Vitamin D Deficiency Is Frequent in Patients with Rapidly Destructive Osteoarthritis-Data from a Single-Center Analysis.

BACKGROUND: Rapidly destructive osteoarthritis (RDO) of the hip joint is characterised by the rapid destruction of the femoral head with or without acetabular involvement. There has been increasing interest in this disease over the past years; however, the entity is still poorly understood, and its pathophysiology remains unknown. Yet, there is ample evidence today that increased bone metabolism might play a role in the onset and progression of the disease. Vitamin D is of utmost importance to maintain a balanced bone metabolism. However, whether vitamin D deficiency is involved in disease development remains to be elucidated. Further, the vitamin D status of patients with RDO has not yet been analysed. For this reason, the objective of this study was to assess the vitamin D status of patients with RDO. Moreover, the aim was to clarify whether there is a difference in the vitamin D status of patients with RDO compared with patients with primary osteoarthritis (OA). METHODS: In this single-centre analysis, the 25(OH)D, PTH, and calcium levels of 29 patients who presented with RDO between 2020 and 2022 were assessed. RESULTS: Altogether, 97% of patients (28/29) were vitamin D deficient, a further 3% (1/29) were vitamin D insufficient, and not a single patient presented with a sufficient vitamin D status. Notably, the vitamin D levels of RDO patients (mean = 11.04 ng/mL) were significantly lower than the vitamin D levels of patients with OA (mean = 22.16 ng/mL, p = 0.001). CONCLUSION: In conclusion, we found a widespread and high rate of vitamin D deficiency in patients with RDO. Hence, we believe that 25(OH)D status should routinely be analysed in these patients.

Epidemiological Analysis of Traumatic Compartment Syndromes in Germany.

Background: Traumatic compartment syndrome is a critical condition that can lead to severe, lifelong disability. Methods: This retrospective study analyzed hospital billing data from 2015 to 2022, provided by the Federal Statistical Office of Germany, to examine the demographics and trends of traumatic compartment syndrome in Germany. The analysis included cases coded with ICD-10 codes T79.60 to T79.69 and any therapeutic OPS code starting with 5-79, focusing on diagnosis year, gender, ICD-10 code, and patient age. Results: The results showed that out of 13,305 cases, the majority were in the lower leg (44.4%), with males having a significantly higher incidence than females (2.3:1 ratio). A bimodal age distribution was observed, with peaks at 22-23 and 55 years. A notable annual decline of 43.87 cases in compartment syndrome was observed, with significant decreases across different genders and age groups, particularly in males under 40 (23.68 cases per year) and in the "foot" and "lower leg" categories (16.67 and 32.87 cases per year, respectively). Conclusions: The study highlights a declining trend in traumatic CS cases in Germany, with distinct demographic patterns. Through these findings, hospitals can adjust their therapeutic regimens, and it could increase awareness among healthcare professionals about this disease.

Does Body Mass Index (BMI) Affect the Reconstruction of Biomechanical Parameters in Patients Undergoing Total Hip Replacement (THR) through the Direct Anterior Approach (DAA)?

OBJECTIVE: Direct anterior approach total hip replacement (DAA-THR) is gaining increased interest due to its tissue-sparing nature and rapid recovery. Obesity has been shown to be a significant parameter influencing cup positioning in DAA-THR. It was the intention of this retrospective study to examine how obesity would influence the restoration of native hip biomechanical parameters during DAA-THR. MATERIALS AND METHODS: A total of 74 patients from a high-volume university orthopedic center after unilateral DAA-THA were included. Patients were retrospectively allocated to a study group (BMI > 30 kg/m2) and a control group (BMI < 30 kg/m2). Furthermore, propensity-score matching for baseline parameters was performed, leaving 30 patients in each group. Biomechanical parameters of the hip (i.e., femoral offset (FO), abductor lever arm (ABL), acetabular offset (AO), center of rotation (COR), stem alignment (SA), body weight lever arm (BWL), cup inclination (CI), and leg length discrepancy (LLD) were evaluated on standardized plain radiographs, and parameters were compared to the native contralateral hip. RESULTS: Mean BMI in the study group was 35.07 ± 5.13 kg/m2 and 25.43 ± 2.64 kg/m2 in the control group. There was a significant decrease of the ABL only in the study cohort (p = 0.01). CI and SA did not differ between both cohorts. FO was slightly increased compared to the native hip in both groups. There was a marginally higher but non-significant proportion of improper FO restoration in the study group (19 vs. 16 patients, p = 0.60). CONCLUSIONS: Obesity, as quantified by BMI, only has a limited impact on the adequate reconstruction of native biomechanical parameters of the hip during DAA-THR. ABL was the only parameter to be significantly decreased in the overweight patients after DAA-THR. Therefore, special care should be taken on proper acetabular reaming and consequent seating of the cup in the obese patient to avoid excessive lateral positioning.

Setting the distal and posterior condyle of the femoral component to restore the medial pre-arthritic femoral articular surface results in better outcomes after total knee arthroplasty.

PURPOSE: The present study of total knee arthroplasty (TKA) describes an intra-operative method that determines the direction and quantifies the magnitude of deviation of the distal and the posterior medial and lateral (DM, PM, DL, and PL) condyle of the femoral component relative to the pre-arthritic femoral articular surface. For each femoral condyle, the deviations were categorized, and an analysis determined which had better or worse Forgotten Joint Score (FJS), Oxford Knee Score (OKS), and WOMAC scores at 1-year follow-up. METHODS: Four academic arthroplasty surgeons supervised a cemented primary CR TKA (Triathlon, Stryker) on 120 consecutive patients. 103 that completed patient-reported outcome measures (PROMs) were analyzed. The surgeon determined the direction and the magnitude of deviation of the condyle of the femoral component by intraoperatively measuring the thickness of the femoral resection, adding compensations of 1 mm for the saw kerf and 2 mm for worn cartilage, and then subtracting the thickness of the femoral component's condyle. For each femoral condyle, a Kruskal-Wallis test determined the categories of deviation with clinically important and significantly different 1-year PROMs. RESULTS: A 1 to 2.5 mm and 3 mm or more proximal deviation of the DM condyle of the femoral component worsened the median FJS by 35 and 40 points, OKS by 9 and 14 points, and WOMAC score by 9 and 17 points, respectively, relative to those with a -0.5 to 0.5 mm deviation (p < 0.01). A 1 to 2.5 mm and 3 mm or more anterior deviation of the PM condyle of the femoral component worsened the FJS by 34 and 48 points, OKS by 7 and 13 points, and WOMAC scores by 8 and 16 points, respectively (p < 0.01). Deviations of the DL and PL condyle of the femoral component did not affect PROMs (p ≥ 0.13). CONCLUSIONS: Although many factors can affect PROM, such as patient expectations, the surgeon should understand that setting the DM and the PM condyles of the femoral component within 1 mm of the patient's pre-arthritic femoral articular surface can potentially result in better FJS, OKS, and WOMAC scores at 1 year. LEVEL OF EVIDENCE: II, Prospective cohort study.

Accuracy of Positioning and Risk Factors for Malpositioning Custom-Made Femoral Stems in Total Hip Arthroplasty-A Retrospective Multicenter Analysis.

Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems.

Impact of COVID-19 on Fracture Incidence in Germany: A Comparative Age and Gender Analysis of Pre- and Post-Outbreak Periods.

In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010-2019) and post-outbreak (2020-2021) periods, using data categorized by age (18-64 years, >65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18-64 after the pandemic's onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population.

Influence of Mechanical Alignment on Functional Knee Phenotypes and Clinical Outcomes in Primary TKA: A 1-Year Prospective Analysis.

In total knee arthroplasty (TKA), functional knee phenotypes are of interest regarding surgical alignment strategies. Functional knee phenotypes were introduced in 2019 and consist of limb, femoral, and tibial phenotypes. The hypothesis of this study was that mechanically aligned (MA) TKA changes preoperative functional phenotypes, which decreases the 1-year Forgotten Joint (FJS) and Oxford Knee Score (OKS) and increases the 1-year WOMAC. All patients included in this study had end-stage osteoarthritis and were treated with a primary MA TKA, which was supervised by four academic knee arthroplasty specialists. To determine the limb, femoral, and tibial phenotype, a long-leg radiograph (LLR) was imaged preoperatively and two to three days after TKA. FJS, OKS, and WOMAC were obtained 1 year after TKA. Patients were categorized using the change in functional limb, femoral, and tibial phenotype measured on LLR, and the scores were compared between the different categories. A complete dataset of preoperative and postoperative scores and radiographic images could be obtained for 59 patients. 42% of these patients had a change of limb phenotype, 41% a change of femoral phenotype, and 24% a change of tibial phenotype of more than ±1 relative to the preoperative phenotype. Patients with more than ±1 change of limb phenotype had significantly lower median FJS (27 points) and OKS (31 points) and higher WOMAC scores (30 points) relative to the 59-, 41-, and 4-point scores of those with a 0 ± 1 change (p < 0.0001 to 0.0048). Patients with a more than ±1 change of femoral phenotype had significantly lower median FJS (28 points) and OKS (32 points) and higher WOMAC scores (24 points) relative to the 69-, 40-, and 8-point scores of those with a 0 ± 1 change (p < 0.0001). A change in tibial phenotype had no effect on the FJS, OKS, and WOMAC scores. Surgeons performing MA TKA could consider limiting coronal alignment corrections of the limb and femoral joint line to within one phenotype to reduce the risk of low patient-reported satisfaction and function at 1-year.

Postoperative Inpatient Rehabilitation Does Not Increase Knee Function after Primary Total Knee Arthroplasty.

Inpatient rehabilitation (IR) is a common postoperative protocol after total knee replacement (TKA). Because IR is expensive and should therefore be justified, this study determined the difference in knee function one year after TKA in patients treated with IR or outpatient rehabilitation, fast-track rehabilitation (FTR) in particular, which also entails a reduced hospital length of stay. A total of 205 patients were included in this multi-center prospective cohort study. Of the patients, 104 had primary TKA at a German university hospital and received IR, while 101 had primary TKA at a Canadian university hospital and received FTR. Patients receiving IR or FTR were matched by pre-operative demographics and knee function. Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), and EuroQol visual analogue scale (EQ-VAS) determined knee function one year after surgery. Patients receiving IR had a 2.8-point lower improvement in OKS (p = 0.001), a 6.7-point lower improvement in WOMAC (p = 0.063), and a 12.3-point higher improvement in EQ-VAS (p = 0.281) than patients receiving FTR. IR does not provide long-term benefits to patient recovery after primary uncomplicated TKA under the current rehabilitation regime.

Short stem hip arthroplasty via the minimally invasive direct anterior approach.

OBJECTIVE: Tissue-sparing, minimally invasive hip arthroplasty via the direct anterior approach (DAA) using a partially neck-preserving, calcar-guided short stem. INDICATIONS: Primary and secondary osteoarthritis of the hip due to developmental dysplasia, femoroacetabular impingement, femoral head necrosis or trauma sequelae. CONTRAINDICATIONS: Severe osteoporosis, active infection, American Society of Anesthesiologists (ASA) > III, large metaphyseal bone defects, severe metaphyseal deformities, Dorr type C femur. SURGICAL TECHNIQUE: Supine position on a standard operating table without extension device. Classic DAA skin incision or bikini incision distal to the inguinal fold. Blunt dissection entering the Hueter interval. Capsulotomy with capsule preservation or partial capsulectomy. Intraoperatively, it is crucial to adhere to the preoperatively planned angle and height of the femoral neck osteotomy. During femoral head removal and acetabular preparation, care must be taken to avoid iatrogenic damage to the remaining neck. After cup positioning, femoral access is achieved by release of superior capsular structures. During opening of the medullary canal and broaching, femoral torsion and axis have to be taken into account for correct rotational and axial alignment. Femoral broaches are inserted in an ascending series of sizes until the last broach is firmly lodged and is in direct contact with the antero-medial femoral neck cortex. Fluoroscopic control in two planes to check for femoral anatomic and overall offset and assess whether the implant is adequately seated with cortical support at the calcar, the distal lateral and the dorsal cortex. Implantation of the definitive implants, local infiltration analgesia and wound closure. RESULTS: Between 1/2011 and 12/2016 60 patients (24 female, 36 male; mean age 44 years) were treated with a partially neck-preserving short stem via the described approach. Seven patients underwent a bi-lateral procedure. Thus, 67 procedures were analysed in this retrospective cohort study. Mean follow-up was 70 months (range 28-93). The median Harris Hip Score was 48 (range 11-88) preoperatively and 98 (range 80-100) postoperatively. CONCLUSION: The minimally invasive implantation of a partially neck-preserving stem via DAA provides a safe technique with good to excellent clinical results in the mid-term.

Sarcopenia and Malnutrition Screening in Female Osteoporosis Patients-A Cross-Sectional Study.

Sarcopenia and malnutrition are important determinants of increased fracture risk in osteoporosis. SARC-F and MNA-SF are well-established questionnaires for identifying patients at risk for these conditions. We sought to evaluate the feasibility and potential added benefit of such assessments as well as the actual prevalence of these conditions in osteoporosis patients. We conducted a cross-sectional, single-center study in female osteoporosis patients ≥ 65 years (SaNSiBaR-study). Results of the sarcopenia (SARC-F) and malnutrition (MNA-SF) screening questionnaires were matched with a functional assessment for sarcopenia and data from patients' medical records. Out of 107 patients included in the analysis, a risk for sarcopenia (SARC-F ≥ 4 points) and a risk for malnutrition (MNA-SF ≤ 11 points) was found in 33 (30.8%) and 38 (35.5%) patients, respectively. Diagnostic overlap with coincident indicative findings in both questionnaires was observed in 17 patients (16%). As compared to the respective not-at-risk groups, the mean short physical performance battery (SPPB) score was significantly reduced in both patients at risk for sarcopenia (7.0 vs. 10.9 points, p < 0.001) and patients at risk for malnutrition (8.7 vs. 10.5 points, p = 0.005). Still, confirmed sarcopenia according to EWGSOP2 criteria was present in only 6 (6%) of all 107 patients, with only 3 of them having an indicative SARC-F score. Bone mineral density was not significantly different in any of the at-risk groups at any site. In summary, applying SARC-F and MNA-SF in osteoporosis patients appears to be a complementary approach to identify individuals with functional deficits.

Physical Function and Health-Related Quality of Life in Adults Treated With Asfotase Alfa for Pediatric-Onset Hypophosphatasia.

Hypophosphatasia (HPP) is a rare, inherited, metabolic disease characterized by tissue-nonspecific alkaline phosphatase deficiency resulting in musculoskeletal and systemic clinical manifestations. This observational study evaluated the effectiveness of enzyme replacement therapy with asfotase alfa on physical function and health-related quality of life (HRQoL) among adults with pediatric-onset HPP who received asfotase alfa for 12 months at a single center (ClinicalTrial.gov no.: NCT03418389). Primary outcomes evaluated physical function with the 6-minute walk test (6MWT), timed up-and-go (TUG) test, Short Physical Performance Battery (SPPB), and handheld dynamometry (HHD). Secondary outcome measures included the Lower Extremity Functional Scale (LEFS), pain prevalence/intensity, and pain medication use; HRQoL was evaluated using the 36-Item Short-Form Health Survey version 2 (SF-36v2). Safety data were collected throughout the study. All 14 patients (11 women) had compound heterozygous ALPL gene mutations and ≥1 HPP bone manifestation, including history of ≥1 fracture. Mean (min, max) age was 51 (19 to 78) years. From baseline to 12 months of treatment, median 6MWT distance increased from 267 m to 320 m (n = 13; p = 0.023); median TUG test time improved from 14.4 s to 11.3 s (n = 9; p = 0.008). Specific components of the SPPB also improved significantly: median 4-m gait speed increased from 0.8 m/s to 1.1 m/s (n = 10; p = 0.007) and median repeated chair-rise time improved from 22 s to 13 s (n = 9; p = 0.008). LEFS score improved from 24 points to 53 points (n = 10; p = 0.002). Improvements in HHD were not clinically significant. SF-36v2 Physical Component Score (PCS) improved after 12 months of treatment (n = 9; p = 0.010). Pain level did not change significantly from baseline to 12 months of treatment. There were significant improvements on chair-rise time and SF-36v2 PCS by 3 months, and on TUG test time after 6 months. No new safety signals were identified. These results show the real-world effectiveness of asfotase alfa in improving physical functioning and HRQoL in adults with pediatric-onset HPP. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Acetabular Revision With Intramedullary and Extramedullary Iliac Fixation for Pelvic Discontinuity.

BACKGROUND: Parallel to the increase in revision hip procedures surgeons face more and more complex anatomical challenges with pelvic discontinuity (PD) being one of the worst-case scenarios. Here we report on our clinical results using an asymmetric acetabular component for the treatment of PD. The implant is armed in a monoblock fashion with an extramedullary iliac flange and provides the possibility to augment it with an intramedullary iliac press-fit stem. METHODS: In a single-center retrospective cohort study we analyzed prospectively collected data of 49 patients (35 female, 14 male) suffering from unilateral periprosthetic PD treated with an asymmetric acetabular component between 2009 and 2017. The mean follow-up was 71 months (21-114). Complications were documented and radiographic and functional outcomes were assessed. RESULTS: Kaplan-Meier analysis revealed a 5-year implant survival of 91% (confidence interval 77%-96%). The 5-year survival with revision for any cause was 87% (CI 74%-94%). The overall revision rate was 16% (n = 8). Two patients required acetabular component revision due to aseptic loosening. Four patients (8%) suffered from periprosthetic infection: one patient was treated with a 2-stage revision, and another one with resection arthroplasty. The other 2 patients were treated with debridement, irrigation, and exchange of the mobile parts. Of 6 patients (12%) suffering from hip dislocation, 2 required implantation of a dual mobility acetabular component. The mean Harris Hip Score improved from 41 preoperatively to 79 at the latest follow-up (P < .001). CONCLUSION: Our findings demonstrate that an asymmetric acetabular component with extramedullary and optional intramedullary iliac fixation is a reliable and safe treatment method for periprosthetic PD resulting in good clinical and radiographic mid-term results.

Revision of unicompartmental knee arthroplasty using the in situ referencing technique.

OBJECTIVE: Revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) with the in situ referencing technique aiming to preserve as much ligament function and epi-metaphyseal bone stock as possible. INDICATIONS: Aseptic loosening, progression of osteoarthritis, periprosthetic fracture, periprosthetic infection, arthrofibrosis, polyethylene wear, malalignment, instability, femoro-tibial impingement. CONTRAINDICATIONS: Unexplained pain, localized or systemic active infection (anywhere). SURGICAL TECHNIQUE: Referencing for the tibia and the femur cuts is performed prior to implant removal. The tibial cutting jig and the initial tibial resection level is set in a way that the sawblade just fits under the tibial implant. In case too much bone needs to be removed to achieve flush implant sitting on both the medial and lateral tibia, a step cut needs to be performed to build up the medial defect with an augment. Prior to femoral component removal, rotational alignment is determined and intramedullary referencing for the distal femur osteotomy is performed. Level of constraint and additional tibial stem fixation is chosen according to the amount of bone resected and according to ligament stability. POSTOPERATIVE MANAGEMENT: Sterile dressings and elastic compression bandaging. No limitation of active/passive range of motion. Full weight-bearing or partial weight-bearing for 2 weeks postoperatively in the presence of bone or soft tissue defects. RESULTS: Between 2008 and 2019, 84 patients underwent revision of unicompartmental knee arthroplasty. The mean follow-up was 64 months (range 3-132 months). Implant survival after revision of UKA to TKA was 92% (95% CI = 82-97%) at 5 years of follow-up and 86% (95% CI = 69-93%) at 10 years of follow-up. The mean Oxford knee score was 20.1 (6-39, SD ± 6.5) preoperatively and 30.2 (3-48, SD ± 11.3) postoperatively. The mean visual analogue scale was 6.9 (range 1-10, SD ± 1.8) preoperatively and 3.9 (range 0-9, SD ± 2.6) postoperatively.