Multicenter survey about leg length discrepancy and total hip arthroplasty: preoperative and intraoperative management.

BACKGROUND: We created a multicenter survey for Italian orthopedic surgeons on how they approach leg length discrepancy (LLD) when dealing with primary total hip arthroplasty. Aim of the study was to show how surgeons manage LLD and follow the literature recommendations during clinical practice. METHODS: The survey was composed of 25 questions divided into four sections: 1-surgeon's profile, 2-preoperative and 3-intraoperative evaluation, and 4-postoperative management. In this paper, we report results to answer Sects. 1 and 2. Absolute and relative frequencies of answers to Sects. 2 and 3 are reported. We divided the participants in subgroups based on the "surgeon's profile" and evaluated difference in the answers given. RESULTS: Absolute and relative frequencies demonstrate low agreement among participants in all phases of LLD management. We demonstrated a statistically significant difference based on the surgeon's profile regarding these questions: radiographic measure of LLD depending on working experience, p = 0.008; digital planning based on surgeons' age, p < 0.001, and workplace, p = 0.026; intraoperative anatomical landmarks based on numbers of procedures per year, p = 0.020; and use of intraoperative X-rays based on working experience, p = 0.002. CONCLUSIONS: LLD is a debated topic with no definitive recommendations. Many decisions still depend on tradition and surgeons' preference.

Approach to the Surgical Theater: Epidemiological Survey in Orthopaedic Italian Private Hospitals.

Surgeons prepare for surgery in a reliable and reproducible manner and according to the guidelines published by the international health institutions. An epidemiological survey on 127 surgeons has shown that in everyday practice they have to follow the most recent knowledge based on evidence-based medicine (EBM) guidelines. However, more standardized approach to the surgical theater practices have to be defined by our health caregivers.

Medial unicondylar knee arthroplasty: technical pearls.

Unicondylar knee arthroplasty implantation is extremely demanding as the prosthesis needs to be integrated in the natural anatomy of the knee. It ensures the integrity of the natural knee kinematic. Some studies and registries data have shown lower success rate in comparison with total knee arthroplasty, and patient-related factors may have an impact on outcome. While, better results have been published by high volume centres. The indications for surgery should be reconsidered critically, even if medial osteoarthritis of the knee remains the most common. This article sets out the diagnostic, and surgical steps in order to fine tuning the unicompartmental replacement of the knee.

DVWA gene polymorphisms and osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a degenerative joints disorder influenced by genetic predisposition. We reported that rs11718863 DVWA SNP was represented in Sicilian with a more severe Kellgren and Lawrence (KL) radiographic grade, displaying its predictive role as OA marker progression. Here, we describe the DVWA SNPs: rs11718863, rs7639618, rs7651842, rs7639807 and rs17040821 probably able to induce protein functional changes. FINDINGS: Sixty-one Sicilian patients with knee OA and 100 healthy subjects were enrolled. Clinical and radiographic evaluation was performed using AKSS scores and KL. Linkage Disequilibrium (LD) analyses were performed in order to verify whether the SNPs segregate as haplotype. All DVWA SNPs'MinorAllele Frequencies (MAF) were greater than in the European. The rs7639618 SNP showed a statistical association with KL. Our analyses show that a LD exists among rs11718863 and rs7639618, as well as between rs7651842, rs7639807 and rs17040821 SNPs. We also observed that three out of the 161 individuals investigated were simultaneously homozygous carriers of the rs7651842, rs7639807 and rs17040821 MAF alleles. CONCLUSIONS: In summary, the purpose of this preliminary research was to highlight possible associations between DVWA SNPs and OA clinical and radiographic data. This work represents a multidisciplinary medicine approach to study OA where clinical, radiological and genetic evaluation could contribute to better define OA grading.

Assessing hospital cost of joint arthroplasty.

PURPOSE: total joint replacement is one of the most successful procedures in medicine and cost reimbursements to hospitals for the joint arthroplasty diagnosis-related group are among the largest payments made by a Regional Health Service. Despite the popularity of these procedures, there are few high-quality cost-effectiveness studies on this topic. This study evaluates the cost of total joint arthroplasty performed in a district hospital. METHODS: direct and indirect costs have been measured and patient procedure pathway was analyzed subdivided into three stages: surgical procedure, inpatient care and outpatient clinic. RESULTS: the cost of the surgical procedure stage was calculated as 3,798 euros, while that of the inpatient stage was 2,924 euros. The mean hospital costs per procedure amounted to 6,952 euros. CONCLUSIONS: although the Health Service tariffs fully reimburse the cost of providing a joint replacement, our data contribute to point out the role of hospital staff's organization to support sustainable improvements on health care for joint replacement surgery. LEVEL OF EVIDENCE: Level VI, single economic evaluation.

Genetic, clinical and radiographic signs in knee osteoarthritis susceptibility.

INTRODUCTION: Osteoarthritis (OA) is considered to be a multifactorial and polygenic disease and diagnosis is mainly clinical and radiological. Correlation between radiographic data and clinical status has been reported. However, very few studies, especially in Caucasian people, describe the association between the Kellgren and Lawrence OA grading scale (KL) and genetic alterations to better understand OA etiopathogenesis and susceptibility. In order to update the knee OA grading, in this study we assessed the associations between KL grade, clinical features such as American Knee Society Score (AKSS), age, and polymorphisms in the principal osteoarthritis susceptibility (OS) genes in Sicilian individuals. METHODS: In 66 Sicilian individuals affected by primary knee OA, the clinical and radiographic evaluation was performed using 2 sub-scores of AKSS (knee score (KS) and function score (FS)) and KL. The patients were also classified according to age. Online Mendelian Inheritance in Man (OMIM) and Database of Single Nucleotide Polymorphisms (dbSNP) Short Genetic Variations databases were used to select gene regions containing the following polymorphisms to analyze: FRZB rs288326 and rs7775, MATN3 rs77245812, ASPN D14 repeats, PTHR2 rs76758470, GDF5 rs143383 and DVWA rs11718863. Patient genotypes were obtained using Sanger DNA sequencing analysis. RESULTS: In our cohort of patients a statistical association between the variables analyzed was reported in all associations tested (KL versus KS, FS and age). We observed that a mild to severe OA radiographic grade is related to severe clinical conditions and loss of articular function and that the severity of symptoms increases with age. Concerning the genotyping analysis, our results revealed a significant statistical association between KL grading and GDF5 rs143383 and DVWA rs11718863 genetic alterations. The latter was also associated with a more severe radiographic grade, displaying its predictive role as OA marker progression. Statistically significant association between clinical, radiographic and genetic signs observed, suggests extending the actual grading of knee OA based mainly on X-ray features. CONCLUSIONS: This work represents a multidisciplinary and translational medicine approach to study OA where clinical, radiological, and OS5 and OS6 SNPs evaluation could contribute to better define grading and progression of OA and to the development of new therapies.

Early assessment of patient perception of outcome in total knee replacement.

PURPOSE: the aim of the present study was to measure patient perception in the early period after knee replacement surgery and to correlate health status with the surgery-related outcome. METHODS: thirty-eight consecutive patients who underwent total knee replacement were evaluated before surgery; at the time Radiographic evaluation was used to assess limb alignment and the Oxford Knee Score (OKS) to assess objective outcome. Health outcome was measured with the three-level version of the EuroQol - five dimension (EQ-5D-3L) self-administered questionnaire, a standardized instrument used to measure patient's perception of health status. Evaluation was performed before surgery, at discharge from hospital, and six weeks after surgery. RESULTS: the mean overall EQ-5D-3L scores were 10.23 before surgery, 8.34 at discharge from the hospital, and 6.52 at six weeks. The overall EQ-5D-3L score before surgery was greater than 8 points in 31 of the 38 patients, ranging from 5 to 8 points in 21 of the 38 patients at the discharge and greater than 8 points in six of the 38 patients six weeks after surgery. Patients with scores of over 8 points at six weeks also scored more than 10 points on the discharge assessment. CONCLUSIONS: analysis of early patient reports of performance after TKR showed marked changes in the level of satisfaction during the first six weeks after surgery. An EQ-5D-3L score of 8 or more at follow-up should be considered a sign that the patient has not achieved satisfaction and, accordingly, should be studied in the context of a personalized follow-up schedule in order to identify as soon as possible the causes of impairment. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Motor dysfunction of the "non-affected" lower limb: a kinematic comparative study between hemiparetic stroke and total knee prosthesized patients.

In patients with hemispheric stroke, abnormal motor performances are described also in the ipsilateral limbs. They may be due to a cortical reorganization in the unaffected hemisphere; moreover, also peripheral mechanisms may play a role. To explore this hypothesis, we studied motor performances in 15 patients with hemispheric stroke and in 14 patients with total knee arthroplasty, which have a reduced motility in the prosthesized leg. Using the unaffected leg, they performed five superimposed circular trajectories in a prefixed pathway on a computerized footboard, while looking at a marker on the computer screen. The average trace error was significantly different between the groups of patients and healthy subjects [F ((2,25)) = 7.9; p = 0.003]; on the contrary, the test time execution did not vary significantly. In conclusion, both groups of patients showed abnormal motor performances of the unaffected leg; this result suggests a likely contribution of peripheral mechanisms.

Comparing in vivo kinematics of unicondylar and bi-unicondylar knee replacements.

Preserving both cruciate ligaments in unicondylar knee arthroplasty likely provides more normal knee mechanics and contributes to enhanced patient function. It follows that preserving both cruciate ligaments with total knee arthroplasty should provide functional benefit compared to arthroplasty sacrificing one or both cruciates. The purpose of this study was to compare knee kinematics in patients with optimally functioning cruciate-preserving medial unicondylar and bi-unicondylar arthroplasty to determine if knee motions differed. Eight consenting patients with seven medial unicondylar and five bi-unicondylar arthroplasties were studied using lateral fluoroscopy during treadmill gait, stair stepping, and maximum flexion activities. Patient-specific geometric models based on CT and CAD data were used for shape matching to determine the three-dimensional knee kinematics. Tibiofemoral contact locations were computed for the replaced compartments. Maximum flexion in kneeling was 135 degrees +/-14 degrees for unicondylar knees and 123 degrees +/-14 degrees for bi-unicondylar knees (p=0.22). For 0 degrees -30 degrees flexion during the stair activity, the medial condyle translated posterior 3.5+/-2.5 mm in unicondylar knees and 4.7+/-1.9 mm in bi-unicondylar knees (p>0.05). Lateral posterior translation was 5.0+/-2.3 mm in bi-unicondylar knees for 0 degrees -30 degrees flexion. From heel-strike to mid-stance phase, there was little tibial rotation, but unicondylar knees showed 1.5+/-1.6 mm posterior translation of the medial condyle, while bi-unicondylar knees showed 5.1+/-2.2 mm (p<<0.05). The bi-unicondylar knees showed 3.8+/-3.4 mm posterior lateral condylar translation. Preserving both cruciate ligaments in knee arthroplasty appears to maintain some basic features of normal knee kinematics. Knees with bi-unicondylar arthroplasty showed kinematics closer to motions observed in total knee arthroplasty, slightly less weight-bearing flexion, and greater dynamic laxity in gait than unicondylar knees. Despite kinematic differences, knees with unicondylar and bi-unicondylar arthroplasty can provide excellent functional outcomes in appropriately selected patients.