Short-Term (6 Months or Less) Pain in Cemented versus Cementless Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Cementless total knee arthroplasty (TKA) has increased in popularity to potentially improve survivorship. Radiostereometric studies demonstrate increased component migration during the first 3 to 6 months in cementless constructs, generating concern for increased postoperative pain during early osseointegration. The purpose of this study was to evaluate short-term (≤ 6 months) pain and function in cemented versus cementless TKA. We hypothesized that cementless TKA patients report increased pain during the short-term (≤ 6 months) postoperative period. METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Libraries were searched for studies evaluating short-term (≤ 6 months) outcomes of cemented versus cementless primary TKA. Studies involving hybrid fixation were excluded. A meta-analysis was performed using standardized mean difference for primary outcomes (early postoperative pain) and weighted mean difference (WMD) for secondary outcomes (early postoperative function). RESULTS: There were eleven studies included. There was no significant difference in acute postoperative pain between cemented and cementless TKA within 6 months of index TKA (standardized mean difference 0.08 in favor of cemented TKA; P = .10). Early postoperative forgotten joint scores (WMD 0.81; P = .81) and knee injury and osteoarthritis outcome scores for joint replacement (WMD 0.80 in favor of cemented TKA; P = .14) were also similar between groups. CONCLUSIONS: There is no difference in short-term (≤ 6 months) pain or early function between patients receiving cemented and cementless TKA. This suggests that surgeons may utilize cementless TKA without fear of increased pain due to micromotion within 6 months of index arthroplasty. However, additional studies with uniform assessment methods are needed to further inform differences in short-term pain and early functional outcomes between cemented and cementless TKA.

Effects of Acetabular Screws on the Initial Stability of Porous Coated Acetabular Implants in Revision Total Hip Arthroplasty.

INTRODUCTION: Revision total hip arthroplasty in the setting of acetabular bone loss remains a challenging clinical entity. Deficiencies of the acetabular rim, walls, and/or columns may limit the bony surface area and initial acetabular construct stability necessary for osseointegration of cementless components. Press-fit acetabular components with supplemental acetabular screw fixation represent a common technique aimed to minimize implant micromotion and allow for definitive osseointegration. Although acetabular screw fixation is commonly practiced in revision hip arthroplasty, few studies to date have examined the screw properties associated with maximal acetabular construct stability. The purpose of the present report is to examine acetabular screw fixation in a pelvis model mimicking Paprosky IIB acetabular bone loss. METHODS: Measuring bone-implant interface micromotion as a surrogate for initial implant stability, experimental models assessed the effect of screw number, screw length, and screw position on construct stability subject to a cyclic loading protocol designed to replicate joint reaction forces of two common daily activities. RESULTS: Trends towards increasing stability were demonstrated with increasing screw number, increasing screw length, and concentrating screws in the supra-acetabular dome. All experimental constructs yielded micromotion levels sufficient for bone ingrowth, except when screws in the dome were moved to the pubis and ischium. CONCLUSIONS: When using a porous coated revision acetabular implant to treat Paprosky IIB defects, screws should be used, and furthermore, increasing number, length, and position within the acetabular dome may help further stabilize the construct.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review.

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis.

BACKGROUND: Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR). METHODS: Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes. RESULTS: From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]). CONCLUSIONS: There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.

Clinical utilization of species-specific immunoassays for identification of Staphylococcus aureus and Streptococcus agalactiae in orthopedic infections.

Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

Nonoperative Management of Craniocervical Ligamentous Distraction Injury: Literature Review.

Study Design Literature review and case report. Objective Review the existing literature and report the successful nonoperative management of a two-level craniocervical ligamentous distraction injury. Methods A PubMed and Medline review revealed only three limited reports involving the nonoperative management of patients with craniocervical distraction injury. This article reviews the existing literature and reports the case of a 27-year-old man who was involved in a motorcycle accident and sustained multiple systemic injuries and ligamentous distraction injuries to both occipitocervical joints and both C1-C2 joints. The patient's traumatic brain injury and bilateral pulmonary contusions precluded safe operative management of the two-level craniocervical distraction injury. Therefore, the patient was placed in a halo immobilization device. Results The literature remains unclear as to the specific indications for nonoperative management of ligamentous craniocervical injuries. Nonoperative management was associated with poor outcomes in the majority of reported patients. We report a patient who was managed for 6 months in a halo device. Posttreatment computed tomography and flexion-extension radiographs demonstrated stable occipitocervical and C1-C2 joints bilaterally. The patient reported minimal neck pain and had excellent functional outcome with a Neck Disability Index score of 2 points at 41 months postoperatively. He returned to preinjury level of employment without restriction. Conclusions Further study is needed to determine which craniocervical injuries may be managed successfully with nonoperative measures.

A radiographic and clinical comparison of reamer-irrigator-aspirator versus iliac crest bone graft in ankle arthrodesis.

PURPOSE: We evaluated radiographic fusion at follow-up and complication rates in patients who had either iliac crest (ICBG) or femoral reamer-irrigator-aspirator (RIA) bone graft for tibiotalar fusion. METHODS: We retrospectively reviewed charts and radiographs of all patients who had a tibiotalar fusion from August 2007 to February 2011. Records were analysed for patient demographics, complications, and clinical symptoms. Radiographs were reviewed in sequential order by two fellowship-trained foot and ankle surgeons and one orthopaedic surgeon who specialises in foot and ankle surgery to determine radiographic fusion at routine follow-up. Patients were contacted to determine current visual analog scores (VAS) at their graft site. RESULTS: Mean patient age was 49.4 ± 12.1 years in the RIA group and 49.3 ± 15.4 years in the ICBG group (p = .97). Pre-operative characteristics showed no significant differences between groups. The ICBG group had significantly more nonunions than the RIA group (six vs. one, p = 0.04). Two patients in the ICBG had chronic pain at their graft site based on their VAS score; there were none in the RIA group. Radiographic fusion at follow-up was similar between groups, with no significant difference (12.48 ± 3.85 weeks vs.12.21 ± 3.19 weeks, p = .80). CONCLUSIONS: There was a significantly higher nonunion rate in the ICBG group, but both groups had a solid radiographic bony fusion at similar follow-up time points. Our results suggest RIA bone graft is a viable alternative to ICBG for tibiotalar fusion.

Short to midterm clinical and radiographic outcomes of the Salto total ankle prosthesis.

BACKGROUND: Total ankle arthroplasty (TAA) has become an increasingly effective treatment option for tibiotalar arthritis. The purpose of this study was to evaluate the short to midterm clinical and radiographic outcomes of the Salto fixed bearing total ankle prosthesis. METHODS: We retrospectively reviewed the radiographs and patient records of 74 consecutive patients with 75 TAA implants from January 2007 to April 2011. The average age was 60.6 years (range, 41-82) with 41 females and 33 males. The average clinical follow-up was 43 months (range, 24-73 months). Radiographs were reviewed for areas of radiolucency and cystic changes around the talar and tibial implants, as well as for implant migration using standardized tibal, talar, talocalcaneal, and tibial slope angular measurements. The validated Foot and Ankle Outcome Score (FAOS), Short Form-12 (SF-12), and Visual Analog Scale (VAS) were used as subjective patient outcome measures. Kaplan Meier (K-M) curves were created for implant survivorship with revision of components as an endpoint and for return to the operating room for any reason. RESULTS: Total ankle survivorship was 98%. Thirteen patients returned to the operating room for any reason. There was 1 deep infection, and no ankles were converted to an arthrodesis. Average ankle dorsiflexion and plantarflexion improved from 4.3 ± 3.3 to 8.7 ± 5.6 degrees (P = .0008) and 24 ± 11 to 29 ± 7 degrees (P = .04), respectively. Patients showed significant improvements in all subscales of the FAOS (P < .0001). The physical component of the SF-12 significantly improved from 30 ± 8 to 41 ± 13 (P < .0001), but this was not observed with the mental component (52 ± 1 vs 53 ± 1, P = .55). The mean VAS for patient satisfaction was 9 (range, 2-10). Two patients had component migration (1 tibial and 1 talar component), neither of which required a revision procedure. Six ankles had a total of 9 radiolucent lines with a radiographically stable implant, and no patients had cystic changes. CONCLUSION: This is one of the first articles to report clinical and radiographic outcome data for the fixed bearing version of this prosthesis. We observed significant improvements in subjective outcome measures and range of motion with a 98% component survivorship at short to midterm follow-up. Longer follow-up will be necessary to determine the durability of this implant. LEVEL OF EVIDENCE: Level IV, case series.