.s.). Satisfaction was only significantly associated with the Lysholm score (OR 1.3; IC 95% 1.06-1.6; p = 0.012), but not with the return to sports (n.s.) or knee anterior laxity (n.s.). CONCLUSION: This study showed no statistical differences between the TT and the TP method in functional outcomes or patient satisfaction in young adult recreational athletes. In those patients, satisfaction with the surgery was not influenced by the return to sport activities. This study can guide surgeons in the decision-making for ACL reconstruction in recreational athletes. LEVEL OF EVIDENCE: Level II.

Varus alignment of the tibial component up to seven degrees is not associated with poor long-term outcomes in a neutrally aligned total knee arthroplasty.

PURPOSE: The purpose of this retrospective study was to evaluate the effect of varus alignment of the tibial component on the outcomes with a minimum follow-up of 10 years. The hypothesis was that varus alignment of the tibial component might not affect the outcomes and survival of a neutrally aligned primary TKA. METHODS: A matched case-control study was designed between 66 patients with varus alignment of the tibial component and 66 with neutral alignment with a minimum follow-up of 10 years. Functional outcome was assessed with the knee surgery scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Patient satisfaction was evaluated by a 0-10 visual analog scale. Radiological evaluation was performed at early postoperative and at final follow-up. RESULTS: The mean follow-up was 11.9 (SD 2.6) years for both groups. The mean postoperative proximal tibial angle in the varus group was 85.0° (SD 0.9) and 88.8° (SD 0.9) in control group. At the final follow-up, there were no significant differences in KSS, WOMAC, range of motion or patient satisfaction. There were no differences in the coronal anatomical alignment of the TKA between groups. Revision of TKA was performed in four knees in the varus group, and one in control group, due to aseptic loosening of the tibial component in all cases. TKA survival at 10 years was not significantly different between groups. CONCLUSION: The alignment of the tibial component up to 7° varus did not negatively affect implant survival, patient satisfaction, and function of a well-aligned TKA, with a minimum postoperative follow-up of 10 years. LEVEL OF EVIDENCE: III.

V-Y turndown flap augmentation for acute quadriceps rupture after total knee arthroplasty: a prospective matched cohort study.

PURPOSE: To evaluate the effectiveness of the quadriceps V-Y turndown augmentation for acute quadriceps tendon ruptures in the setting of TKA. METHODS: Prospective cohort of 22 patients with quadriceps rupture after TKA were compared with 44 matched patients underwent TKA without quadriceps rupture. Quadriceps ruptures were treated within three weeks after injury by suture augmented with Scuderi quadriceps V-Y turndown flap. Clinical evaluation was performed by the Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion. Patellar height was assessed by the Blackburne-Peel ratio. RESULTS: The mean follow-up was 3.3 (range, 3-4) years. At the final follow-up, there were significant improvements in mean KSS scores in both groups (p = 0.001). In the quadriceps group, the mean flexion for all patients, but one with arthrodesis for periprosthetic infection, was 100.1° (range, 90-110°) and mean extensor lag was 7.1° (range, 0-20°). There were significant differences between groups in KSS scores (p = 0.001). Active flexion (p = 0.020) and extension (p = 0.001) were significantly better in the control group. However, there was no significant difference in WOMAC scores (p = 0.252) or patient satisfaction (p = 0.352). There were no quadriceps reruptures. One patient with periprosthetic infection was treated with arthrodesis. CONCLUSION: The quadriceps V-Y turndown is an effective and safe procedure for quadriceps ruptures in the setting of TKA. Although the functional outcomes were lower than in TKA patients with no quadriceps rupture, the quality of life and satisfaction were successful in the TKA patients with quadriceps rupture.

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a prospective cohort study at a minimum five year follow-up.

PURPOSE: To evaluate prospectively the functional outcomes of tibiotalocalcaneal (TTC) arthrodesis with a contemporary retrograde intramedullary nail after a minimum follow-up of five years. METHODS: Sixty-one patients with a mean age of 51.3 (range, 18-79) years were included in the study. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score (AOFAS), Short-Form 12-item Health Survey (SF12), and visual analog scales (VAS) for both pain and patient satisfaction. Radiographic evaluation was also assessed. RESULTS: The mean post-operative follow-up was 6.8 (range, 5-8) years. Mean AOFAS and SF12 scores significantly improved at the final follow-up (p < 0.001), and the mean VAS for pain significantly decreased (p < 0.001). At the final follow-up, only five (8.2%) patients gave an AOFAS score of less than 50, 52 (85.2%) were satisfied with their surgery, and 32 (52.4%) returned to their employment. There were two tibiotalar joint nonunions that required re-operations, and another patient required re-operation for screw removal. There was no deep infection. CONCLUSIONS: The retrograde intramedullary nail provided a stable TTC arthrodesis with a high union rate, acceptable functional outcomes, and a low severe complication rate. This procedure appears to offer a reliable salvage option for TTC arthrodesis in patients with severe ankle and hindfoot degeneration.

Better clinical outcomes and overall higher survival with hybrid versus cemented primary total knee arthroplasty: a minimum 15 years follow-up.

PURPOSE: To compare the clinical outcomes and survival at long-term between hybrid and cemented primary total knee arthroplasty (TKA). A better clinical outcome and survival following a follow-up as long as 15 years with the use of hybrid fixation as compared with cemented fixation was hypothesized. METHODS: Case-control study of 126 patients with a mean age of 62.4 years who underwent hybrid TKA matched with 126 patients underwent cemented TKA. Clinical outcome was assessed by the Knee Society scores (KSS) and reduced Western Ontario and MacMaster Universities questionnaire (WOMAC). Radiological assessment was made by the Knee Society method. RESULTS: The mean follow-up was 15.7 (range 15-17) years. At the final follow-up, clinical scores were significantly better in the hybrid group, although the differences were not clinically relevant. Revisions for all reasons were performed in five knees in the hybrid group and 15 knees in the cemented group (p = 0.033). In the hybrid group, there was one aseptic femoral loosening and no aseptic tibial loosening. In the cemented group, the main reasons for aseptic revisions were polyethylene wear (six knees) and tibial loosening (four knees). Cemented fixation was a significant risk factor for aseptic revision (hazard ratio 2.3; 95% CI 1.3-3.7%; p = 0.004). Survival at 15 years for aseptic reasons was 96.5% (95% CI 93.4-98.7%) in hybrid groups and 90.3% (95% CI 88.7-93.9%) in cemented group (p = 0.020). CONCLUSION: After a minimum follow-up of 15 years, hybrid fixation of primary TKA for osteoarthritis provide significantly higher clinical benefits compared with cemented fixation, but the differences were not clinically relevant. Hybrid fixation provides longer overall survival, although the femoral component survival was similar between groups. LEVEL OF EVIDENCE: III.

Successful mid- to long-term outcome after reconstruction of the extensor apparatus using proximal tibia-patellar tendon composite allograft.

PURPOSE: The purpose of the study was to assess the outcomes of extensor mechanism reconstruction with proximal tibia-patellar tendon composite allograft. METHODS: 24 consecutive patients treated with allograft-prosthetic composite for proximal tibia tumour resection and a conventional total knee arthroplasty were included. Extensor mechanism reconstruction was performed with a proximal tibia-patellar tendon composite allograft and the suture of the donor tendon to the remnant native patellar tendon. Function was evaluated by the Musculoskeletal Tumor Society score (MSTS) and range of motion. Western Ontario and MacMaster University (WOMAC) and visual analogue scale for pain also were used. RESULTS: After a mean follow-up of 11.7 (range 3-15) years, mean MSTS score was 22.4 (range 20-30), mean flexion was 94.0° (range 84°-110°), and mean extension lag was 7.2° (range 0°-18°). The mean VAS-pain was 4.3 (range 2-6), and WOMAC score was 72.4 (range 58-100). There was no failure of the reconstructed extensor mechanism. CONCLUSION: Patellar tendon reconstruction with allogeneic tissue from the proximal tibia allograft sutured to the recipient's remnant patellar tendon provides the mechanical support needed for healing of the reconstructed extensor mechanism with a substantial functional benefit to stabilize active knee extension and successful reconstruction survival at long-term. LEVEL OF EVIDENCE: III.

First Metatarsophalangeal Arthrodesis After Failed Distal Chevron Osteotomy for Hallux Valgus.

BACKGROUND: The purpose of this study was to compare the clinical outcomes after first metatarsophalangeal (MTP) joint arthrodesis for hallux rigidus between patients who underwent primary arthrodesis and those who had had a prior surgery for hallux valgus. METHODS: Our design was a retrospective cohort study comparing 29 patients who underwent primary arthrodesis (primary group) and 34 patients with hallux rigidus after hallux valgus surgery (secondary group). The clinical assessment included the American Orthopaedic Foot & Ankle Society (AOFAS) score and a visual analog scale (VAS) for pain. Radiological evaluation was also performed. Overall, the mean postoperative follow-up was 3.4 (range, 2-5) years. RESULTS: At final follow-up, AOFAS and VAS pain scores significantly improved in both groups (P = .001). However, the mean AOFAS (P = .001) and VAS pain (P = .008) scores were significantly better in the primary group than in the secondary group. Radiologically, there were no significant differences between the groups in any angle after arthrodesis. Revision surgeries were not required in the primary group. In the secondary group, there was 1 revision due to deep infection, and 3 other patients required dorsal plate removal. Excluding plate removal, the Kaplan-Meier survival at 3 years was not significantly different between groups (P = .775). CONCLUSION: Although arthrodesis of the first MTP joint was an effective procedure for hallux rigidus, the clinical outcomes in patients who had prior hallux valgus surgery were worse than those for patients who underwent primary surgery for hallux rigidus. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Prospective comparison of functional outcomes of primary reverse shoulder arthroplasty for acute fractures versus rotator cuff deficiencies.

AIMS: The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years. METHODS: This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed. RESULTS: Mean follow-up was 8.4 years (5 to 11). There were no significant differences in mean absolute (p = 0.125) or adjusted (p = 0.569) Constant, UCLA (p = 0.088), QuickDASH (p = 0.135), VAS-pain (p = 0.062), or range of movement at the final follow-up. However, patient satisfaction was significantly lower in the fracture group (p = 0.002). The complication rate was 1.5% (one patient) versus 9.3% (six patients), and the revision rate was 1.5% (one patient) versus 7.8% (five patients) in the fracture and arthropathy groups, respectively. The ten-year arthroplasty survival was not significantly different (p = 0.221). CONCLUSION: RSA may be used not only for patients with irreparable rotator cuff deficiencies, but also for those with acute complex proximal humeral fractures. We found that RSA provided similar functional outcomes and a low revision rate for both indications at long-term. However, satisfaction is lower in patients with an acute fracture. Cite this article: Bone Joint J 2020;102-B(11):1555-1559.