Should We Use Bipolar Hemiarthroplasty in Patients ≥70 Years Old With a Femoral Neck Fracture? A Review of Literature and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Bipolar (BHA) and unipolar hemiarthroplasties (UHA) are interchangeably used in elderly patients with a displaced femoral neck fracture. We ask if there is a difference between BHA and UHA with regards to hip function, in elderly patients. METHODS: Systematic review and meta-analysis was conducted of randomized controlled trials comparing BHA to UHA. The primary outcome was postoperative hip function scores. Secondary outcomes were overall health-related quality of life patient-reported outcomes, acetabular erosion, and postoperative complications. Data sources, last searched on June 1, 2020, were MEDLINE, EMBASE, Cochrane Library, and Web of Science. RESULTS: Fourteen randomized controlled trials were eligible for meta-analysis. There was no difference in hip function scores between BHA and UHA (standardized mean difference 0.32, 95% confidence interval [CI] -0.06 to 0.71, n = 1084, I2 = 87%). Patients with BHA with more than 2-year follow-up had better hip function scores (standardized mean difference 0.68, 95% CI 0.18-1.18, n = 700, I2 = 87%). There was no difference in European Quality of life- five dimensions scores with BHA (mean difference 0.08, 95% CI -0.01 to 0.17, n = 967, I2 = 82%). The use of BHA decreased the risk of acetabular erosion (relative risk 0.38, 95% CI 0.17-0.83, n = 1239, I2 = 0%). There was no difference for revision, mortality, infection, and dislocation (I2 = 0%). CONCLUSION: There seems to be no difference between BHA and UHA with regards to hip function at 2 years. BHA might decrease the risk of acetabular erosion. There is a need for a large randomized controlled trial with a follow-up >2 years and better measurement tools to assess clinical benefits. LEVEL OF EVIDENCE: II.

Anatomical variants of the rectus femoris motor innervation.

Adult periacetabular osteotomy (PAO) was originally performed through the classic Smith-Petersen approach for optimal operative visibility and acetabular fragment correction. Evolution towards an abductor-sparing technique significantly lowered the post-operative morbidity. The rectus-sparing approach represents a step further, but the innervation of the rectus femoris is theoretically more at risk. Although the topographic anatomy of the femoral nerve has been well described, it was never studied with specificity to surgical landmarks. The femoral nerve's spatial relation with the anterior-inferior iliac spine (AIIS) and the amount of possible dissection in the rectus femoris and iliopsoas interval is uncertain. Seven formalin-preserved human cadaveric specimens without history of inguinal injury or surgery were dissected using the distal limb of an iliofemoral approach. The level of entry of motor innervation was measured and number of branches to the rectus femoris was noted. The average longitudinal distance from the AIIS to the first motor nerve to the rectus femoris was 8.6 ± 1.4 cm. The number of branches varied between 1 and 4 with the most common innervation pattern being composed of two segments. Dissection medial to the rectus femoris should not be carried out further than 7 cm distal to the AIIS and stretching of that interval during surgical exposure should be done cautiously. The clinical efficiency of the rectus-sparing approach should be studied further in order to confirm its advantage over the classic direct anterior approach. The study provides a better understanding of the localization and the anatomical variations of the structures encountered at the level of and below the AIIS. It also assesses the relative risk of denervation of the rectus femoris during PAO through the rectus-sparing approach. The authors recommend that the dissection medial to the rectus femoris should be carried out no further than 7 cm distal to the AIIS and stretching of that interval during surgical exposure should be done cautiously.

Total knee arthroplasty with distal femoral replacement is associated with an important complication rate. A case series.

BACKGROUND: With the aging population and an increasing number of total knee arthroplasties (TKAs) performed yearly worldwide, revision surgeries for many causes (septic or aseptic loosening, periprosthetic femoral fractures (PDFF), non-unions, malunions) are more frequent and challenging. Distal femoral replacement (DFR) is sometimes the only option to restore knee function and quality of life. DFR in non-oncologic patient is still a rare indication and few reports are published on this topic, with a non-consistent variety of functional results, complication rates and survivorship. METHODS: We present a retrospective series of patients who underwent a DFR for a non-oncologic indication between 2010 and 2017. Nineteen patients were available for a full evaluation (clinical and radiological) with a mean follow-up of 48.3 months (range 15-99). Goniometry was performed at the six-week postoperative visit. Complications were reported. Osteolysis and/or signs of aseptic loosening were described using the Knee Society Radiographic Evaluation. Survivorship was calculated for aseptic loosening, infection, and revision for any cause. RESULTS: The mean Knee Society Score was good for the pain score (42.2, range 10-50) and fair for the function score (60.6, range 0-100). Four deep infections (21.1%) were successfully treated with mobile parts exchange and debridement. Three patients presented femoral osteolysis ≥5 years after the DFR. Survivorship for aseptic loosening was 100% at four years, 81.8% after five years and 53.3% after eight years. CONCLUSIONS: TKA with DFR is a valuable option for patients with a severe bone loss and poor bone quality in the distal femur. DFR restores an acceptable quality of life but is related to an important complication rate.

Risk Factors for Removal of Calcaneus Screws: A Retrospective Study.

Although techniques using calcaneus screws have shown high union rates, posterior heel pain due to prominent hardware at the posterior and plantar aspect of the calcaneal tuberosity seems to be a significant complaint that often leads to hardware removal. The purpose of the present study was to identify the clinical and radiologic risk factors associated with calcaneus screw removal. A retrospective study of adult patients who required calcaneus screw fixation from January 2008 to December 2016 was conducted. We reviewed the medical records and radiographs to evaluate the risk factors for screw removal. Of the 123 patients included in the present study, 63 were male and 60 were female. The mean age was 55.0 ± 6.0 years, and the mean body mass index was 31.0 ± 6.0 kg/m2. The removal rate was 8.8% (10 of 114 evaluated) at the 1-year follow-up point and 13.6% (12 of 88 evaluated) at the 2-year follow-up point. The mean interval to removal was 1.23 ± 1.22 years. A total of 16 screws (72.7%) were removed for heel pain. At the 1-year follow-up examination, the removal rate due to inflammatory arthritis was 25.0% (p = .07). Moreover, the proportion of screw removal was greater at 2 years in illicit drug users (p = .008). Screw sizes ≤6.5 mm showed a tendency (p = .12) toward a lower rate of removal at the 2-year follow-up point. Calcaneus screws should be used with caution in specific patient populations such as illicit drug users and those with inflammatory arthritis. The use of smaller diameter calcaneus screws might be an option to lower the rate of screw removal due to heel pain.

Up to seven years' follow-up of short cemented stems in complex primary total knee arthroplasty: A prospective study.

BACKGROUND: Although primary total knee arthroplasty (TKA) shows good clinical, functional and radiological results, it can be complicated by certain conditions or pathologies. The main objective of this study was to evaluate the global performance of short cemented metaphyseal stem components in patients undergoing complex primary TKA. METHODS: This is a single-surgeon prospective case series of 91 patients who underwent complex primary TKA requiring short stem fixation between January 2009 and October 2014. Knee Society Scores, physical examinations, and radiological assessments were performed pre- and postoperatively at six weeks, three months, six months, 12months, and annually thereafter. RESULTS: There were 40 females (46 TKAs) and 40 males (45 TKAs) in the study cohort. The left knee accounted for 52.7% of the surgeries. The average body-mass index (BMI) was 31.8kg/m2. Knee Society Scores obtained at the latest follow-up showed 96.4% and 95.5% good-to-excellent results respectively for the Knee and Function sub-scores. Radiological assessment showed that all Knee Society roentgenographic scores were below 10, without any evidence of impending or possible failure. Only one revision was required in this cohort for a patient suffering a deep chronic infection. At seven years, the Kaplan-Meier survivorship analysis revealed a 100% survivorship for aseptic loosening and a 98.9% survivorship for infection and revision of the components for any reason. CONCLUSION: This study demonstrated that TKA with short cemented stems resulted in good functional, clinical, and radiological outcomes for up to seven years for patients requiring complex TKA.

Traffic in the operating room during joint replacement is a multidisciplinary problem.

BACKGROUND: Door openings disrupt the laminar air flow and increase the bacterial count in the operating room (OR). We aimed to define the incidence of door openings in the OR during primary total joint arthroplasty (TJA) surgeries and determine whether measures were needed and/or possible to reduce OR staff traffic. METHODS: We recorded the number of door openings during 100 primary elective TJA surgeries; the OR personnel were unaware of the observer's intention. Operating time was divided into the preincision period, defined as the time from the opening of surgical trays to skin incision, and the postincision period, defined as time from incision to dressing application. RESULTS: The mean number of door openings during primary TJA was 71.1 (range 35-176) with a mean operative time of 111.9 (range 53-220) minutes, for an average of 0.64 (range 0.36-1.05) door openings/min. Nursing staff were responsible for 52.2% of total door openings, followed by anesthesia staff at 23.9% and orthopedic staff at 12.7%. In the preincision period, we observed an average of 0.84 door openings/ min, with nursing and orthopedic personnel responsible for most of the door openings. The postincision period yielded an average of 0.54 door openings/min, with nursing and anesthesia personnel being responsible for most of the door openings. CONCLUSION: There is a high incidence of door openings during TJA. Because we observed a range in the number of door openings per surgery, we believe it is possible to reduce this number during TJA.

CONTEXTE: Les ouvertures de porte perturbent le flux laminaire et accroissent la numération bactérienne au bloc opératoire. Nous avons voulu mesurer l'incidence des ouvertures de porte au bloc opératoire durant les chirurgies pour prothèse articulaire totale (PAT) et déterminer si des correctifs étaient requis ou s'il était possible de réduire la circulation du personnel au bloc opératoire. MÉTHODES: Nous avons dénombré les ouvertures de porte durant 100 chirurgies électives primaires pour PAT; le personnel du bloc opératoire n'était pas au courant de l'intention de l'observateur. Le temps opératoire a été subdivisé en une période pré-incision, définie par l'intervalle entre l'ouverture des plateaux chirurgicaux et l'incision chirurgicale, et une période post-incision, définie par l'intervalle entre l'incision et l'application du pansement. RÉSULTATS: Le nombre moyen d'ouvertures de porte par intervention pour PAT primaire a été de 71,1 (entre 35 et 176) et la durée moyenne des interventions a été de 111,9 (entre 53 et 220) minutes, pour une moyenne de 0,65 (entre 0,36 et 1,05) ouverture/ minute. Le personnel infirmier était responsable de 52,2 % du nombre total d'ouvertures de porte, suivi du personnel d'anesthésie avec 23,9 % et du personnel d'orthopédie avec 12,7 %. Durant la période pré-incision, nous avons observé une moyenne de 0,84 ouverture de porte/minute, le personnel infirmier et d'orthopédie ayant été responsable de la majorité des ouvertures de porte. La période post-incision a donné lieu à une moyenne de 0,54 ouverture de porte/minute, le personnel infirmier et d'anesthésie ayant été responsable de la majorité des ouvertures de porte. CONCLUSION: On observe un nombre important d'ouvertures de porte durant les interventions pour PAT. Étant donné que ce nombre varie, nous croyons qu'il est possible de le réduire.