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.

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.

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.

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.

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.

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.

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.

Dorsal wedge phalangeal osteotomy for grade II-III hallux rigidus in active adult patients.

BACKGROUND: The purpose of this study was to evaluate prospectively the results of the dorsal wedge phalangeal osteotomy for treating moderate hallux rigidus. METHODS: The prospective study included 42 consecutive feet in 40 active patients, with an average age of 55.1 (range, 41-65) years. Clinical evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale, range of motion, and subjective patient satisfaction. Radiographic evaluation was performed, including linear and angular measurements. The average follow-up was 2.7 (range, 2-3.8) years. RESULTS: The preoperative and postoperative mean AOFAS scores were 51.7 and 88.8, respectively (P = .001), and for pain VAS were 7.6 and 1.9, respectively (P = .001). Good and excellent results at final follow-up were seen in 34 feet. All patients returned to their previous activities. Satisfaction with surgery was good or excellent in 39 patients. The average passive metatarsophalangeal (MTP) dorsiflexion improved from 20.3 to 55.7 degrees (P = .001). The average MTP joint space improved from 2.2 to 2.3 degrees (P = .001). The radiographic measurements were unchanged, except anatomic angles related to phalangeal dorsiflexion. The average width of the bone wedge was 3.5 (range, 2.2-5.0) mm, and significant correlation was found with final AOFAS score (P = .006) and pain VAS (P = .001). There were 2 revisions for screw irritation. CONCLUSION: Phalangeal osteotomy was a reliable and reproducible treatment for moderate hallux rigidus in active patients, with substantial improvement in AOFAS score and MTP dorsiflexion and decreased pain. LEVEL OF EVIDENCE: Level IV, prospective case series.