Hip arthroscopy with initial access to the peripheral compartment for femoroacetabular impingement: midterm results from a large-scale patient cohort.

BACKGROUND: Hip arthroscopy with initial access to the peripheral compartment could reduce the risk of iatrogenic injury to the labrum and cartilage; furthermore, it avoids the need for large capsulotomies with separate portals for peripheral and central (intra-articular) arthroscopy. Clinical results of the peripheral-compartment-first technique remain sparse, in contrast to those of conventional hip arthroscopy starting in the intra-articular central compartment. The purpose of this study was to assess outcome of hip arthroscopy with the peripheral-compartment-first technique, including complication rates, revision rates and patient-reported outcome scores. MATERIALS AND METHODS: This outcome study included 704 hips with femoroacetabular impingement. All arthroscopies were performed using the peripheral-compartment-first technique. A joint replacement registry and the institutional database were used to assess the revision and complication rates, while patient-reported outcome measures were used to assess functional outcomes and patient satisfaction. RESULTS: In total, 704 hips (615 patients) were followed up for a mean of 6.2 years (range 1 to 9 years). The mean age of the patients was 32.1 ± 9.2 years. During the follow-up period, 26 of 704 (3.7%) hips underwent total hip arthroplasty (THA) after a mean of 1.8 ± 1.2 years, and 18 of the 704 (2.6%) hips required revision hip arthroscopy after a mean of 1.2 ± 2.1 years. 9.8% of the hips had an unsatisfactory patient-reported outcome at final follow-up. CONCLUSIONS: The results for the peripheral-compartment-first technique were promising. We recommend a well-conducted randomized controlled clinical trial to guide future therapeutic recommendations regarding the most favorable hip arthroscopy technique. LEVEL OF EVIDENCE: Level IV, therapeutic study. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov (U.S. National Library of Medicine; ID: NCT05310240).

Can gadolinium contrast agents be replaced with saline for direct MR arthrography of the hip? A pilot study with arthroscopic comparison.

OBJECTIVE: To compare image quality and diagnostic performance of preoperative direct hip magnetic resonance arthrography (MRA) performed with gadolinium contrast agent and saline solution. METHODS: IRB-approved retrospective study of 140 age and sex-matched symptomatic patients with femoroacetabular impingement, who either underwent intra-articular injection of 15-20 mL gadopentetate dimeglumine (GBCA), 2.0 mmol/L ("GBCA-MRA" group, n = 70), or 0.9% saline solution ("Saline-MRA" group, n = 70) for preoperative hip MRA and subsequent hip arthroscopy. 1.5 T hip MRA was performed including leg traction. Two readers assessed image quality using a 5-point Likert scale (1-5, excellent-poor), labrum and femoroacetabular cartilage lesions. Arthroscopic diagnosis was used to calculate diagnostic accuracy which was compared between groups with Fisher's exact tests. Image quality was compared with the Mann-Whitney U tests. RESULTS: Mean age was 33 years ± 9, 21% female patients. Image quality was excellent (GBCA-MRA mean range, 1.1-1.3 vs 1.1-1.2 points for Saline-MRA) and not different between groups (all p > 0.05) except for image contrast which was lower for Saline-MRA group (GBCA-MRA 1.1 ± 0.4 vs Saline-MRA 1.8 ± 0.5; p < 0.001). Accuracy was high for both groups for reader 1/reader 2 for labrum (GBCA-MRA 94%/ 96% versus Saline-MRA 96%/93%; p > 0.999/p = 0.904) and acetabular (GBCA-MRA 86%/ 83% versus Saline-MRA 89%/87%; p = 0.902/p = 0.901) and femoral cartilage lesions (GBCA-MRA 97%/ 99% versus Saline-MRA 97%/97%; both p > 0.999). CONCLUSION: Diagnostic accuracy and image quality of Saline-MRA and GBCA-MRA is high in assessing chondrolabral lesions underlining the potential role of non-gadolinium-based hip MRA. KEY POINTS: • Image quality of Saline-MRA and GBCA-MRA was excellent for labrum, acetabular and femoral cartilage, ligamentum teres, and the capsule (all p > 0.18). • The overall image contrast was lower for Saline-MRA (Saline-MRA 1.8 ± 0.5 vs. GBCA-MRA 1.1 ± 0.4; p < 0.001). • Diagnostic accuracy was high for Saline-MRA and GBCA-MRA for labrum (96% vs. 94%; p > 0.999), acetabular cartilage damage (89% vs. 86%; p = 0.902), femoral cartilage damage (97% vs. 97%; p > 0.999), and extensive cartilage damage (97% vs. 93%; p = 0.904).

Are degenerative findings detected on traction MR arthrography of the hip associated with failure of arthroscopic femoroacetabular impingement surgery?

OBJECTIVES: To identify preoperative degenerative features on traction MR arthrography associated with failure after arthroscopic femoroacetabular impingement (FAI) surgery. METHODS: Retrospective study including 102 patients (107 hips) undergoing traction magnetic resonance arthrography (MRA) of the hip at 1.5 T and subsequent hip arthroscopic FAI surgery performed (01/2016 to 02/2020) with complete follow-up. Clinical outcomes were assessed using the International Hip Outcome Tool (iHOT-12) score. Clinical endpoint for failure was defined as an iHOT-12 of < 60 points or conversion to total hip arthroplasty. MR images were assessed by two radiologists for presence of 9 degenerative lesions including osseous, chondrolabral/ligamentum teres lesions. Uni- and multivariate Cox regression analysis was performed to assess the association between MRI findings and failure of FAI surgery. RESULTS: Of the 107 hips, 27 hips (25%) met at least one endpoint at a mean 3.7 ± 0.9 years follow-up. Osteophytic changes of femur or acetabulum (hazard ratio [HR] 2.5-5.0), acetabular cysts (HR 3.4) and extensive cartilage (HR 5.1) and labral damage (HR 5.5) > 2 h on the clockface were univariate risk factors (all p < 0.05) for failure. Three risk factors for failure were identified in multivariate analysis: Acetabular cartilage damage > 2 h on the clockface (HR 3.2, p = 0.01), central femoral osteophyte (HR 3.1, p = 0.02), and femoral cartilage damage with ligamentum teres damage (HR 3.0, p = 0.04). CONCLUSION: Joint damage detected by preoperative traction MRA is associated with failure 4 years following arthroscopic FAI surgery and yields promise in preoperative risk stratification. CLINICAL RELEVANCE STATEMENT: Evaluation of negative predictors on preoperative traction MR arthrography holds the potential to improve risk stratification based on the already present joint degeneration ahead of FAI surgery. KEY POINTS: • Osteophytes, acetabular cysts, and extensive chondrolabral damage are risk factors for failure of FAI surgery. • Extensive acetabular cartilage damage, central femoral osteophytes, and combined femoral cartilage and ligamentum teres damage represent independent negative predictors. • Survival rates following hip arthroscopy progressively decrease with increasing prevalence of these three degenerative findings.

Patients with combined pelvic and spinal injuries have worse clinical and operative outcomes than patients with isolated pelvic injuries analysis of the German Pelvic Registry.

BACKGROUND: Pelvic fractures are often associated with spine injury in polytrauma patients. This study aimed to determine whether concomitant spine injury influence the surgical outcome of pelvic fracture. METHODS: We performed a retrospective analysis of data of patients registered in the German Pelvic Registry between January 2003 and December 2017. Clinical characteristics, surgical parameters, and outcomes were compared between patients with isolated pelvic fracture (group A) and patients with pelvic fracture plus spine injury (group B). We also compared apart patients with isolated acetabular fracture (group C) versus patients with acetabular fracture plus spine injury (group D). RESULTS: Surgery for pelvic fracture was significantly more common in group B than in group A (38.3% vs. 36.6%; p = 0.0002), as also emergency pelvic stabilizations (9.5% vs. 6.7%; p < 0.0001). The mean time to emergency stabilization was longer in group B (137 ± 106 min vs. 113 ± 97 min; p < 0.0001), as well as the mean time until definitive stabilization of the pelvic fracture (7.3 ± 4 days vs. 5.4 ± 8.0 days; p = 0.147). The mean duration of treatment and the morbidity and mortality rates were all significantly higher in group B (p < 0.0001). Operation time was significantly shorter in group C than in group D (176 ± 81 min vs. 203 ± 119 min, p < 0.0001). Intraoperative blood loss was not significantly different between the two groups with acetabular injuries. Although preoperative acetabular fracture dislocation was slightly less common in group D, postoperative fracture dislocation was slightly more common. The distribution of Matta grades was significantly different between the two groups. Patients with isolated acetabular injuries were significantly less likely to have neurological deficit at discharge (94.5%; p < 0.0001). In-hospital complications were more common in patients with combined spine plus pelvic injuries (groups B and D) than in patients with isolated pelvic and acetabular injury (groups A and C). CONCLUSIONS: Delaying definitive surgical treatment of pelvic fractures due to spinal cord injury appears to have a negative impact on the outcome of pelvic fractures, especially on the quality of reduction of acetabular fractures.

Mid-Term Results After 517 Primary Total Hip Arthroplasties With a Shortened and Shoulderless Double-Taper Press-Fit Stem: High Rates of Aseptic Loosening.

BACKGROUND: Shorter double-taper stems with reduced lateral shoulders facilitate implantation via the muscle-sparing direct anterior approach and are becoming increasingly popular. We observed an unusually high number of cases of aseptic loosening with the use of a modified stem. Therefore, the aim of this prospective single-center study was to assess safety and efficacy of this cementless stem. METHODS: A total of 486 consecutive patients receiving 517 primary total hip arthroplasties using the MonoconMIS stem were prospectively followed up for a mean period of 5.29 years (standard deviation [SD], 1.47). Surgical and clinical data, complications, and revision surgeries were analyzed. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was recorded before surgery and at one year and five years after surgery. RESULTS: The overall 5-year implant survival rate was 95.2%. The individual component survival rates were 96.1% for the stem, 99.4% for the acetabular cup, and 99.0% for the isolated mobile component exchange. The most common reasons for revision were periprosthetic fracture (1.5%), aseptic stem loosening (1.4%), and infection (1.0%). The WOMAC score improved significantly from 49.57 (SD, 21.42) at baseline to 13.33 (SD, 16.47) at one year and 9.84 (SD, 14.45) at five years after surgery. Aseptic stem loosening occurred only in patients with Dorr type A proximal femur morphology. CONCLUSION: The evaluated femoral stem is associated with revision rates higher than what has been reported for other implants. The WOMAC scores suggest adequate efficacy. Our data do not support the use of the MonoconMIS for primary total hip arthroplasty in patients with Dorr type A proximal femur morphology.

Survivorship of Ceramic-on-Ceramic Total Hip Arthroplasty With Metal-Backed Acetabular Liners at 10 Years.

BACKGROUND: Ceramic-on-ceramic bearings are becoming increasingly popular in primary total hip arthroplasty (THA). To enhance ceramic-on-ceramic liner exchange in case of revision surgery, metal-backed liner systems have been proposed. Little is known about the clinical performance of these implants. The purpose of this study is to evaluate a metal-backed liner implant system for primary THA. METHODS: A total of 422 patients (with 468 consecutive THAs) were followed over a mean period of 10 years. All arthroplasties were performed with a cementless stem, a press-fit cup, and a metal-backed liner system. Surgical and clinical data, complications, and revisions were analyzed. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before surgery and at 1 and 10 years after surgery were compared. RESULTS: The overall 10-year implant survival rate was 93.8%. The survival rate was 97.0% for heads and liners, 97.5% for stem, and 99.3% for acetabular cup. The most common reason for revision was ceramic breakage (2.4%) of the third-generation (BIOLOX forte) acetabular liner. Mean WOMAC score improved significantly from 50.1 before surgery to 13.2 at 1 year after surgery. There was no difference in WOMAC scores between surgical approach and type of bearing at 1 and 10 years after surgery. CONCLUSION: THA using cementless stem, press-fit cup, and metal-backed liner system provides satisfactory long-term outcomes, with revision rate comparable to that with other systems available in the market. The metal-backed liner system has low risk of mal-seating. Third-generation ceramic liners should be avoided as they seem to be more prone to breakage.

The negative impact of the COVID-19 lockdown on pain and physical function in patients with end-stage hip or knee osteoarthritis.

PURPOSE: The purpose of this study was to evaluate pain, functional impairment, mental health, and daily activity in patients with end-stage hip and knee osteoarthritis (OA) during the COVID-19 lockdown. METHODS: The study included 63 patients, with hip or knee OA, who had been scheduled for arthroplasty that was postponed because of COVID-19. Patients were evaluated by telephone interviews during the first week after lockdown, in the fourth week, and again at the end of the lockdown. Patients rated their pain level on the basis of a visual analog scale (VAS) and completed WOMAC, SF-12 and Tegner activity scale (TAS) questionnaires. RESULTS: VAS and WOMAC scores increased significantly during lockdown, while physical activity significantly decreased. At the final evaluation, VAS and WOMAC showed a significant negative correlation with TAS. The SF-12 subscale scores showed a significant decrease of the physical component during the lockdown, while the mental component remained largely unchanged. Patients with knee OA showed a faster progress of pain compared to those with hip OA. 50 patients (79%) stated they wished to have arthroplasty as soon as possible. CONCLUSION: The COVID-19 lockdown had a significant impact on pain, joint function, physical function, and physical activity in patients with end-stage hip and knee OA. LEVEL OF EVIDENCE: II (Prospective cohort study).

Three-dimensional computed tomography reconstruction improves the reliability of tibial pilon fracture classification and preoperative surgical planning.

PURPOSE: In the present study, we aimed to evaluate the impact of two-dimensional multi-planar computed tomography (2D-MP-CT) scans and three-dimensional surface rendering computed tomography reconstruction (3D-SR-CT) on the inter- and intra-observer reliability of four commonly used classification systems for tibial pilon fractures, and on the reliability and validity of surgical treatment planning for fracture fixation. METHODS: Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for bone graft augmentation. Fractures were first evaluated using 2D-MP-CT, followed by 3D-SR-CT. We calculated the Kappa values for the correlation between the fracture classifications, types of surgical approaches, implant positions, and bone graft recommendations by the observers. Furthermore, we assessed the correlation between the treatment plans recommended by the observers and the actual surgical procedure performed. RESULTS: All classifications showed poor inter-observer reliability and moderate intra-observer reliability with 2D-MP-CT scans. The inter-observer reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications improved to moderate, whereas the intra-observer reliability of the AO/OTA classification improved to good with additional 3D-SR-CT. The correlation between the suggested and the actually performed surgical approaches was poor with 2D-MP-CT, but improved to moderate with 3D-SR-CT. The suggested plate positions showed a moderate correlation with the actually performed plating; although the correlation improved significantly, it remained moderate with 3D-SR-CT. CONCLUSION: The use of 3D-SR-CT reconstruction can improve the reliability of the Rüedi and Allgöwer, AO/OTA, and Tang classifications. Furthermore, three-dimensional imaging enables a more valid planning of the surgical approach and implant position.

Evaluation criteria for the assessment of occupational diseases of the lumbar spine - how reliable are they?

BACKGROUND: In 2005, the German Association of Occupational Accident Insurance Funds (DGUV) defined radiological evaluation criteria for the assessment of degenerative occupational diseases of the lumbar spine. These include the measurement of intervertebral osteochondrosis and classification of vertebral osteosclerosis, antero-lateral and posterior spondylosis, and spondyloarthritis via plain radiography. The measures currently remain in daily use for determining worker compensation among those with occupational diseases. Here, we aimed to evaluate the inter- and intra-observer reliability of these evaluation criteria. METHODS: We enrolled 100 patients with occupational degenerative diseases of the lumbar spine. Native antero-posterior and lateral radiographs of these patients were evaluated according to DGUV recommendations by 4 observers with different levels of clinical training. Evaluations were again conducted after 2 months to assess the intra-observer reliability. RESULTS: The measurement of intervertebral osteochondrosis showed good inter-observer reliability (ICC: 0.755) and excellent intra-observer reliability (ICC: 0.827). The classification of vertebral osteosclerosis exhibited moderate kappa values for inter-observer reliability (К: 0.426) and intra-observer reliability (К: 0.441); the remaining 3 criteria showed poor inter- and intra-observer reliabilities. CONCLUSION: The measurement of intervertebral osteochondrosis and classification of vertebral osteosclerosis showed adequate inter- and intra-observer reliability in the assessment of occupational diseases of the lumbar spine, whereas the classification of antero-lateral and posterior spondylosis and spondyloarthritis stage exhibited insufficient reliability. Hence, we recommend the revision of the DGUV recommendations for the evaluation of occupational diseases of the lumbar spine.

Screw tip augmentation leads to improved primary stability in the minimally invasive treatment of displaced intra-articular fractures of the calcaneus: a biomechanical study.

PURPOSE: To investigate if the stability of minimally invasive screw osteosynthesis of displaced intra-articular calcaneal fractures (DIACF) can be effectively increased by an innovative approach to screw tip augmentation. METHODS: In eight-paired human cadaver hindfoot specimens, DIACF of Sanders type IIB were treated with either standard screw osteosynthesis or with bone cement augmentation of the screw tips in the main fragments. The instrumented specimens were subjected to a cyclic loading protocol (9000 cycles, with stepwise increasing loads, 100-1000 N). The interfragment motions were quantified as tuber fragment tilt (TFT) and posterior facet inclination angle (PFIA) using a 3-D motion analysis system. Böhler's angle (BA) was evaluated from X-rays. A load-to-failure test was performed after the cyclic loading protocol. RESULTS: All but one specimen of the augmented group withstood more cycles than the respective specimens of the non-augmented group. Mean cycles to failure for the failure criterion of 5° TFT were 7299 ± 1876 vs. 3864 ± 1810, corresponding to loads of 811 N ± 195 vs. 481 N ± 180, (P = 0.043). There were no significant differences observed in the PFIAs. The failure criterion of 5° BA was reached after a mean of 7929 cycles ± 2004 in the augmented group and 4129 cycles ± 2178 in the non-augmented group, corresponding to loads of 893 N ± 200 vs. 513 N ± 218, (P = 0,090). The mean load-to-failure of the four specimens in the augmented group that completed the cyclic loading was 1969 N over a 1742-2483 N range. CONCLUSION: Screw tip augmentation significantly improved the mechanical stability of the calcanei after osteosynthesis in terms of decreased tuber fragment tilts and less changes in Böhler's angle.

Isolated radial neck delayed union/nonunion after conservative treatment in adults: two case reports and a literature review.

BACKGROUND: Treatment recommendations for isolated radial neck delayed union/nonunion are sparse, but include mainly conservative treatment, electro-stimulation, bone grafting, open reduction and internal fixation (ORIF) and radial head resection. The purpose of this study was to perform a literature review on isolated delayed union/nonunion of radial neck fractures and to evaluate the reported outcomes of proposed treatment strategies. Furthermore, we aimed to generate data-based recommendations for this rare pathology. In the second part of this paper, we report two clinical cases of delayed union of isolated radial neck fractures recently treated at the senior authors institution. METHODS: A literature search on PubMed was performed. We selected all papers with a documented delayed union, pseudarthrosis or nonunion of the radial neck. All papers were reviewed for patient demographics, patient occupation, treatment type and timing relative to the initial trauma, X-ray documentation and outcome. The two patients with delayed union after isolated radial neck fractures recently treated at our institution were evaluated for age, mechanism of injury, occupation, treatment and outcome. Clinical and radiological follow-up examinations were performed 6, 12 weeks, and 1 year after initial trauma. Final clinical evaluations included the Mayo Elbow Performance Score (MEPS) [1] and the Disabilities of the Arm, Shoulder and Hand (DASH) Score [2]. RESULTS: We found 17 cases reported in 11 articles matching our selection criteria of isolated radial neck delayed union or nonunion in adult patients. Average age was 55 years (range 29-73 years). The most frequent mechanism of injury was a fall on an outstretched arm from standing height. Initial treatment consisted of an arm sling for 1-4 weeks and physiotherapy. From the 17 included cases, six were operated on due to persistent pain. Three received bone grafts, one was supplemented with additional K-wire fixation, and three had radial head resections. Ten patients were treated conservatively: six were pain free and three were symptomatic at last follow-up; symptoms were not reported for one case. All surgically treated cases were pain free at the last follow-up, average 32 months (range 6-84). Of the conservatively treated group, eight of ten had documented nonunion. The two reported cases from our institution were initially treated conservatively for 4 and 6 months. Both had a radiologically documented delayed union. Both patients were operated on due to persistent pain precluding them from returning to work. At the last follow-up, MEPS and DASH scores were 100 points and 29 in one case and 100 points and 18 in the other, respectively. CONCLUSION: Isolated delayed union or nonunion of the radial neck after conservative treatment in adult patients appears to be rare and often remains asymptomatic. Operative treatment is recommended for symptomatic delayed union/nonunion in patients with altered elbow function [3]. All surgically treated patients in our study with symptomatic delayed unions/nonunions had favorable clinical outcomes.

Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.

BACKGROUND: Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. METHODS: Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m2; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. RESULTS: Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for inpatient care in our study population. Furthermore, medical input factors such as the surgeon's level of experience, operation time or use of local anaesthesia at the end of surgery had also no significant influence on whether patients preferred inpatient care or not. Medical output factors not found to contribute to the patients' decisions included co-morbidities or postoperative nausea and vomiting (PONV). Patients of experienced surgeons reported significantly less pain at the operation site. This was correlated with a somewhat increased willingness to accept ambulatory treatment. CONCLUSION: Given the choice, about half of the LC patients in central Switzerland prefer to stay in hospital overnight. PONV, age, sex or social surroundings were not predictive of the preferred treatment modality. Only being a non-Swiss citizen and experiencing little pain at the operation site due to the surgeon's skills seem to be factors that lead to a preference for ambulatory LC (ALC). Therefore, ALC in central Switzerland is most acceptable to non-Swiss citizens, operated upon by experienced surgeons.

The dorsal tangential X-ray view to determine dorsal screw penetration during volar plating of distal radius fractures.

PURPOSE: To evaluate whether the dorsal tangential view (DTV) allows for reliable and valid in vivo measurement of the distance between screw tips and the dorsal radial cortex (STCD) during volar plating of distal radius fractures. METHODS: Subjects included 22 patients with displaced distal radius fractures who had volar plate osteosynthesis. We performed standardized DTV images intraoperatively. After surgery, we performed computed tomography (CT) scans with reconstructions parallel to the distal screws. Three independent observers blinded to the study protocol measured the STCD on the basis of the DTV images and CT reconstructions. We calculated inter- and intraobserver reliability and the correlation between STCD values measured with DTV images and CT scans. RESULTS: Eleven screws were changed intraoperatively. We observed no cases of postoperative screw perforations. Inter- and intraobserver reliability of STCD measurement was good when measured with DTV images and excellent when measured on the basis of CT reconstructions. Statistical analysis showed a good correlation between mean STCD values measured with DTV and CT. CONCLUSIONS: The DTV allowed in vivo evaluation of the dorsal radial cortex and enabled reliable assessment of the distance between the screw tip and the dorsal cortex. It may allow detection of dorsal screw perforation during volar plating of distal radial fractures.

Subtalar arthrodesis stabilisation with screws in an angulated configuration is superior to the parallel disposition: a biomechanical study.

PURPOSE: The purpose of this study was to compare the stability of two established screw configurations (SC) for subtalar arthrodesis using a cyclic loading model. METHODS: Eight paired human cadaver hindfoot specimens underwent subtalar arthrodesis with either parallel or angulated SC. The instrumented specimens were subjected to a cyclic loading protocol (1000 cycles: ±5 Nm rotation moment, 50 N axial force). The joint range of motion (ROM) was quantified before and after cyclic loading, in the three principal motion planes of the subtalar joint using pure bending moments of ±3 Nm. RESULTS: After instrumentation, the angulated SC showed significantly less mean ROM compared to the parallel SC in internal/external rotation (1.4° ± 2.2° vs. 3.3° ± 2.8°, P = 0.006) and in inversion/eversion (0.9° ± 1.4° vs. 1.5° ± 1.1°, P = 0.049). After cyclic loading, the angulated SC resulted in significantly less mean ROM compared to the parallel SC in internal/external rotation (3.3° ± 4.6° vs. 8.8° ± 8.0°, P = 0.006) and in inversion/eversion (1.9° ± 2.3° vs. 3.9° ± 3.9°, P = 0.017). No significant differences in the mean ROM were found between the angulated and parallel SC in dorsal extension/plantar flexion. CONCLUSION: The angulated SC resulted in decreased ROM in the subtalar arthrodesis construct after instrumentation and after cyclic loading compared to the parallel SC. The data from our study suggest that the clinical use of the angulated SC for subtalar arthrodesis might be superior to the parallel SC.

Is the cortical thickness index a valid parameter to assess bone mineral density in geriatric patients with hip fractures?

INTRODUCTION: Reduced bone quality is a common problem during surgical fixation of geriatric hip fractures. The cortical thickness index (CTI) was proposed to assess the bone mineral density (BMD) of the proximal femur on the basis of plain X-rays. The purpose of this study was to evaluate the inter- and intraobserver reliability of the CTI and to investigate correlation between CTI and BMD in geriatric patients. METHODS: 60 patients (20 pertrochanteric fractures, 20 femoral neck fractures, 20 without fractures) were included. All patients had ap and lateral hip X-rays and measurement of BMD by Dual Energy X-ray Absorptiometry at different areas of the hip. The ap and lateral CTI was measured twice by four blinded observers and correlation between mean CTI and BMD was calculated. RESULTS: Mean ap CTI was 0.52 and mean lateral CTI was 0.45. Inter- and intraobserver reliability was good for ap CTI (ICC 0.71; 0.79) and lateral CTI (ICC 0.65; 0.69). A significant correlation between CTI and overall BMD was found in patients without fractures (r = 0.74; r = 0.67). No significant correlation between CTI and overall BMD was found in patients with proximal femoral fractures. CONCLUSION: The CTI has sufficient reliability for the use in daily practice. It showed significant correlation with BMD in patients without hip fractures. In patients with proximal femoral fractures, no correlation between CTI and BMD was found. We do not recommend the CTI as parameter to assess the BMD of the proximal femur in geriatric patients with hip fractures.

An MR-compatible stereoscopic in-room 3D display for MR-guided interventions.

BACKGROUND AND METHODS: A commercial three-dimensional (3D) monitor was modified for use inside the scanner room to provide stereoscopic real-time visualization during magnetic resonance (MR)-guided interventions, and tested in a catheter-tracking phantom experiment at 1.5 T. Brightness, uniformity, radio frequency (RF) emissions and MR image interferences were measured. RESULTS AND DISCUSSION: Due to modifications, the center luminance of the 3D monitor was reduced by 14%, and the addition of a Faraday shield further reduced the remaining luminance by 31%. RF emissions could be effectively shielded; only a minor signal-to-noise ratio (SNR) decrease of 4.6% was observed during imaging. During the tracking experiment, the 3D orientation of the catheter and vessel structures in the phantom could be visualized stereoscopically.

Manual lymphatic drainage before and after total knee arthroplasty, a randomized controlled trial.

Purpose: Manual lymphatic drainage (MLD) is a routine therapeutic technique used to decrease peripheral oedema by activating lymphatic drainage. Evidence for its efficacy remains sparse. Therefore, the purpose of this study was to evaluate the effect of MLD before and after total knee arthroplasty (TKA). Methods: This was a single-centre randomized, controlled and observer-blinded trial. 112 patients were randomly assigned to one of three groups: group 1 underwent MLD for 30 min daily on five consecutive days both before and after TKA; group 2 underwent MLD for 30 min daily on five consecutive days only after TKA; and the control group did not undergo MLD. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, range of knee motion, swelling and pain were assessed before TKA, after two days, five days and six weeks. Results: The overall age of the patients was 69.4 years (SD = 9.8, range = 41-87). The groups were well matched in terms of sex, age, height, weight, and body mass index. There was no statistically significant difference with regard to any of the outcome measures between the groups. Conclusions: The present results indicate that MLD had no significant benefits when applied either before or early after TKA. Therefore, we do not recommend the routinely use of MLD in the early period before or after TKA. Further studies should evaluate the effect of MLD after arthroscopic surgery. Level of evidence: Therapeutic Level II, Lower quality RCT with follow up <80.

Radiological predictors of outcomes in hip arthroscopy for femoroacetabular impingement.

Aims: Hip arthroscopy has gained prominence as a primary surgical intervention for symptomatic femoroacetabular impingement (FAI). This study aimed to identify radiological features, and their combinations, that predict the outcome of hip arthroscopy for FAI. Methods: A prognostic cross-sectional cohort study was conducted involving patients from a single centre who underwent hip arthroscopy between January 2013 and April 2021. Radiological metrics measured on conventional radiographs and magnetic resonance arthrography were systematically assessed. The study analyzed the relationship between these metrics and complication rates, revision rates, and patient-reported outcomes. Results: Out of 810 identified hip arthroscopies, 359 hips were included in the study. Radiological risk factors associated with unsatisfactory outcomes after cam resection included a dysplastic posterior wall, Tönnis grade 2 or higher, and over-correction of the α angle. The presence of acetabular retroversion and dysplasia were also significant predictors for worse surgical outcomes. Notably, over-correction of both cam and pincer deformities resulted in poorer outcomes than under-correction. Conclusion: We recommend caution in performing hip arthroscopy in patients who have three positive acetabular retroversion signs. Acetabular dysplasia with a lateral centre-edge angle of less than 20° should not be treated with isolated hip arthroscopy. Acetabular rim-trimming should be avoided in patients with borderline dysplasia, and care should be taken to avoid over-correction of a cam deformity and/or pincer deformity.

CT-guided infiltration of the ischiofemoral space in young patients with ischiofemoral impingement is an effective diagnostic tool.

OBJECTIVES: To present our technique of diagnostic CT-guided ischiofemoral space injection and report on pain response, complications, and associated imaging findings in young patients with ischiofemoral impingement (IFI). METHODS: Retrospective case series of patients with a clinical diagnosis of IFI that underwent CT-guided IFS injection with local anesthetic in a prone position with the feet in maximum internal rotation between 06/2019 and 04/2021. The response was evaluated using maximum subjective pain evaluation on a 0-10 visual analog scale (VAS) during a standardized pre- and postinterventional clinical examination. Patient charts and radiographic imaging data were reviewed to report associated imaging findings and subsequent surgeries. RESULTS: Eleven patients (13 hips, 9 females) with a median age of 31 years (interquartile range; IQR: 25-37 years) were included. Median baseline VAS was 7 points (IQR: 5-8) with a pain reduction of 5 points (IQR: 5-7 points, p = 0.001) after the injection. One patient reported transient ischial nerve paresthesia, otherwise, no complications occurred. Quadratus femoris muscle edema was present in 85% (11 of 13 hips). Excessively high femoral torsion (11/13 hips, 85%) and cam deformities (8/13 hips, 62%) were the most common osseous deformities. Eight of 13 hips (62%) underwent subsequent surgery for IFI. CONCLUSION: CT-guided diagnostic injection of the ischiofemoral space is safe and feasible. In young IFI patients, diagnostic IFS injections have the potential to improve the differential diagnosis of hip pain and to inform decision-making with regard to a possible benefit of joint-preserving hip surgery. CRITICAL RELEVANCE STATEMENT: In young patients with hip pain, diagnosis of IFI can be challenging due to concomitant pathologies. Furthermore, surgical treatment in these patients is controversial. In this context, CT-guided diagnostic infiltrations of the ischiofemoral space may facilitate not only the initial diagnosis of IFI, but could also improve surgical decision-making. KEY POINTS: CT-guided diagnostic injection of local anesthetic in the ischiofemoral space is safe. In young patients with IFI, it leads to subjective pain reduction. In young patients with concomitant osseous deformities, it may improve surgical decision-making.