Cup-cage constructs in revision total hip arthroplasty for pelvic discontinuity.

Aims: Pelvic discontinuity is a challenging acetabular defect without a consensus on surgical management. Cup-cage reconstruction is an increasingly used treatment strategy. The present study evaluated implant survival, clinical and radiological outcomes, and complications associated with the cup-cage construct. Methods: We included 53 cup-cage construct (51 patients) implants used for hip revision procedures for pelvic discontinuity between January 2003 and January 2022 in this retrospective review. Mean age at surgery was 71.8 years (50.0 to 92.0; SD 10.3), 43/53 (81.1%) were female, and mean follow-up was 6.4 years (0.02 to 20.0; SD 4.6). Patients were implanted with a Trabecular Metal Revision Shell with either a ZCA cage (n = 12) or a TMARS cage (n = 40, all Zimmer Biomet). Pelvic discontinuity was diagnosed on preoperative radiographs and/or intraoperatively. Kaplan-Meier survival analysis was performed, with failure defined as revision of the cup-cage reconstruction. Results: The five-year all-cause survival for cup-cage reconstruction was 73.4% (95% confidence interval (CI) 61.4 to 85.4), while the ten- and 15-year survival was 63.7% (95% CI 46.8 to 80.6). Survival due to aseptic loosening was 93.4% (95% CI 86.2 to 100.0) at five, ten, and 15 years. The rate of revision for aseptic loosening, infection, and dislocation was 3/53 (5.7%), 7/53 (13.2%), and 6/53 (11.3%), respectively. The mean leg length discrepancy improved (p < 0.001) preoperatively from a mean of 18.2 mm (0 to 80; SD 15.8) to 7.0 mm (0 to 35; SD 9.8) at latest follow-up. The horizontal and vertical hip centres improved (p < 0.001) preoperatively from a mean of 9.2 cm (5.6 to 17.5; SD 2.3) to 10.1 cm (6.2 to 13.4; SD 2.1) and 9.3 cm (4.7 to 15.8; SD 2.5) to 8.0 cm (3.7 to 12.3; SD 1.7), respectively. Conclusion: Cup-cage reconstruction provides acceptable outcomes in the management of pelvic discontinuity. One in four constructs undergo revision within five years, most commonly for periprosthetic joint infection, dislocation, or aseptic loosening.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Outcomes of Plug Osteochondral Allograft Transplantation With or Without Concomitant Osteotomy for Cartilage Defects in the Knee: Minimum 2-year Follow-up.

INTRODUCTION: Isolated osteochondral defects of the knee can cause notable pain and disability. Osteochondral allograft (OCA) transplantation using trephined plug grafts is a highly effective, often curative, treatment option. In knees with malalignment into the transplanted compartment, osteotomy can be done concurrently. This study investigates early-to-midterm survivorship, as well as clinical and radiographic outcomes, of plug OCAs with and without concomitant osteotomy in the knee. METHODS: Plug OCA was done on active, young to middle-aged patients with osteochondral defects ≤4 cm diameter. Prospectively collected data for 102 patients who underwent plug OCA between 2004 and 2020 were reviewed. Survivorship according to Kaplan-Meier analysis was the primary outcome. Failure was defined as conversion to total knee arthroplasty or repeat allograft. Clinical and radiographic outcomes were evaluated using the modified Hospital for Special Surgery (mHSS) score and Kellgren-Lawrence grading. RESULTS: Eighty-six patients with a mean age of 29 ± 9.7 years (15 to 54) and a mean follow-up of 6.8 ± 3.7 years (2 to 15.9) were studied. Concomitant realignment osteotomy was done in 66 patients (76.7%). Graft survivorship was 100%, 93.8% (95% confidence interval 90.8% to 96.8%), and 89.7% (95% confidence interval 85.6% to 93.8%) at 2, 5, and 10 to 15 years, respectively. Six grafts (7.0%) required knee arthroplasty at a mean of 4.6 ± 1.8 years (2.2 to 7.1). Most common reasons for revision surgeries with graft retention included implant removal (11.6%), débridement (8.1%), and repeat osteotomy (5.8%). The mean mHSS score of 90.8 ± 10.4 (51 to 100) at the final follow-up was significantly higher than the preoperative value of 72.5 ± 12.1 (36 to 90) (P < 0.001). Subgroup analyses revealed a markedly greater risk of failure in grafts with a diameter of 30 mm or larger. DISCUSSION: Plug OCA with or without concurrent realignment osteotomy resulted in an excellent graft survival of 93% at a mean of 6.8 years, with reliable functional improvement demonstrated by notable improvements in mHSS knee scores.

Mid-term outcomes of the Wagner Cone Prosthesis™ stem for developmental dysplasia of the hip: minimum two year follow-up.

PURPOSE: Treatment of symptomatic developmental dysplasia of the hip (DDH) requires a technically demanding total hip arthroplasty (THA) reconstruction. In patients with DDH, prostheses can be difficult to implant and often face the risk of fracture, mismatch, and loosening. The Wagner Cone Prosthesis™ is a tapered, conical stem which can improve treatment success in this population. We look at midterm survivorship and outcomes of THA for DDH using the Wagner Cone Prosthesis™. METHODS: We retrospectively analyzed 28 patients (33 hips) with DDH undergoing THA using the Wagner Cone Prosthesis™ between January 2008 and January 2020. Ten, nine, and fourteen included patients were classified as Hartofilakidis A, B, and C, respectively. Survivorship according to Kaplan-Meier analysis was the primary outcome, with re-operation and revision as endpoints. The Oxford hip score (OHS) was used to assess clinical outcome. We used multivariate analysis to determine predictors of poor outcomes. The average follow-up was 4.6 years, with a minimum of two years. RESULTS: Kaplan-Meier survivorship over the 13-year study period was 93.9 ± 4.2% for all-cause revision as an endpoint and 96.9 ± 3.1% for stem revisions only. The overall reoperation rate was 6.1%, with periprosthetic fracture and dislocation being reasons for re-operation. No patients were revised for aseptic loosening, and no patients were revised for subsidence. OHS improved from 19.3 ± 9.6 (4-39) pre-operatively to 37.6 ± 8.4 (19-48) at latest follow-up (p < 0.05). CONCLUSION: In patients with DDH, THA with the Wagner Cone Prosthesis™ demonstrates excellent clinical, radiographic, and patient-reported functional outcomes at midterm follow-up.

3D-Printed Personal Protective Face Shields During the COVID-19 Pandemic: A Survey of Canadian Frontline Workers.

Background During the coronavirus disease 2019 pandemic, three-dimensional (3D) printing was utilized to rapidly produce face shields for frontline workers in response to an acute shortage of personal protective equipment (PPE). In this study, we examine the perceived utility and performance of 3D-printed (3DP) face shields through a survey of frontline workers in Ontario, Canada. Methodology Frontline workers who received community-produced 3DP face shields from the Canadian initiative "3DPPE GTHA" (March-December 2020) were invited to participate in the study. The survey response rate was 54.3%. Of 63 respondents, 39 were patient-facing and 24 were community-facing frontline workers. Participants were asked to rate performance measures in 10 categories on a five-point Likert scale. Data were categorized by organization and frontline worker type, and a t-test was used to determine statistically significant differences among subgroups. Results The mean preference for 3DP face shields among respondents was 3.2 out of 5 (95% confidence interval [CI]: 2.1-4.3). Community-facing respondents reported significantly greater overall utility scores for 3DP face shields (3.58, 95% CI: 3.38-3.79) compared to respondents working in a patient-facing profession (2.95, 95% CI: 2.77-3.13; p < 0.05). However, no differences were reported in portability and compatibility with other PPE. Respondents from organizations with large service volumes reported significantly lower overall utility scores (2.67, 95% CI: 2.44-2.89) than respondents in organizations with smaller service volumes (3.45, 95% CI: 3.28-3.62; p < 0.05). Conclusions Community-facing frontline workers and those from smaller service volume organizations endorse higher utility for 3DP face shields than patient-facing frontline workers. Despite this, frontline workers generally rate 3DP face shields positively. 3DP face shields are a viable option for personal and community use and can be used to supplement supply in a community setting.

Outcomes of Bulk Fresh Osteochondral Allografts for Cartilage Restoration in the Knee.

BACKGROUND: Symptomatic osteochondral defects of the knee in young patients can cause substantial disability and predispose to osteoarthritis. Fresh osteochondral allografts (FOCAs) are a treatment option for such defects. With our institution having one of the longest-running FOCA programs, we investigated the long-term outcomes of bulk FOCA in the knee, focusing on graft survivorship, function, complications, and reoperation. METHODS: A total of 244 patients underwent bulk FOCA in the knee from 1972 to 2018, with a mean age of 37.8 years (range, 10 to 75 years) and a mean follow-up of 9.0 years (range, 1.0 to 29.8 years). Cartilage defects were very large and uncontained, such that they were not amenable to plug transplantation. Survivorship according to Kaplan-Meier analysis was the primary outcome, and failure was defined as conversion to total knee arthroplasty, repeat allograft, graft removal, knee arthrodesis, or amputation. Functional outcome was evaluated with use of the modified Hospital for Special Surgery (mHSS) score, and radiographic evidence of osteoarthritis was classified with use of the Kellgren-Lawrence grading scale. RESULTS: Graft survivorship was 86.6% at 5 years, 73.3% at 10 years, 58.1% at 15 years, 43.7% at 20 years, 31.9% at 25 years, and 22.6% at 30 years. The most common complications were pain (14.8%), malalignment (13.9%), and stiffness (5.8%). A total of 93 grafts (38.1%) failed at a mean of 11.0 years (range, 0.5 to 34.0 years). The mean mHSS score improved significantly, from 68.7 (range, 19 to 91) preoperatively to 80.3 (range, 52 to 100) at the time of the latest follow-up (p < 0.001). Preoperative mHSS score had a negative correlation with Kellgren-Lawrence grade at the time of the latest follow-up. Multivariate analysis revealed that graft location (i.e., medial-sided or multiple grafts) and increased age were significantly negatively associated with survival. Ten-year survival was >80% in patients below 50 years old, but <40% in patients >60 years old. CONCLUSIONS: Bulk FOCA provided promising long-term graft survival and functional improvement in patients <50 years old. It can delay or prevent the need for total knee arthroplasty in young patients. Older patients and patients with a medial-sided graft, or multiple grafts within the same knee, had a less favorable prognosis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Return to Paralympic Rowing After Partial Joint Transplantation: A Case Report.

CASE: A 24-year-old competitive rower suffered a severe road injury to the medial aspect of his knee. He was referred to us for a partial joint transplantation consisting of a medial tibiofemoral fresh osteochondral allograft (FOCA), medial collateral ligament, meniscal allograft, and osteotomy. Two years after reconstruction, the patient won a bronze medal in the Summer Paralympics. At the 6-year follow-up, he demonstrates excellent clinical and radiographic outcomes and high satisfaction. CONCLUSION: For extensive knee injuries with large, complex defects, FOCA with concomitant meniscal allograft transplantation, ligamentous allograft, and osteotomy may be considered in high-demand athletes who wish to return to play.

Temporizing Wound VAC Dressing Until Final Negative Margins are Achieved Reduces Myxofibrosarcoma Local Recurrence.

BACKGROUND: The microinvasive nature of suprafascial myxofibrosarcoma reduces the accuracy of intraoperative margin assessment, and tumor bed resections after soft-tissue reconstruction are unreliable. In 2017, we began temporizing the excised tumor bed with a wound VAC, delaying soft-tissue coverage until final negative margins were achieved. We compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS). METHODS: We retrospectively studied suprafascial myxofibrosarcomas managed from January 1, 2000 to January 1, 2019 for patients who received neoadjuvant or adjuvant radiation and had at least 2 years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed by using Fisher's exact test or Student's t test. A p value < 0.05 was considered significant. RESULTS: Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed reexcision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Postoperative infectious and wound complications were equivalent. CONCLUSIONS: Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.

The association of preoperative blood markers with postoperative readmissions following arthroplasty.

AIMS: While preoperative bloodwork is routinely ordered, its value in determining which patients are at risk of postoperative readmission following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is unclear. The objective of this study was to determine which routinely ordered preoperative blood markers have the strongest association with acute hospital readmission for patients undergoing elective TKA and THA. METHODS: Two population-based retrospective cohorts were assembled for all adult primary elective TKA (n = 137,969) and THA (n = 78,532) patients between 2011 to 2018 across 678 North American hospitals using the American College of Surgeons National Quality Improvement Programme (ACS-NSQIP) registry. Six routinely ordered preoperative blood markers - albumin, haematocrit, platelet count, white blood cell count (WBC), estimated glomerular filtration rate (eGFR), and sodium level - were queried. The association between preoperative blood marker values and all-cause readmission within 30 days of surgery was compared using univariable analysis and multivariable logistic regression adjusted for relevant patient and treatment factors. RESULTS: The mean TKA age was 66.6 years (SD 9.6) with 62% being females (n = 85,163/137,969), while in the THA cohort the mean age was 64.7 years (SD 11.4) with 54% being female (n = 42,637/78,532). In both cohorts, preoperative hypoalbuminemia (< 35 g/l) was associated with a 1.5- and 1.8-times increased odds of 30-day readmission following TKA and THA, respectively. In TKA patients, decreased eGFR demonstrated the strongest association with acute readmission with a standardized odds ratio of 0.75 per two standard deviations increase (p < 0.0001). CONCLUSION: In this population level cohort analysis of arthroplasty patients, low albumin demonstrated the strongest association with acute readmission in comparison to five other commonly ordered preoperative blood markers. Identification and optimization of preoperative hypoalbuminemia could help healthcare providers recognize and address at-risk patients undergoing TKA and THA. This is the most comprehensive and rigorous examination of the association between preoperative blood markers and readmission for TKA and THA patients to date. Cite this article: Bone Jt Open 2021;2(6):388-396.

Periacetabular Osteotomy and Femoral Head Allograft for Hip Dysplasia and Femoral Head Cyst: A Case Report.

CASE: A 34-year-old woman with developmental dysplasia of the hip (DDH) presented with chronic left hip pain related to a femoral head cyst. The patient strongly preferred a joint-preserving option. Periacetabular osteotomy (PAO) has shown reliable options for managing DDH, and femoral head fresh osteochondral allograft (FOCA) can be performed for cysts. We performed these procedures concomitantly for the first time. At 1-year follow-up, the patient had functional, pain-free motion and high satisfaction. CONCLUSION: PAO and femoral head FOCA can be performed concomitantly with a common, anterior hip approach. They are a viable, joint-preserving option for patients with DDH and osteochondral lesions.

Optimization of community-led 3D printing for the production of protective face shields.

BACKGROUND: As the healthcare system faced an acute shortage of personal protective equipment (PPE) during the COVID-19 pandemic, the use of 3D printing technologies became an innovative method of increasing production capacity to meet this acute need. Due to the emergence of a large number of 3D printed face shield designs and community-led PPE printing initiatives, this case study examines the methods and design best optimized for community printers who may not have the resources or experience to conduct such a thorough analysis. CASE PRESENTATION: We present the optimization of the production of 3D printed face shields by community 3D printers, as part of an initiative aimed at producing PPE for healthcare workers. The face shield frames were manufactured using the 3DVerkstan design and were coupled with an acetate sheet to assemble a complete face shield. Rigorous quality assurance and decontamination protocols ensured community-printed PPE was satisfactory for healthcare use. CONCLUSION: Additive manufacturing is a promising method of producing adequate face shields for frontline health workers because of its versatility and quick up-start time. The optimization of stacking and sanitization protocols allowed 3D printing to feasibly supplement formal public health responses in the face of a global pandemic.

Fibrin and Thrombin Sealants in Vascular and Cardiac Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: In vascular and cardiac surgery, the ability to maintain haemostasis and seal haemorrhagic tissues is key. Fibrin and thrombin based sealants were introduced as a means to prevent or halt bleeding during surgery. Whether fibrin and thrombin sealants affect surgical outcomes is poorly established. A systematic review and meta-analysis was performed to examine the impact of fibrin or thrombin sealants on patient outcomes in vascular and cardiac surgery. DATA SOURCES: Cochrane CENTRAL, Embase, and MEDLINE, as well as trial registries, conference abstracts, and reference lists of included articles were searched from inception to December 2019. REVIEW METHODS: Studies comparing the use of fibrin or thrombin sealant with either an active (other haemostatic methods) or standard surgical haemostatic control in vascular and cardiac surgery were searched for. The Cochrane risk of bias tool and the ROBINS-I tool (Risk Of Bias In Non-randomised Studies - of Interventions) were used to assess the risk of bias of the included randomised and non-randomised studies; quality of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two reviewers screened studies, assessed risk of bias, and extracted data independently and in duplicate. Data from included trials were pooled using a random effects model. RESULTS: Twenty-one studies (n = 7 622 patients) were included: 13 randomised controlled trials (RCTs), five retrospective, and three prospective cohort studies. Meta-analysis of the RCTs showed a statistically significant decrease in the volume of blood lost (mean difference 120.7 mL, in favour of sealant use [95% confidence interval {CI} -150.6 - -90.7; p < .001], moderate quality). Time to haemostasis was also shown to be reduced in patients receiving sealant (mean difference -2.5 minutes [95% CI -4.0 - -1.1; p < .001], low quality). Post-operative blood transfusions, re-operation due to bleeding, and 30 day mortality were not significantly different for either RCTs or observational data. CONCLUSION: The use of fibrin and thrombin sealants confers a statistically significant but clinically small reduction in blood loss and time to haemostasis; it does not reduce blood transfusion. These Results may support selective rather than routine use of fibrin and thrombin sealants in vascular and cardiac surgery.