Is the Direct Fixation of Displaced Quadrilateral Plates in Acetabular Fractures Necessary?

Quadrilateral plate fractures represent a heterogeneous group of acetabular fractures. Accurate reduction is required to prevent post-traumatic arthritis. The purpose of this study is to determine the reduction effect of the direct fixation of quadrilateral plates in acetabular fractures, and to evaluate the strength of direct fixation compared to indirect fixation. Between 2005 and 2021, 49 patients underwent surgery for open reduction and internal fixation in acetabular fractures with severely displaced quadrilateral plates. Twenty-nine patients comprised the indirect fixation group, and twenty patients comprised the direct fixation group. In a comparison of primary outcome between two groups, 10 out of 29 indirect-group patients and 1 out of 20 direct-group patients developed post-traumatic osteoarthritis, wherein the difference between the two groups is statistically significant. In the assessment of postoperative Matta's radiological reduction status, 19 out of 20 patients in the direct group had achieved anatomical and congruent reduction. The treatment using a direct reduction and internal fixation improved the reduction quality of articular displacement and offered a better survivorship of the affected hip joint.

Clinical Efficacy and Safety of the Intra-articular Injection of Autologous Adipose-Derived Mesenchymal Stem Cells for Knee Osteoarthritis: A Phase III, Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Intra-articular injection of autologous culture-expanded adipose-derived mesenchymal stem cells (ADMSCs) has introduced a promising treatment option for knee osteoarthritis. Although the clinical efficacy and safety of ADMSCs have been reported, the treatment remains controversial owing to the small sample sizes and heterogeneous osteoarthritis grades in previous studies. PURPOSE: To assess the efficacy and safety of intra-articular injection of ADMSCs as compared with placebo in alleviating pain and improving functional capacity in a large sample of patients with knee osteoarthritis of Kellgren-Lawrence (K-L) grade 3. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This phase III multicenter clinical trial was a double-blind randomized controlled study that included 261 patients with K-L grade 3 symptomatic knee osteoarthritis who were administered a single injection of autologous culture-expanded ADMSCs or placebo. Clinical data were assessed at baseline and at 3 and 6 months after the injection. The primary endpoints were improvements in 100-mm visual analog scale (VAS) for pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for function at 6 months after the injection. The secondary endpoints included clinical and radiologic examinations and safety after injection. The changes in cartilage defects after injection were assessed by magnetic resonance imaging at 6 months. RESULTS: The ADMSC and control groups included 125 and 127 patients available for follow-up, respectively. At 6 months, the ADMSC group showed significantly better improvements in 100-mm VAS (ADMSC vs control, 25.2 vs 15.5; P = .004) and total WOMAC score (21.7 vs 14.3; P = .002) as compared with the control group. The linear mixed model analysis indicated significantly better improvements in all clinical outcomes in the ADMSC group after 6 months. At 6 months, the ADMSC group achieved significantly higher proportions of patients above the minimal clinically important difference in 100-mm VAS and WOMAC score. Radiologic outcomes and adverse events did not demonstrate significant differences between the groups. No serious treatment-related adverse events were observed. Magnetic resonance imaging revealed no significant difference in change of cartilage defects between the groups at 6 months. CONCLUSION: Intra-articular injection of autologous culture-expanded ADMSCs provided significant pain relief and functional improvements in patients with K-L grade 3 osteoarthritis. Long-term results are needed to determine the disease-modifying effects of ADMSCs, such as structural changes, and the duration of effect of intra-articular injection of ADMSCs in knee osteoarthritis. REGISTRATION: NCT03990805 (ClinicalTrials.gov identifier).

Posterior Medial Meniscus Root Repair Using Two Transtibial Tunnels with Modified Mason-Allen Stitches: A Technical Note.

Complete tear of the posterior medial meniscus root can result in a loss of hoop tension and increased contact pressure. Thus, medial meniscus posterior root tear (MMPRT) is increasingly recognized as an important pathology. Although several surgical techniques for MMPRT have recently been introduced, the ideal technique is not yet established. This technical note is aimed at introducing a novel surgical technique using two transtibial tunnels with modified Mason-Allen stitches in the treatment of MMPRT.

Correlation of Y Balance with Clinical Scores and Functional Tests after Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients.

Background: Criteria for return to sports (RTS) following anterior cruciate ligament (ACL) reconstruction have been extensively studied. But there is no consensus among investigators regarding which factors are most important in determining a safe RTS. Methods: Sixty-one patients who underwent ACL reconstruction were included. Subjective knee scoring systems (International Knee Documentation Committee [IKDC] score and Lysholm score), functional performance tests (carioca test and single-leg hop for distance [SLHD] test), and isokinetic knee strength test were used for assessment and analyzed for association with the limb symmetry index (LSI) of the Y-balance test for lower quarter (YBT-LQ). Results: The LSI of the YBT-LQ was significantly correlated with Lysholm score, IKDC score, Carioca, LSI for the SLHD, and extensor strength deficit at 6 months after ACL reconstruction. At 12 months, Lysholm score, IKDC score, LSI for the SLHD, and extensor strength deficit were significantly correlated with the LSI of the YBT-LQ. Conclusions: The YBT-LQ test could be used conveniently as an additional tool to assess the patient's functional performance results after ACL reconstruction in outpatient clinics.

Comparison of Lower-Limb Alignment in Patients with Advanced Knee Osteoarthritis: EOS Biplanar Stereoradiography versus Conventional Scanography.

Background: Accurate measurement of the lower limb alignment is one of the most crucial factors in advanced knee osteoarthritis patients scheduled for surgery. Recently, EOS biplanar stereoradiography with three-dimensional reconstruction was developed. The purpose of this study was to compare radiographic parameters between conventional scanography and EOS in patients with advanced knee osteoarthritis who need surgical treatment. Methods: A total of 52 consecutive patients (104 knees) with bilateral knee osteoarthritis of advanced stage (Kellgren-Lawrence [KL] grade 3 or 4) were retrospectively reviewed. We measured the hip-knee-ankle angle (HKA) on conventional scanograms. In EOS, we measured HKA, hip-knee-shaft angle, mechanical lateral distal femoral angle, and mechanical medial proximal tibial angle. To evaluate sagittal and axial plane alignment, knee flexion angle (KFA), and knee joint rotation (KJR) were also measured. Results: Ninety knees were KL grade 4, and 14 knees were grade 3. The average HKA was 10.14° ± 6.16° on conventional scanograms and 11.26° ± 6.21° in EOS. HKA was greater in EOS than on conventional scanograms, and the difference (1.12°; range, -1.07° to 3.22°) was statistically significant (p < 0.001). Significant correlations were observed on the difference in HKA and mechanical medial proximal tibial angle (r = -0.198, p = 0.044), KFA (r = 0.193, p = 0.049), and KJR (r = 0.290, p = 0.003). In multivariable linear regression analysis, the difference in HKA had significant relationship with KFA (ß = 0.286, p = 0.003) and KJR (ß = 0.363, p < 0.001). Conclusions: HKA measured on conventional scanograms and in EOS differed significantly and the difference had a significant correlations with KFA, KJR, and medial proximal tibial angle. Surgeons can consider these results before orthopedic surgery in patients who have advanced knee osteoarthritis.

Screw augmented cement spacer for deficient acetabulum in periprosthetic infection following Total Hip Arthroplasty.

For periprosthetic joint infection (PJI) treatment, revision total hip arthroplasty using an antibiotic loaded cement spacer is one of the important surgical methods. However, revision total hip arthroplasty using antibiotic-loaded cement spacers poses a risk of spacer dislodgement in patients with acetabular deficiency. We hypothesized that screw augmentation would be more stable and result in lower rates of cement spacer dislodgement in acetabular deficient patients. Thus, we suggest a method of screw augmentation with cement spacers to treat periprosthetic infection in patients with a deficient acetabulum. And we aim to report better clinical outcomes after revision total hip arthroplasty for infection control using screw augmented cement spacer insertion technique. Level of evidence: IV.

Intra-Articular Injection of a Novel DVS Cross-Linked Hyaluronic Acid Manufactured by Biological Fermentation (YYD302) in Patients With Knee Osteoarthritis: A Double-Blind, Randomized, Multicenter, Noninferiority Study.

PURPOSE: This double-blind, randomized, Phase III clinical trial was conducted to assess the efficacy and safety of the novel divinyl sulfone cross-linked hyaluronate (YYD302) compared with the 1,4-butanediol diglycidyl ether cross-linked hyaluronate (Synovian) in patients with knee osteoarthritis. METHODS: A total of 184 patients with osteoarthritis (Kellgren-Lawrence grade I-III) were randomized to 1 of 2 study groups (YYD302 group, n = 95; Synovian group, n = 89). A single injection of YYD302 or Synovian was given to both groups, and 182 participants completed the study (YYD302 group, n = 95; Synovian group, n = 87). The primary end point was the change in weight-bearing pain (WBP) at 12 weeks after the primary single injection. Secondary end points included the Knee Injury and Osteoarthritis Outcome Score; the Western Ontario and McMaster Universities Osteoarthritis Index score; the Patient Global Assessment and Investigator Global Assessment; the range of motion, swelling, and tenderness of the target knee; OMERACT-OARSI responder rate; WBP responder rate (the proportion of patients achieving at least 20 mm or 40% decrease in WBP); and rate of rescue medicine use and its total consumption at weeks 2, 4, and 12. Based on the efficacy results at week 12, the responders were administered an additional single injection of the same study drug at week 24, and safety and efficacy were additionally assessed at week 36. FINDINGS: Mean changes of WBP at 12 weeks after the primary injection were -31.76 mm with YYD302 and -29.74 mm with Synovian, proving noninferiority of the YYD302 group to the Synovian group as the lower bound of the 95% CI (-4.3 to 8.3) was well above the predefined margin (-10 mm). At week 2, the Knee Injury and Osteoarthritis Outcome Score (total, pain, activities of daily living, and sports/recreation) and Western Ontario and McMaster Universities Osteoarthritis Index scores (total, stiffness) were significantly better in the YYD302 group than in the Synovian group. There were no significant differences between the groups in all other end points. Local overall adverse events (pain, heat, erythema, or swelling) at the injection site were observed in 48.4% of the YYD302 group and in 47.7% of the Synovian group. No serious reactions were reported. There was no statistically significant difference between the 2 groups regarding re-injected patients (YYD302 group, n = 54; Synovian group, n = 46) in any of the efficacy outcomes at week 36. IMPLICATIONS: The results of this study support that YYD302 is comparable to Synovian in terms of the efficacy and safety of the intra-articular injection treatment for osteoarthritis of the knee joint. Furthermore, YYD302 provided faster improvements in some efficacy assessments compared with Synovian. ClinicalTrials.gov identifier: NCT03561779.

Biomaterials Used for Suture Anchors in Orthopedic Surgery.

Suture anchors are broadly used for attaching soft tissue (e.g., tendons, ligaments, and meniscus) to the bone and have become essential devices in sports medicine and during arthroscopic surgery. As the usage of suture anchors has increased, various material-specific advantages and challenges have been reported. As a result, suture anchors are continually changing to become safer and more efficient. In this ever-changing environment, it is clinically essential for the surgeon to understand the key characteristics of existing anchors sufficiently. This paper aims to summarize the current concepts on the characteristics of available suture anchors.

A prospective double-blind randomized trial on ultrasound-guided versus blind intra-articular corticosteroid injections for primary frozen shoulder.

AIMS: Ultrasound (US)-guided injections are widely used in patients with conditions of the shoulder in order to improve their accuracy. However, the clinical efficacy of US-guided injections compared with blind injections remains controversial. The aim of this study was to compare the accuracy and efficacy of US-guided compared with blind corticosteroid injections into the glenohumeral joint in patients with primary frozen shoulder (FS). METHODS: Intra-articular corticosteroid injections were administered to 90 patients primary FS, who were randomly assigned to either an US-guided (n = 45) or a blind technique (n = 45), by a shoulder specialist. Immediately after injection, fluoroscopic images were obtained to assess the accuracy of the injection. The outcome was assessed using a visual analogue scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the subjective shoulder value (SSV) and range of movement (ROM) for all patients at the time of presentation and at three, six, and 12 weeks after injection. RESULTS: The accuracy of injection in the US and blind groups was 100% (45/45) and 71.1% (32/45), respectively; this difference was significant (p < 0.001). Both groups had significant improvements in VAS pain score, ASES score, SSV, forward flexion, abduction, external rotation, and internal rotation throughout follow-up until 12 weeks after injection (all p < 0.001). There were no significant differences between the VAS pain scores, the ASES score, the SSV and all ROMs between the two groups at the time points assessed (all p > 0.05). No injection-related adverse effects were noted in either group. CONCLUSION: We found no significant differences in pain and functional outcomes between the two groups, although an US-guided injection was associated with greater accuracy. Considering that it is both costly and time-consuming, an US-guided intra-articular injection of corticosteroid seems not always to be necessary in the treatment of FS as it gives similar outcomes as a blind injection. Cite this article: Bone Joint J 2021;103-B(2):353-359.

Progression of Asymptomatic Contralateral Femur in Patients with Complete Atypical Femoral Fracture, According to Initial Radiographic Findings.

BACKGROUND: Atypical femoral fracture (AFF) is associated with high prevalence rates of prodromal symptoms, bilateral involvement, complications, and the need for prophylactic fixation due to a risk of an impending fracture. Although most complete AFF cases have an asymptomatic contralateral femur at the initial presentation, there is lack of clarity on its progression. We evaluated the radiographic progression of asymptomatic contralateral femora in patients with a complete AFF and investigated the characteristics of these patients. METHODS: The medical records of 80 consecutive patients who had been treated for a complete AFF were retrospectively evaluated. We excluded 14 patients who had been lost to follow-up, 10 whose contralateral femur initially had been symptomatic and had been treated simultaneously, and 3 whose contralateral femur had previously been treated surgically. The remaining 53 patients were all women with an average age of 71.8 years. The average duration of bisphosphonate (BP) use was 63.6 months, and the mean follow-up duration was 48.9 months. All of the contralateral femora were asymptomatic and were divided into 2 grades according to the initial radiographic findings. We evaluated the prevalence of radiographic progression according to the grades and compared patient characteristics between the progression and non-progression groups. RESULTS: Radiographic progression was noted in 18 patients (34%) during the follow-up: 3 (12%) of 25 in grade 1 and 15 (53.6%) of 28 in grade 2 (p < 0.001). The mean time to progression for these 18 patients was 25.6 months, which also differed significantly depending on the grade (p = 0.02). Eleven and 9 (61.1% and 25.7%) of the patients received BP postoperatively in the progression and non-progression groups, respectively (p = 0.01). CONCLUSIONS: The prevalence of radiographic progression was relatively high, even though the contralateral femur was initially asymptomatic, and differed significantly according to the initial radiographic grade. The frequency of postoperative BP use was significantly higher in the progression group. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients who have undergone rotator cuff repair experience around 75% functional recovery at 6 months after surgery.

PURPOSE: The purposes of this study were to (1) evaluate changes in recovery patterns [i.e., clinical outcomes, range of motion (ROM)] in the first 12 months following surgery, (2) identify potential prognostic factors of early clinical outcomes after rotator cuff repair (RCR). METHODS: The study cohort included 344 consecutive patients treated with RCR. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariate linear regression analyses for various parameters including demographics, pre- and perioperative variables were used to predict shoulder function at 12-month follow-up, as measured by clinical outcomes and ROM. RESULTS: Significant improvement in all clinical scores and ROM were noted during serial follow-ups after RCR (all p < 0.001). Multivariate analysis revealed that female sex, older age, more anchors, diabetes mellitus, and preoperative stiffness were independently associated with worse shoulder function 3 months after RCR. Including the 3 months factors, heavy labor, use of the suture-bridge technique, and large tears were also independently associated with worse outcomes 6 months after surgery. Heavy labor, suture-bridge technique, diabetes mellitus, and preoperative stiffness were associated with significantly worse functional outcomes at 12 months after surgery (all p < 0.05). CONCLUSION: Functional recovery based on clinical outcomes (i.e., UCLA, ASES scores) showed approximately 60% of ultimate recovery at 3 months and approximately 75% recovery at 6 months after RCR. Female sex, diabetes mellitus, preoperative stiffness, a larger number of anchors, suture bridge technique, heavy labor, old age and, larger tears were prognostic factors of poor clinical results or ROM in the short-term follow-up intervals. Knowledge of these prognostic factors may lead to improved insight for physicians to predict the pattern of the recovery and patient expectations accordingly. LEVEL OF EVIDENCE: III, A cohort study.

Chronicity is associated with the glenohumeral synovitis in patients with a rotator cuff tear.

Synovitis of the glenohumeral joint (GHJ) and subacromial space (SAS) is one of the most common findings during arthroscopic rotator cuff repair (RCR). The purpose of this study is to determine clinical factors associated with the degree of synovitis in patients with a rotator cuff tear and whether macroscopic synovitis affects early clinical outcomes following arthroscopic RCR. Arthroscopic videos of 230 patients treated with arthroscopic RCR were randomly reviewed by two experienced shoulder surgeons. The synovitis scores of the GHJ using Davis's grading system and the SAS using Jo's grading system were rated with a consensus. Univariate and multivariate analyses were used to identify the associations between the synovitis scores and various parameters, including demographics, preoperative, and postoperative clinical outcomes. Univariate analyses revealed that age, side, body mass index, duration of symptoms, preoperative stiffness, diabetes, muscle atrophy, fatty infiltration, tear size, preoperative clinical scores, and preoperative range of motion were significantly associated with the GHJ synovitis score (all p < 0.05). Multivariate analyses revealed that the duration of symptoms, tear size, and diabetes was significantly associated with the GHJ synovitis score (p = 0.048, p = 0.025, p = 0.011, respectively). Longer duration of symptoms, larger tear size, and the presence of diabetes was independently associated with increased GHJ synovitis in patients with a rotator cuff tear. These results suggest that GHJ synovitis might be more involved in the pathogenesis for pain and tear progression of rotator cuff disease compared with SAS synovitis.

Highly Cross-Linked Polyethylene in Cementless Total Hip Arthroplasty in Patients with Previous Acetabular Fractures: A Minimum 5-Year Follow-Up Study.

BACKGROUND: Outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic arthritis due to a higher rate of cup loosening and osteolysis. We, therefore, investigated whether highly cross-linked polyethylene liners positively impact outcomes of THA in patients with posttraumatic osteoarthritis after acetabular fracture. METHODS: We retrospectively evaluated 39 patients with previous acetabular fracture who underwent THA using highly cross-linked polyethylene liner after a mean 8.5 year follow-up. All procedures were performed at a single institution by a single surgeon using the same type of THA implants. Wear measurements were performed using a computer-assisted PolyWare software. Osteolysis was evaluated with use of radiography and computed tomography. RESULTS: The mean preoperative Harris hip score was 44.4 points, which improved to 93.1 points at final follow-up. Neither femoral nor acetabular components displayed mechanical loosening and no components had been revised. Radiographs and CT scans did not demonstrate osteolysis. The mean linear wear was 0.043 mm/y (range 0-0.098 mm/y). With the data available, univariate regression analysis suggests that age, gender, weight, initial fracture type, the duration of follow-up, activity level, liner thickness, acetabular cup inclination, and the necessity of bone graft had no influence on liner penetration. CONCLUSION: While the long-term effects of the polyethylene particles from highly cross-linked polyethylene remain unknown, implant survivorship and wear data in this study are promising for this high-risk population. Our encouraging results support the continued use of this type of polyethylene in patients after acetabular fractures. LEVEL OF EVIDENCE: Level IV Therapeutic study.

Protection of Surgical Team from COVID-19 during Bipolar Hemiarthroplasty in an Infected Elderly Patient.

The novel coronavirus disease 2019 (COVID-19), which began in Wuhan, China, has rapidly flared up all over the world, evolving into a pandemic. During these critical times, we should give emphasis on infection prevention for the health care staff as well as appropriate patient management in order to maintain the health care system. We report our experience in protecting a surgical team from COVID-19 infection during a bipolar hemiarthroplasty in an infected patient. This case highlights the importance of appropriate protection of the health care staff and education in minimizing the risk of transmission of the infection and maintaining the health care system.

Risk factors of uncontrolled periprosthetic knee joint infection after two-stage reimplantation.

BACKGROUND: Periprosthetic infection after total knee arthroplasty is a challenging problem, and physicians should identify risk factors to decrease recurrence. However, risk factors for reinfection with two-stage reimplantation have not yet been well established. The purpose of this study was to assess treatment outcomes of subsequent two-stage knee reimplantation and identify risk factors for uncontrolled periprosthetic knee joint infections. METHODS: We retrospectively reviewed 70 knees diagnosed with a periprosthetic knee joint infection treated with two-stage reimplantation between September 2011 and October 2016 at our institution. Patients in the controlled infection group (group C) required no further medication or surgical treatment within 2 years after reimplantation. Patients in the uncontrolled infection group (group U) displayed symptoms of active infection after resection arthroplasty or were reinfected after two-stage reimplantation. We compared group C and group U, and analyzed potential risk factors for uncontrolled prosthetic joint infection (PJI). RESULTS: Of 70 knees included in this analysis, 53 (75.7%) were clinically deemed free from infection at the latest follow-up. The remaining 17 knees (24.3%) required additional surgical procedures after two-stage reimplantation. Demographics were not statistically significantly different between the two groups. Wound complications were statistically more frequent in group U (p = 0.030). Pre-reimplantation C-reactive protein (CRP) was statistically different between groups C and U (0.44 and 1.70, respectively, p = 0.025). Among the cultured microorganisms, fungus species were statistically more frequently detected in group U compared with group C (p = 0.031). CONCLUSIONS: The reinfection rate of our two-stage reimplantation protocol was 24.3% in the included cases. Wound complications, higher pre-reimplantation CRP levels, and fungus species were statistically more common in group U compared with group C. Our findings will help in counseling patients and physicians to understand that additional caution may be required when treating PJI if the aforementioned risk factors are present. LEVEL OF EVIDENCE: IV, case series.

Recovery pattern after arthroscopic treatment for calcific tendinitis of the shoulder.

INTRODUCTION: The purpose of this study was to investigate serial outcomes in the early postoperative period in patients who have undergone arthroscopic treatment for calcific tendinitis of the shoulder and to determine prognostic factors affecting outcomes. HYPOTHESIS: Our hypothesis was that functional recovery will take more than three months but additional procedures such as rotator cuff repair and subacromial decompression will have a slower recovery and poorer outcomes. MATERIAL AND METHODS: We retrospectively reviewed 35 patients with a mean follow-up of 50.6 months. Arthroscopic surgery was performed in all patients. The visual analog scale (VAS) pain score; University of California, Los Angeles (UCLA) score; American Shoulder and Elbow Surgeons (ASES) score were evaluated preoperatively; 3, 6, and 12 months after surgery; and at the final follow-up. To evaluate the extent of calcific deposit removal and recurrence of calcification, we conducted plain radiography at each follow-up. RESULTS: Nine patients had complete removal of all calcium deposits, and 26 had partial removal. At the final follow-up, all patients sustained complete resorption without any recurrence. All clinical scores showed improvement significantly in each follow-up period (p<0.001). However, VAS pain score decreased to less than 3 points at 6 months after surgery, UCLA and ASES scores also increased more than 75 percent at 6 months. Subacromial decompression was negatively correlated with VAS pain score and rotator cuff repair was negatively correlated with UCLA score, respectively (p=0.041 and p=0.028). On multivariate analysis, rotator cuff repair was negatively correlated with the final UCLA score (p=0.009). CONCLUSION: This study revealed that all clinical scores were significantly improved from 3 months after arthroscopic treatment for calcific tendinitis of shoulder. However, clinical scores improved slowly, recovery of shoulder function and pain relief required up to 6 months. Subacromial decompression and rotator cuff repair were poor prognostic factors after arthroscopic treatment. LEVEL OF EVIDENCE: IV, Retrospective Case Series.

Unintended Retention of Temporary Articulating Spacers in the Treatment of Periprosthetic Hip Joint Infection.

A considerable number of patients who underwent a 2-stage exchange protocol for periprosthetic hip joint infection could not complete the second-stage reimplantation. The aim of this study was to evaluate the results of unintended retention of temporary articulating spacers for the treatment of periprosthetic hip joint infection. Ninety-four patients with infection after total hip arthroplasty were treated by using a 2-stage exchange protocol with temporary articulating spacers. Of the 94 patients, 35 did not complete the 2-stage exchange protocol and retained spacers for more than 12 months. The authors retrospectively investigated the clinical and radiographic results after a mean follow-up of 36.1 months. Thirty-one patients had well-healed wounds without recurrent infection and did not receive further surgery for any reason (success group). Spacers were revised in 2 patients, and the other 2 patients underwent incision and debridement because of recurrent infection (failure group). There were no statistical differences between the 2 groups in terms of demographics or presence of resistant organisms. After 3 years of follow-up, temporary articulating spacers functioned well in 89% of the patients who retained them. These results support that retention of temporary articulating spacers could be considered an alternative treatment option for select patients. [Orthopedics. 2020;43(4):e251-e257.].

Is Acromial Fracture after Reverse Total Shoulder Arthroplasty a Negligible Complication?: A Systematic Review.

BACKGROUND: The purpose of this study was to investigate the incidence of acromial fracture after reverse total shoulder arthroplasty (RTSA) and clinical and radiological outcomes of treatment of the fracture. METHODS: A systematic review was performed to identify studies that reported the results of treatment of acromial fractures after RTSA. A literature search was conducted by two investigators using four databases (PubMed, Embase, Cochrane, and Ovid Medline). RESULTS: Fifteen studies (2,857 shoulders) satisfied our inclusion criteria. The incidence of acromial fracture after RTSA was 4.0% (114 / 2,857). The mean age of the patients at the time of fracture was 72.9 years (range, 51 to 91 years). The mean time from RTSA to diagnosis of acromial fracture was 9.4 months (range, 1 to 94 months). One hundred shoulders (87.7%) were treated conservatively and 14 shoulders (12.3%) were treated surgically. The mean follow-up period after acromial fracture was 33.8 months. The overall union rate was 50.0% (43.8% for conservative treatment and 87.5% for operative treatment). The fracture incidence was significantly different among the medial glenoid and medial humerus prosthesis design (8.4%), the lateral glenoid and medial humerus design (4.0%), and the medial glenoid and lateral humerus design (2.8%). The mean values at final follow-up were as follows: visual analog scale score, 2.2; American Shoulder and Elbow Surgeons score, 59.1; Constant score, 59.7; and Simple Shoulder Test, 5.8. The mean forward flexion, abduction, and external rotation were 102.3°, 92.3°, and 25.8°, respectively. CONCLUSIONS: Acromial fractures after RTSA are a complication neither uncommon nor negligible. In the absence of studies with high-level evidence, there is a controversy on the outcomes after treatment. Further well-designed prospective randomized controlled studies with a long-term follow-up should be performed to ascertain the diagnosis, treatment, and prognosis of acromial fractures after RTSA.

Diagnosis of periprosthetic joint bacterial infections by culture of sonication fluid from infected implants.

PURPOSE: This study compared the results of a culture method using sonication with those yielded by the conventional culture method, for patients with infected total knee arthroplasty (TKA). We also evaluated the usefulness of sonication for the identification of pathogens in infected TKA cases. METHODS: Isolates were cultured from 13 implants that had been removed from 13 patients with infected TKA. Preoperative culture was performed on aspirated joint fluid, and during the operation, infected tissue was collected for culture. The removed prosthetic implants were cultured before and after sonication. Next, we identified the cultured bacteria using API biochemical kits and 16 S rRNA sequencing. RESULTS: The cultures from preoperative joint fluid and intraoperative tissue were positive in 9 of 13 cases (69.2%). For the removed implants, 10 cases were positive before sonication. After sonication, 12 cases (92.3%) had positive cultures. The pathogen most commonly isolated from the cultures was Staphylococcus aureus. CONCLUSIONS: This study found that a culturing workflow incorporating sonication diagnosed pathogens in patients with infected TKA with higher sensitivity than did the conventional culturing method.

Two-stage revision anterior cruciate ligament reconstruction.

With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are becoming increasingly common. A revision procedure may be performed to improved knee function, correct instability, and facilitate a return to normal activities. When performing a revision reconstruction, the surgeon decides between a single-stage or a two-stage revision. Two-stage revisions are rarely performed, but are particularly useful when addressing substantial tunnel-widening, active infection, and concomitant knee pathology (e.g., malalignment, other ligamentous injuries, meniscal or chondral lesions). Among these potential scenarios requiring a two-stage revision, tunnel-widening is the most common cause; the first stage involves graft removal, tunnel curettage, and bone grafting, followed by revision ACL reconstruction in the second stage. The purpose of this article is to review the preoperative planning, surgical considerations, rehabilitation, and outcomes of two-stage revision ACL reconstructions and summarize the recent literature outlining treatment results.