High prevalence and undertreatment of osteoporosis in elderly patients undergoing total hip arthroplasty.

We detected a high prevalence of low bone mineral density assessed by DXA in 268 elderly patients with end-stage osteoarthritis scheduled for total hip arthroplasty (18% osteoporosis, 41% osteopenia). Therefore, and due to the identified concomitant undertreatment, routine DXA measurements should be considered in elderly patients prior to surgery. INTRODUCTION: Bone quality represents a decisive factor for osseointegration, durability, and complications of an implanted prosthesis. Although the risk of osteoporosis increases with age and the assessment of bone mineral density (BMD) prior to total hip arthroplasty (THA) is recommended in elderly patients, a systematic, unbiased analysis of such patients is not available in the literature. METHODS: In this retrospective study, we examined 268 elderly patients (age ≥70 years) who underwent dual-energy X-ray absorptiometry (DXA) within 3 months prior to primary THA. Demographics, medical history, radiographic OA grade, and stem fixation method (i.e., cemented or cementless) were obtained. RESULTS: In total, 153 (57%) cemented and 115 (43%) cementless stem fixations during THA were performed. Forty-nine patients (18%) were diagnosed with osteoporosis (T-score ≤-2.5), 110 patients (41%) with osteopenia (T-score ≤-1.0), and 109 patients (41%) with normal BMD (T-score >-1.0). Importantly, 36/49 patients (73%) with osteoporosis were not diagnosed before, resulting in a relevant undertreatment. Female sex and low body mass index (BMI) were the main factors negatively influencing the bone mineral density (BMD). CONCLUSIONS: Due to a high incidence of undiagnosed and untreated osteoporosis in elderly patients with potential effects on the success of osseointegration as well as other clinical outcomes, DXA measurements should be included in the clinical routine for these patients prior to THA.

Diagnostic accuracy of alpha-defensin enzyme-linked immunosorbent assay in the clinical evaluation of painful hip and knee arthroplasty with possible prosthetic joint infection: a prospective study of 202 cases.

AIMS: The aim of this study was to evaluate the diagnostic accuracy of the synovial alpha-defensin enzyme-linked immunosorbent assay (ELISA) for the diagnosis of prosthetic joint infection (PJI) in the work-up prior to revision of total hip (THA) and knee arthroplasty (TKA). PATIENTS AND METHODS: Inclusion criteria for this prospective cohort study were acute or chronic symptoms of the index joint without specific exclusion criteria. Synovial fluid aspirates of 202 patients were analyzed and semiquantitative laboratory alpha-defensin ELISA was performed. Final diagnosis of PJI was established by examination of samples obtained during revision surgery. RESULTS: Sensitivity and specificity of the alpha-defensin ELISA for PJI were 78.2% (95% confidence interval (CI) 66.7 to 88.5) and 96.6% (95% CI 93.0 to 99.3). Positive and negative predictive values were 89.6% (95% CI 80.6 to 97.8) and 92.2% (95% CI 87.5 to 96.1). The test remained false-negative in 22% of septic revisions, most of which were due to coagulase-negative staphylococci all occurring in either late-chronic or early-postoperative PJI. CONCLUSION: The routine use of synovial fluid alpha-defensin laboratory ELISA in the preoperative evaluation of symptomatic THAs and TKAs is insufficient to accurately diagnose PJI. Particularly in cases involving low-virulence organisms, such as coagulase-negative staphylococci, there remains a need for tests with a higher sensitivity. Cite this article: Bone Joint J 2019;101-B:970-977.

MRI and sonography in Legg-Calvé-Perthes disease: clinical relevance of containment and influence on treatment.

PURPOSE: The containment orientated treatment of Legg-Calvé-Perthes disease (LCPD) affected hip joints is broadly accepted in the literature. The prerequisite is early recognition of loss of containment. An often-used quantitative MRI containment parameter is the cartilaginous acetabulum-head-index (CAHI). Based on ultrasound (US), we analyzed the newly created 'femoral head extrusion angle' (HA) as a containment parameter in comparison with the CAHI in severe LCPD. METHODS: In a prospective study with 40 children (mean age 5.8 years sd 2.3) with unilateral LCPD classified as Catterall group III/IV, we measured the CAHI versus HA to assess the containment of the femoral head. HA in US was determined by the tangent from the bony acetabular rim to the cartilaginous cranio-lateral femoral head. RESULTS: The HA was significantly higher in LCPD-affected hip joints (25° sd 7°) than in healthy ones (13° sd 5°; p < 0.001). Correlation analysis of all hip joints revealed a significant correlation between HA and CAHI (r = -0.69; p < 0.001). Hip joints with a low CAHI indicating loss of containment showed a higher HA in sonography. CONCLUSION: The results of our study suggest that the HA in US is a reliable containment parameter in severe LCPD with a HA > 22° defining a pathologic value. In comparison with the CAHI, HA measurement in ultrasound is easier than the assessment of various parameters to calculate an index. Frequent sonographical follow-up assessment in critical joints is an alternative if MRI is not available, helping to detect an impending loss of containment early enough. LEVEL OF EVIDENCE: Level II.

Dissociable cerebellar activity during spatial navigation and visual memory in bilateral vestibular failure.

OBJECTIVE: Spatial orientation and navigation depends on information from the vestibular system. Previous work suggested impaired spatial navigation in patients with bilateral vestibular failure (BVF). The aim of this study was to investigate event-related brain activity by functional magnetic resonance imaging (fMRI) during spatial navigation and visual memory tasks in BVF patients. METHODS: Twenty-three BVF patients and healthy age- and gender matched control subjects performed learning sessions of spatial navigation by watching short films taking them through various streets from a driver's perspective along a route to the Cathedral of Cologne using virtual reality videos (adopted and modified from Google Earth). In the scanner, participants were asked to respond to questions testing for visual memory or spatial navigation while they viewed short video clips. From a similar but not identical perspective depicted video frames of routes were displayed which they had previously seen or which were completely novel to them. RESULTS: Compared with controls, posterior cerebellar activity in BVF patients was higher during spatial navigation than during visual memory tasks, in the absence of performance differences. This cerebellar activity correlated with disease duration. CONCLUSIONS: Cerebellar activity during spatial navigation in BVF patients may reflect increased non-vestibular efforts to counteract the development of spatial navigation deficits in BVF. Conceivably, cerebellar activity indicates a change in navigational strategy of BVF patients, i.e. from a more allocentric, landmark or place-based strategy (hippocampus) to a more sequence-based strategy. This interpretation would be in accord with recent evidence for a cerebellar role in sequence-based navigation.