Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients.

INTRODUCTION: Tibial plateau fractures are typically treated with osteosynthesis. In older patients, osteosynthesis is associated with some complications, risk of post-traumatic osteoarthritis and long partial, or non-weight bearing during the recovery phase. To avoid these problems, primary total knee replacement (TKR) has become an increasingly common treatment option. The aim of this study was to evaluate all the relevant literature and summarize the current evidence-based knowledge on the treatment of tibial plateau fractures with primary TKR in older patients. MATERIALS AND METHODS: A systematic literature search of studies on total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture was conducted using OVID Medline, Scopus, and Cochrane databases from 1946 to 18 November 2019. We included all studies without restrictions regarding total knee replacement (TKR) as primary treatment for acute traumatic tibial plateau fracture. RESULTS: Of the 640 reviewed articles, 16 studies with a total of 197 patients met the inclusion criteria. No controlled trials were available, and the overall quality of the literature was low. The results, using different clinical scoring systems, were good or fair. Four-year follow-up complication (6.1%) and revision (3.6%) rates after primary TKR appeared to be lower than after secondary TKR (complication rate 20-48%, revision rate 8-20%) but higher than after elective primary TKR. CONCLUSION: Based on low-quality evidence, TKR appears to be a useful treatment option for tibial plateau fractures in older patients. Controlled trials are mandatory to determine the relative superiority of these two options as primary treatment of tibial plateau fractures in older patients.

Defective WNT signaling may protect from articular cartilage deterioration - a quantitative MRI study on subjects with a heterozygous WNT1 mutation.

OBJECTIVE: WNT signaling is of key importance in chondrogenesis and defective WNT signaling may contribute to the pathogenesis of osteoarthritis and other cartilage diseases. Biochemical composition of articular cartilage in patients with aberrant WNT signaling has not been studied. Our objective was to assess the knee articular cartilage in WNT1 mutation-positive individuals using a 3.0T MRI unit to measure cartilage thickness, relaxation times, and texture features. DESIGN: Cohort comprised mutation-positive (N = 13; age 17-76 years) and mutation-negative (N = 13; 16-77 years) subjects from two Finnish families with autosomal dominant WNT1 osteoporosis due to a heterozygous missense mutation c.652T>G (p.C218G) in WNT1. All subjects were imaged with a 3.0T MRI unit and assessed for cartilage thickness, T2 and T1ρ relaxation times, and T2 texture features contrast, dissimilarity and homogeneity of T2 relaxation time maps in six regions of interest (ROIs) in the tibiofemoral cartilage. RESULTS: All three texture features showed opposing trends with age between the groups in the medial tibiofemoral cartilage (P = 0.020-0.085 for the difference of the regression coefficients), the mutation-positive individuals showing signs of cartilage preservation. No significant differences were observed in the lateral tibiofemoral cartilage. Cartilage thickness and means of T2 relaxation time did not differ between groups. Means of T1ρ relaxation time were significantly different in one ROI but the regression analysis displayed no differences. CONCLUSIONS: Our results show less age-related cartilage deterioration in the WNT1 mutation-positive than the mutation-negative subjects. This suggests, that the WNT1 mutation may alter cartilage turnover and even have a potential cartilage-preserving effect.

Unicompartmental Knee Arthroplasties are Performed on the Patients with Radiologically Too Mild Osteoarthritis.

BACKGROUND: Patient selection for either total knee arthroplasty or unicompartmental knee arthroplasty remains controversial. The latter has several reported advantages over total knee arthroplasty, but it also appears to have significant drawbacks in terms of revision rates. AIMS: This study aimed to determine the influence of the preoperative degree of osteoarthritis on the risk of reoperation following unicompartmental knee arthroplasty. METHODS: Surgery was carried out on 294 knees in 241 patients between 2001 and 2012 at a single institute, using cemented Oxford phase III unicompartmental knee arthroplasty. The mean age at the time of operation was 67 years, and the mean follow-up time was 8.7 years. RESULTS AND CONCLUSION: The knees with a preoperative Kellgren-Lawrence grade of 0-2 osteoarthritis had a higher risk of reoperation than those with a Kellgren-Lawrence grade of 3-4 (odds ratio = 1.89; 95% confidence interval, 1.03-3.45; p = 0.04). In addition, the knees with a medial joint space width of more than 1 mm or a high medial/lateral joint space width ratio had an increased risk of reoperation. In conclusion, we suggest that unicompartmental knee arthroplasty should only be performed in cases showing severe osteoarthritis in preoperative radiographs, with medial bone-on-bone contact, and a medial/lateral ratio of <20%.

The classification of osteonecrosis in patients with cancer: validation of a new radiological classification system.

AIM: To validate a new, non-joint-specific radiological classification system that is suitable regardless of the site of the osteonecrosis (ON) in patients with cancer. MATERIAL AND METHODS: Critical deficiencies in the existing ON classification systems were identified and a new, non-joint-specific radiological classification system was developed. Seventy-two magnetic resonance imaging (MRI) images of patients with cancer and ON lesions were graded, and the validation of the new system was performed by assessing inter- and intra-observer reliability. RESULTS: Intra-observer reliability of ON grading was good or very good, with kappa values of 0.79-0.86. Interobserver agreement was lower but still good, with kappa values of 0.62-0.77. Ninety-eight percent of all intra- or interobserver differences were within one grade. Interobserver reliability of assessing the location of ON was very good, with kappa values of 0.93-0.98. CONCLUSION: All the available radiological ON classification systems are joint specific. This limitation has spurred the development of multiple systems, which has led to the insufficient use of classifications in ON studies among patients with cancer. The introduced radiological classification system overcomes the problem of joint-specificity, was found to be reliable, and can be used to classify all ON lesions regardless of the affected site.

Survivorship of high tibial osteotomy in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees.

Previous studies from single centres or single-surgeon series report good early and mid-term results for high tibial osteotomy (HTO) in the treatment of osteoarthritis of the knee. However, the survivorship of HTO at a national level is unknown. This registry-based study included 3195 high HTOs performed between 1987 and 2008. Kaplan-Meier analysis revealed an overall survivorship of 89% (95% confidence interval (CI) 88 to 90) at five years and 73% (95% CI 72 to 75) at ten years, when conversion to total knee replacement was taken as the endpoint. Females and patients aged > 50 years had worse survivorship than males or patients aged ≤ 50 years (hazard ratio (HR) 1.26 (95% CI 1.11 to 1.43) and HR 1.41 (95% CI 1.23 to 1.64), respectively). The survivorship of HTOs performed between 1998 to 2008 was worse than for those performed between 1987 and 1997.

A proximal fixed anatomic femoral stem reduces stress shielding.

In 24 patients with total hip replacement using a short anatomic femoral stem, bone mineral density (BMD) was measured after a 7-year follow-up using dual-energy X-ray absorptiometry. The contralateral side was used as a control. The BMD on the side of the prosthesis was lower by a mean of 7% than that on the control side. The difference was greatest in the area of the calcar and laterally and proximally around the stem. BMD at the metaphyseal and diaphyseal areas were the same as on the contralateral side. The bone loss around the proximal aspect of the stem may be related to the proximal porous coating. It is concluded that stress shielding can be diminished by appropriate design of the femoral component.

Epidural abscess after lumbar discography. A case report.

STUDY DESIGN: The patient who suffered from pain in both lower legs and in whom discography was performed experienced a rare complication after discography. The findings and method of discography is described, as is usefulness of magnetic resonance imaging to image this rare complication. OBJECTIVES: To establish the possibility of getting a spinal epidural abscess after discography, how to make the diagnosis, and how to treat the complication. SUMMARY OF BACKGROUND DATA: Discitis after discography is a well-known complication, but epidural abscess is rare. METHODS: C-reactive protein concentration was measured and was more than 100 mg/L. Infection was suspected, and antibiotic therapy was started immediately. Magnetic resonance imaging was performed, and the diagnosis became clear. A laminotomy was performed. RESULTS: Symptoms due to epidural abscess disappeared soon after laminotomy. CONCLUSIONS: Some harmful and unpleasant complications are possible after discography. Antibiotic prophylaxis and stiletted needles should be used. Magnetic resonance imaging is the best radiologic procedure to image the complication, and surgery must be performed as soon as possible.

Bone loss from the proximal femur after arthroplasty with an isoelastic femoral stem. BMD measurements in 25 patients after 9 years.

To quantify the bone loss from the proximal femur after total hip arthroplasty with an isoelastic femoral stem, the bone mineral densities (BMD) around 25 such stems were measured after an 8.5 (7.5-9.5)-year follow-up. The contralateral, healthy side was used as a control. The BMD on the prosthesis side was lower by a mean of 14 percent than on the control side. The difference was greatest in the calcar area and smallest in the cortex medially of the prosthesis stem. The decreases in BMD around the metaphyseal and diaphyseal areas of the stem were smaller than those reported for stiff stems. The marked bone loss in the calcar region is possibly due to stress bypass-i.e., the axial load is transmitted directly into the metaphyseal area of the femoral shaft, causing an increase in its stiffness and in the jamming of the prosthesis stem.

Voiding dysfunction and urodynamic findings in patients with lumbar spinal stenosis and the effect of decompressive laminectomy.

Eighteen consecutive patients (12 men and 6 women, mean age 55) with clinically and radiologically verified lumbar spinal stenosis underwent urodynamic examinations before decompressive laminectomy (n = 16) and 15 afterwards. Twelve of the patients (67%) had symptoms of voiding dysfunction preoperatively but urodynamic findings were normal in most cases only one patient showing detrusor hyperreflexia and one obstruction. Three patients reported an improvement in voiding postoperatively. Three patients showed obstructive voiding postoperatively, one undergoing TURP with a good outcome. One patient developed detrusor areflexia after the operation, with difficulties in bladder emptying. The only statistically significant changes in urodynamic parameters were rises in the maximum urethral pressure and urethral closure pressure. When considering the radicular symptoms and back pains the overall outcome was assessed as excellent or good in 6 cases, 6 had a fair outcome and 4 poor. Decompressive laminectomy gives acceptable results but the effects on bladder and urethral function remain controversial and unexpected. Electrophysiological investigations are needed for more detailed analysis of these cases.

Pocket-size, portable surface EMG device in the differentiation of low back pain patients.

The relevance of surface EMG of the paraspinal muscles measured by a portable, pocket-size device with a special amplifier was evaluated in different low back pain groups. Patients with only local low back pain had significantly higher EMG activities than those with unilateral radiating pain without verified disc herniation, those with verified disc herniation, and controls, but there were no differences between the latter three groups. Pain clearly modified paravertebral muscle activity, as the patients experiencing pain during the recording showed significantly higher EMG activities than those with no pain. It is concluded that surface EMG is a valid tool for indirectly assessing pain in low back pain patients but not for classification into different diagnostic groups.

Revision arthroplasty with an isoelastic uncemented femoral stem.

We carried out 102 hip revision arthroplasties using an uncemented isoelastic femoral stem on 92 patients between 1985 and 1989. The proximal femoral bone stock had deteriorated in 45%. Eleven patients died during the mean follow up of 5.7 years. The femoral component has been revised again for loosening in 13, for infection in 5 and for dislocation in 3. Radiographs of 70 hips showed incipient migration at 3 months in 20, and at the time of review 27 hips had migrated 5 mm or more. Nine stems had migrated more than 8 mm and were judged to be loose. There were 11 fractures before operation and 15 during operation; they all healed. Slight cortical hypertrophy of not more than 2 mm was present in most cases. Three patients (4 hips) were excluded because of severe systemic illness. Of the remaining 66 hips, the clinical outcome was excellent in 18%, good in 50%, fair in 26% and poor in 6%. The isoelastic stem is associated with poor primary fixation which is indicated by early subsidence. The results, with a total failure rate of 33%, are unsatisfactory and the isoelastic femoral stem used in this series cannot be recommended for revision operations.

Osteolysis around uncoated polyethylene acetabular cups : A seven- to nine-year follow-up of 79 hips.

From 1983 to 1985, we performed 105 primary hip replacements in 92 osteoarthritic patients, using a non-cemented uncoated RM polyethylene cup. After a follow-up of 8.2 (7.0-9.0) years, 12 patients had died, five sockets had been revised for loosening and three for dislocation, three patients had been lost to follow-up, and three had been excluded due to severe general illnesses.The remaining 66 patients with 79 hip replacements were reviewed clinically and by radiography, which showed osteolytic foci, mean size 13×18 mm, around 17 acetabular sockets mostly around the superior dome of the cup. Osteolytic foci were also seen around 10 femoral stems, and they were significantly more frequent in the 12 cases, where the socket had migrated.After an exclusion of 11 patients due to a loose stem (one revised) and eight for other illnesses, an excellent or good overall functional outcome was seen in 51% of the remaining 61 hips, a fair outcome in 20% and a poor outcome in 29%. The influence of acetabular pathology on pain and function seemed to be slight.The non-cemented uncoated polyethylene socket involves over time, a high rate of osteolysis and migration, which also endangers the fixation of the stem. These phenomena do not necessarily give symptoms. Regular radiographic reviews are therefore essential. The socket should be exchanged if the stem is revised.

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture.

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after primary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.

Total hip arthroplasty using isoelastic femoral stems. A seven- to nine-year follow-up in 108 patients.

From 1983 to 1985 we performed 114 primary hip replacements in 108 consecutive osteoarthritic patients using a non-cemented RM isoelastic femoral stem. After a mean follow-up of 8.2 years, ten patients had died, 11 hips had been revised, six patients had been lost to follow-up and two had been excluded due to severe general illnesses. Of 85 arthroplasties (in 79 patients) 14 could not be assessed because of other illness or disability. The 71 remaining were reviewed by questionnaire and radiography; an excellent or good overall functional result was found in 31, 16 were fair and 24 were poor. Radiographically, 21 of 71 stems were judged to be loose and ten showed osteolytic foci, six of these without obvious loosening. We conclude that the isoelastic RM stem shows a high rate of loosening, but that this is not always associated with a poor subjective result. Regular radiographic review is necessary. The results are worse than those reported for other uncemented stems and for cemented stems.

Results of the surgical treatment of Morton's neuralgia in 58 operated intermetatarsal spaces followed over 6 (2-12) years.

In 45 patients (52 feet), 58 intermetatarsal spaces were operated on for Morton's neuralgia. The procedure included dorsal incision, division of the deep intermetatarsal ligament, and resection of the common digital nerve including the neuroma. The outcome of the operation was excellent in 13 clefts good in 20, fair in 14, and poor in 11 after a mean follow-up period of 6 years. Five clefts were reoperated, with improvement in four. The feet with Morton's neuralgia displayed a significantly higher rate of other foot pathologies than feet in a randomly selected control group. The results show the efficacy of the surgical treatment of Morton's neuralgia over a long follow-up period, with an improvement in 80% of cases.

Increasing demands on orthopedic services.

In Finland, waiting lists have been analyzed country-wide several times during the last two decades. In this presentation, the data obtained are reviewed. The orthopedic waiting lists grew threefold from 1969 to 1987, more rapidly than the total waiting list to hospitals in the country. Meanwhile, the average duration of hospitalization decreased. The reliability and problems of data bases available are discussed; it is concluded that especially the studies on waiting lists need new objective methods.

Is DRG useful in orthopedics?

The increasing hospital costs have provoked discussions about Diagnose Related Groups (DRG) and its role in controlling the growth of hospital budgets. The relevance to current operation statistics and the structure of DRG in orthopedics are analyzed. The direct application of DRG to Scandinavian statistics does not appear to be reliable.

Acute acromioclavicular dislocations treated by fixation of the joint and ligament repair or reconstruction.

We reviewed 55 patients, median age 34 years, who had had acute complete acromioclavicular dislocation treated by transient acromioclavicular fixation with a Knowles pin and ligament repair by suturing or reconstruction of the superior acromioclavicular ligament with transfer of the coracoid end of the coracoacromial ligament onto the clavicle. At followup examination 50 patients showed at least a satisfactory result. Five cases, two of which had had subsequent resection of the distal end of the clavicle, were classified as poor, mainly because of pain, even though the functional result was good in three. Reconstruction of the superior acromioclavicular ligament, although it improved the anatomic result, was shown to be of no advantage and may even have caused discomfort. The numerous radiological findings of residual subluxation or dislocation, deformity of the distal end of the clavicle, soft tissue calcification and osteoarthritis or pathological physical findings did not correlate significantly with the clinical outcomes. In general this operation gave results comparable with those achieved by other operative methods. It is useful if surgery is preferred to conservative treatment.

The significance of residual stenosis after decompression for lumbar spinal stenosis.

Thirty-one patients with degenerative or combined degenerative and developmental lumbar spinal stenosis diagnosed by myelography and at subsequent surgery were thoroughly examined by computed tomography (CT) to reveal the completeness of the decompression and its correlation with the outcome. Complete elimination of the stenosis was achieved in 10 cases (32%) of whom 9 (90%) showed improvement. Various combinations of residual stenosis (some type of stenosis of the lateral part of vertebral canal at the laminectomy sites and also central stenosis outside the laminectomy field) were observed in 21 cases (68%). Of these, 14 (67%) had nearly complete, subtotal decompression with minimal or some residual stenosis, 7 (33%) had only minor decompression of the most constricted part of the spinal canal with a considerable amount of residual stenosis. The latter groups showed improvement in 8 cases (57%) and 6 cases (86%), respectively. Three patients (10%) with increased postoperative symptoms had only minimal or some residual stenosis. The significance of these findings is discussed.