Which patient-specific parameters correlate with operation time for total hip arthroplasty? - A retrospective analysis of the direct anterior approach.

PURPOSE: The current study aims to identify patient-specific factors that correlate with operation time for total hip arthroplasty (THA) performed via the direct anterior approach (DAA). METHODS: In this retrospective study, patient-specific factors were tabulated from the charts and measured from preoperative templating radiographs. These factors were correlated with operation time by bivariate analysis. Significant factors were used for stepwise multiple regression analysis. RESULTS: Nine hundred-sixty procedures were included. BMI (R = 0.283), the distance from the superior iliac spine to the greater trochanter (DAA Plane) (R = - 0.154), patients age (R = 0.152) and the abdominal fat flap (R = 0.134) showed the strongest correlations (p < 0.005) with operation time. The multiple regression model including BMI, Kellgren and Lawrence Score, Age, DAA Plane and the Canal to Calcar ratio had the best predictive accuracy (corrected R2 = 0.122). CONCLUSIONS: Patient-specific factors that make the entry into the femur difficult correlate significantly with operation time of THA via the DAA.

Resource Consumption and Remuneration Aspects in Navigated Screw Fixation Procedures with or without Additional Sacroplasty for Fragility Fractures of the Sacrum-A Prospective Clinical Study.

Surgical treatment for sacral fragility fractures using navigation-assisted screw fixation (NSF) is a modern, technically demanding procedure. Additional sacroplasty (ASP) has been shown to provide only insignificant clinical benefits for patients. This investigation highlights procedural economic aspects and evaluates results with regard to resource scarcity in order to be able to decide, whether ASP has a justification in NSF procedures beyond clinical aspects. From February 2011 to May 2017, all individuals with sacral fragility fractures surgically treated using 3D-fluoroscopy for NSF (n = 26) or NSF + ASP (n = 26) were enrolled. Outcome parameters were operative time, 3D-/2D-radiation dose, 2D-fluoroscopy time, material costs and reimbursement. In the two groups, a total of 52 individuals with 124 fragility fracture sites in sacral vertebrae I and II were surgically treated with similar numbers of screws inserted (p ≈ 0.679) requiring similar 3D- (p ≈ 0.546) and 2D-fluoroscopy radiation doses (p ≈ 0.236). In procedures with ASP, average 2D-fluoroscopy time (46.6 s vs. 32.7 s, p ≈ 0.004), and mean surgical duration (119 min vs. 96 min, p ≈ 0.011) were significantly longer. Mean implant costs (EUR 668.68 vs. EUR 204.34, p < 0.001), and reimbursement (EUR 8416.01 vs. EUR 6584.49, p ≈ 0.006) were significantly higher. Although comparison of costs and reimbursements indicated a positive financial balance, profitability was not confirmed, because financial expense for extended operative time prevented an economic advantage of procedures with ASP in this investigation. A formula was developed based on presented study data to allow similar economical decisions in other health care systems or institutions with differing resource costs.

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.

Do not exchange the spacer during staged TKA exchange!

PURPOSE: The aim of this study was to investigate the reinfection rate and risk factors for septic failure after two-stage exchange for chronic periprosthetic joint infections of primary total knee arthroplasties. Reinfections should be classified as new infection or as infection recurrence after two-stage exchange. METHODS: We performed a retrospective study of 60 knees with chronic periprosthetic joint infections. Follow-up information was extracted from the departments electronic database. RESULTS: The reinfection rate after a mean follow-up of 35.6 months (1-135) was 20.0%. The only significant risk factor for reinfection was spacer exchange during two-stage exchange (OR = 10.42; p = 0.001). Of the 12 cases with reinfection 6 cases were classified as new infection and 2 as infection recurrence. CONCLUSIONS: Patient specific factors for reinfection remain furtive. If a spacer exchange is preformed, the risk of reinfection increases. Culture results indicate that the benefit of spacer exchanges during two-stage exchange is highly questionable, particularly because reinfection is an issue of new infection rather than of infection recurrence.

Impact of Tranexamic Acid on Chondrocytes and Osteogenically Differentiated Human Mesenchymal Stromal Cells (hMSCs) In Vitro.

The topical application of tranexamic acid (TXA) helps to prevent post-operative blood loss in total joint replacements. Despite these findings, the effects on articular and periarticular tissues remain unclear. Therefore, this in vitro study examined the effects of varying exposure times and concentrations of TXA on proliferation rates, gene expression and differentiation capacity of chondrocytes and human mesenchymal stromal cells (hMSCs), which underwent osteogenic differentiation. Chondrocytes and hMSCs were isolated and multiplied in monolayer cell cultures. Osteogenic differentiation of hMSCs was induced for 21 days using a differentiation medium containing specific growth factors. Cell proliferation was analyzed using ATP assays. Effects of TXA on cell morphology were examined via light microscopy and histological staining, while expression levels of tissue-specific genes were measured using semiquantitative RT-PCR. After treatment with 50 mg/mL of TXA, a decrease in cell proliferation rates was observed. Furthermore, treatment with concentrations of 20 mg/mL of TXA for at least 48 h led to a visible detachment of chondrocytes. TXA treatment with 50 mg/mL for at least 24 h led to a decrease in the expression of specific marker genes in chondrocytes and osteogenically differentiated hMSCs. No significant effects were observed for concentrations beyond 20 mg/mL of TXA combined with exposure times of less than 24 h. This might therefore represent a safe limit for topical application in vivo. Further research regarding in vivo conditions and effects on hMSC functionality are necessary to fully determine the effects of TXA on articular and periarticular tissues.

The human arthritic hip joint is a source of mesenchymal stromal cells (MSCs) with extensive multipotent differentiation potential.

BACKGROUND: While multiple in vitro studies examined mesenchymal stromal cells (MSCs) derived from bone marrow or hyaline cartilage, there is little to no data about the presence of MSCs in the joint capsule or the ligamentum capitis femoris (LCF) of the hip joint. Therefore, this in vitro study examined the presence and differentiation potential of MSCs isolated from the bone marrow, arthritic hyaline cartilage, the LCF and full-thickness samples of the anterior joint capsule of the hip joint. METHODS: MSCs were isolated and multiplied in adherent monolayer cell cultures. Osteogenesis and adipogenesis were induced in monolayer cell cultures for 21 days using a differentiation medium containing specific growth factors, while chondrogenesis in the presence of TGF-ß1 was performed using pellet-culture for 27 days. Control cultures were maintained for comparison over the same duration of time. The differentiation process was analyzed using histological and immunohistochemical stainings as well as semiquantitative RT-PCR for measuring the mean expression levels of tissue-specific genes. RESULTS: This in vitro research showed that the isolated cells from all four donor tissues grew plastic-adherent and showed similar adipogenic and osteogenic differentiation capacity as proven by the histological detection of lipid droplets or deposits of extracellular calcium and collagen type I. After 27 days of chondrogenesis proteoglycans accumulated in the differentiated MSC-pellets from all donor tissues. Immunohistochemical staining revealed vast amounts of collagen type II in all differentiated MSC-pellets, except for those from the LCF. Interestingly, all differentiated MSCs still showed a clear increase in mean expression of adipogenic, osteogenic and chondrogenic marker genes. In addition, the examination of an exemplary selected donor sample revealed that cells from all four donor tissues were clearly positive for the surface markers CD44, CD73, CD90 and CD105 by flow cytometric analysis. CONCLUSIONS: This study proved the presence of MSC-like cells in all four examined donor tissues of the hip joint. No significant differences were observed during osteogenic or adipogenic differentiation depending on the source of MSCs used. Further research is necessary to fully determine the tripotent differentiation potential of cells isolated from the LCF and capsule tissue of the hip joint.

Antibiotic elution and compressive strength of gentamicin/vancomycin loaded bone cements are considerably influenced by immersion fluid volume.

The effect of doubling the immersion fluid (eluate) volume on antibiotic concentrations and on mechanical stability from vancomycin and gentamicin loaded bone cements was investigated in vitro. Antibiotic loaded bone cements containing premixed 1.34% gentamicin antibiotic concentration in the cement powder (wt), premixed 1.19% gentamicin wt and 4.76% vancomycin wt and premixed 1.17% wt gentamicin additionally manually blended with 4.68% wt vancomycin were tested. Six specimens per group were immersed in 4 ml and 8 ml for 6 weeks while the eluate was exchanged every 24 h. The antibiotic concentrations were repeatedly measured. Then the specimens were tested for compressive strength. Doubling the eluate volume significantly decreased gentamicin and vancomycin concentrations from 6 h and 24 h on, except for the gentamicin concentration of the additionally manually blended formulation after 3 weeks. The additionally manually blended vancomycin formulation produced significantly higher gentamicin concentrations in 8 ml compared to the other formulations. The reduction ratios of the vancomycin concentrations were significantly smaller than the reduction ratios of the gentamicin concentrations for the manually blended vancomycin formulation. Vancomycin containing formulations showed significantly lower compressive strengths than the vancomycin free formulation after immersion. Doubling the eluate volume lead to significant compressive strength reduction of the vancomycin containing formulations. Eluate volume change influences antibiotic elution dependent on the antibiotic combination and loading technique. The reducing effect is higher on vancomycin than on gentamicin elution. Compressive strength of gentamicin/vancomycin loaded bone cements after immersion is eluate volume dependent.

Evaluation of implant fit and frontal plane alignment after bi-compartmental knee arthroplasty using patient-specific instruments and implants.

INTRODUCTION: The goals of successful bi-compartmental knee arthroplasty are to achieve correct fit and positioning of the implant, while appropriately correcting the mechanical alignment of the leg after surgery. As these requirements are not always reliably fulfilled using off-the-shelf implant systems, newer approaches for bi-compartmental resurfacing have been explored. MATERIAL AND METHODS: In this article we report the radiographic results of 30 patients with anteromedial osteoarthritis (OA) who were treated with a novel patient-specific fixed-bearing bi-compartmental knee resurfacing system using custom-made implants and instruments. Utilizing standardized pre- and postoperative radiographic analyses (based on anterior-posterior and lateral, anterior-posterior weight-bearing full-length radiographs, patella skyline views and preoperative computed tomography (CT) scanning) implant fit and positioning as well as correction of the mechanical axis (hip-knee-ankle angle, HKA) were determined. RESULTS: On average, HKA was corrected from 173.4 ±3.47° preoperatively to 179.4 ±2.85° postoperatively. The coronal femoro-tibial angle was corrected on average 5.61°. The preoperative tibial slope measured on lateral views was 6.38 ±2.4°, while the average slope in the CT-based planning protocol (iView) was 6.14 ±2.40°. Postoperative lateral tibial slope was determined to be 5.77 ±1.97°. The thickness of the posterior femoral cuts was measured intraoperatively and, in all cases, corresponded well to the targeted thickness of the cuts provided by the iView. The joint line was preserved in all cases and the average Insall-Salvati index was 1.078 ±0.11 pre- and 1.072 ±0.11 postoperatively. The fit of the implant components measured by over- or underhang was excellent throughout (< 1.01 mm). CONCLUSIONS: Custom-made bicompartmental knee arthroplasty can ensure optimized fitting and positioning of the implant with restoration of the leg axis. These implants could be considered as an alternative primary solution for knee surgeons treating bi-compartmental disease.

Synovial Fluid Aspiration Should Not Be Routinely Performed during the Two-Stage Exchange of the Knee.

PURPOSE: Detection of infection persistence during the two-stage exchange of the knee for periprosthetic joint infection is challenging. Synovial fluid culture (SFC) and synovial white blood cell count (SWBCC) before joint reimplantation are widespread diagnostic means for this indication. The sensitivity and specificity of SFC and of SWBCC for infection persistence before planned reimplantation were evaluated. METHODS: 94 two-stage exchanges of the knee with synovial fluid aspiration performed after a drug holiday of at least 14 days and before reimplantation or spacer exchange (planned reimplantation) were retrospectively analyzed. Only cases with at least 3 intraoperative samples at planned reimplantation were included. SFC and SWBCC were compared to pathogen detection (SFC(culture)/SWBCC(culture)) and to histopathological signs of infection persistence (SFC(histo)/SWBCC(histo)) from intraoperative samples at planned reimplantation. For SFC, the sensitivity and specificity were calculated. For SWBCC, the optimal cut-off value with its sensitivity and specificity was calculated with the Youden-Index. RESULTS: Sensitivity and specificity of SFC(culture) were 0.0% and 98.9%. Sensitivity and specificity of SFC(histo) were 3.4% and 100%. The optimal cut-off value for SWBCC(culture) was 4450 cells/µl with a sensitivity of 50.0% and a specificity of 86.5%. The optimal cut-off value for SWBCC(histo) was 3250 cells/µl with a sensitivity of 35.7% and a specificity of 92.9%. CONCLUSION: The detection of infection persistence remains challenging and a consented approach is lacking. The results do not warrant the routine performance of SFC during the two-stage exchange at the knee. SWBCC can be used to confirm infection persistence at high cut-offs, but they only occur in few patients and are therefore inappropriate for the routine use.

Revision knee arthroplasty with rotating hinge systems in patients with gross ligament instability.

PURPOSE: The clinical and radiographic outcomes after revision total knee arthroplasty (TKA) for instability with two rotating hinge knee prostheses were compared. METHODS: Fifty-one patients revised for TKA instability were prospectively randomized to either the Link Endo-Model (N = 26) or the EnduRo (N = 25). Clinical and radiographic outcome scores were compared pre-operatively and at 12 months' follow-up. Failure mechanisms were recorded. RESULTS: Age, BMI, operation, and tourniquet-time did not differ significantly between groups. Radiographic evaluation demonstrated correct implant alignment. The Endo-Model was implanted with a higher slope (p = 0.0001) and the mechanical lower extremity axis was straighter (p = 0.0323). Except for the patient function Knee Society Score and the Physical Health Component Summary Score in the EnduRo group, all clinical scores (range of motion/knee function Knee Society Score/Oxford Knee Score/Visual Analog Scale/Mental Health Component Summary Score) improved significantly for both prosthesis designs during the follow-up period. The Visual Analog Scale and Mental Health Component Summary score were significantly better (p = 0.045 and p = 0.0148) in the Endo-Model group at the 12 months' follow-up. In the EnduRo group 2 patients (8%) and in the Endo-Model group 1 patient (3.8%) had to be revised for infection. CONCLUSION: Both prosthetic designs provide significant improvement in pain and function scores after TKA revision for gross instability. We found slight advantages in favor of the Endo-Model; however, no design yielded superior results throughout the study.

Loading with vancomycin does not decrease gentamicin elution in gentamicin premixed bone cement.

Antibiotic loaded bone cements are used as drug delivery systems for the treatment of periprosthetic joint infections. They can be loaded with antibiotics during industrial component production (premixing) and during cement preparation (manually blending). Although double premixed antibiotic loaded bone cements are available, manually blending of a gentamicin premixed antibiotic loaded bone cement with vancomycin is still popular. We compared in vitro antibiotic elution and compressive strength of 0.5 g gentamicin premixed bone cement (PALACOS® R + G), 0.5 g gentamicin premixed bone cement (PALACOS® R + G) manually blended with 2.0 g vancomycin, 0.5 g gentamicin and 2.0 g vancomycin premixed bone cement (COPAL® G + V), 1 g gentamicin and clindamycin premixed bone cement (COPAL® G + C) and bone cement without an antibiotic (PALACOS® R) as control. Antibiotic concentration measurements were performed for 6 weeks and then compression strength was tested. Concentrations of gentamicin showed no significant differences between PALACOS® R + G, PALACOS® R + G with vancomycin and COPAL G® + V. After 48 h COPAL G® + C produced significantly higher gentamicin concentrations than the other formulations. After 12 h PALACOS® R + G with vancomycin produced significantly higher vancomycin concentrations, but had the lowest compression strength. We found no influence of vancomycin addition on gentamicin elution, irrespectively of the loading method. However, the manually vancomycin blended ALBC produced higher vancomycin concentrations. Compression strength after aging is reduced by loading with vancomycin.

Toxicity of antiseptics against chondrocytes: what is best for the cartilage in septic joint surgery?

In septic joint surgery, the most frequently used antiseptics are polyhexanide, hydrogen peroxide and taurolidine. The aim of this study was to examine the effects of these antiseptics on viability of human chondrocytes. Our hypothesis was that antiseptics and supplemental irrigation with sodium chloride lavage are less toxic on human chondrocytes than treatment with antiseptics only. Primary human chondrocytes were isolated and cultured from six donated human knee joints. Polyhexanide, hydrogen peroxide or taurolidine were added to the cultures. Toxicity analysis was performed by visualisation of cell structure using light microscopy and LDH activity. The determination of vital cells and total cell numbers of chondrocytes treated with antiseptics partly followed by irrigation with sodium chloride solution was performed by using Casy Cell-Counter. Light microscopic data revealed a defect in cell structure after addition of antiseptics. We showed a significant increase of LDH enzyme activity after the treatment with polyhexanide or taurolidine. After treatment with antiseptics followed by sodium chloride solution a significant increase of vital and total cell numbers resulted in comparison with the chondrocytes that were only treated with antiseptics. The data show that treatment with polyhexanid, hydrogen peroxide or taurolidine induces cell death of human chondroctes in vitro. The application of sodium chloride solution after the treatment with polyhexanide and hydrogen peroxide possibly has a protective effect on chondrocyte viability.