Correction to: Outcomes of surgical treatments of spinal metastases: a prospective study

The correct name of F. Saihlan should be F. Sailhan.

Is the discopathy associated with Modic changes an infectious process? Results from a prospective monocenter study

BACKGROUND

The local infectious origin and the putative role of Cutibacterium acnes (CA) of a particular subtype of discopathy (Modic 1) are still debated.

PURPOSE

To establish the association of CA in intervertebral disc (IVD) and Modic 1 discopathy in patients with low back pain.

METHODS

The prevalence of bacteria in IVD samples obtained by anterior approach in patient with chronic low back pain harboring Modic type 1, 2 or no Modic changes was compared to that measured in IVD samples obtained by posterior approach for sciatica. From 45 patients included in the study, 77 discs samples were obtained: 58 by anterior approach (32 Modic 1/2 changes, 26 without Modic change) and 19 by posterior approach. Conventional microbial cultures, universal 16S rRNA molecular detection and a CA specific PCR were performed.

RESULTS

12 /77 (15.6%) disc samples were culture positive. Among the 10 CA positive cultures, 5 out of 58 (8.6%) were identified from specimens obtained by anterior approach and 5/19 (26.3%) from posterior approach (p = 0.046). Moreover, the percentage of CA culture positive sample was statistically no different between the patient with or without Modic changes. The CA prevalence was lower through molecular, culture-free approaches: the universal 16S rRNA PCR was positive for 6 specimens, including one CA positive sample and the CA specific PCR was positive for one specimen obtained by posterior approach.

CONCLUSIONS

In spine surgery the prevalence of CA in culture was significantly higher in IVD samples collected through a posterior approach compared to an anterior approach, suggesting a contamination process. This study did not support the CA related local infectious origin of Modic 1 discopathy.

Outcomes of surgical treatments of spinal metastases: a prospective study

BACKGROUND

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.

OBJECTIVE

To analyse the outcomes of surgical treatments of spinal metastases.

METHODS

Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.

RESULTS

A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.

CONCLUSION

Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee

PURPOSE

Total knee arthroplasty (TKA) implanted in patients with secondary osteonecrosis (ON) related to corticosteroids have relatively poor outcome (20% revision rate) at a mean follow-up of only eight years. With the hypothesis that subchondral bone marrow injection might improve knees in these patients, we evaluated 30 patients who had bilateral knee osteoarthritis with severe joint space narrowing and received TKA in one knee and subchondral bone marrow concentrate injection in the contralateral knee.

MATERIAL AND METHODS

A prospective randomized controlled clinical trial was carried out in 60 knees of 30 patients (mean age 28 years, 18-41) who presented bilateral osteoarthritis secondary to knee ON related to corticosteroids in relation with different severe medical conditions. During the same anesthesia, one knee received TKA; for the other knee, a bone marrow graft containing an average of 6500 MSCs/mL (counted as CFU-F, range 3420 to 9830) was delivered to the subchondral bone of the femur and tibia. The length of anesthesia related to each procedure (bone marrow aspiration and subchondral injection of concentrated bone marrow versus total knee arthroplasty) was measured. Peri-operative outcomes, morbidity, complications, and safety of the two procedures were compared. Subsequent admissions for revision surgery were identified. At the most recent follow-up (average of 12 years, range 8 to 16 years), clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (MRIs for knees with subchondral bone marrow injection).

RESULTS

Anesthesia related to the TKA side was longer than for the cell therapy group. Medical and surgical complications were more frequent after TKA. A higher number of thrombophlebitis was observed on the side with TKA (15%) versus none on the side with cell therapy (0%). At the most recent follow-up (average of 12 years, range 8 to 16 years), six (out of 30) TKA knees needed subsequent surgery versus only one with cell therapy. The Knee Score had improved and remained similar in the TKA and cell therapy groups (respectively 80.3 points ± 11 versus 78.3 ± 23); 21 patients preferred the knee with cell therapy and 9 preferred the knee with TKA. Knees with cell therapy had improvement on cartilage and bone marrow lesions observed at the site of bone marrow subchondral injection.

CONCLUSIONS

Subchondral autologous bone marrow concentrate was an effective procedure for treating young patients with knee osteoarthritis following secondary ON of the knee related to corticosteroids with a lower complication rate and a quicker recovery as compared with TKA.

Higher prevalence of periprosthetic fractures with ceramic on polyethylene hip bearing compared with ceramic on ceramic on the contralateral side: a forty year experience with hip osteonecrosis

PURPOSE

It is unclear whether late THA periprosthetic femoral fractures are related to a mechanical mechanism that decreases strength of the femur (for example, loosening) or to a biological problem as osteolysis. It is also unknown if ceramic on ceramic bearing couples decrease the risk of late periprosthetic fractures as a result of the absence of wear and osteolysis.

MATERIAL AND METHODS

We therefore asked whether the cumulative long-term fractures were different according to the couple of friction ceramic on ceramic or ceramic on polyethylene in 327 patients (654 hips) with bilateral THA (one ceramic-ceramic, and the contralateral ceramic-polyethylene) who had THA with cemented stems performed between from 1978 to 2000 for osteonecrosis.

RESULTS

There were two intra-operative fractures (0.3%). The median follow-up was 22 years (range, 15-40 years), and at the most recent follow-up, the cumulative number of late (after 7 years of follow-up) post-operative fractures was 32 (5% of 654 hips). Fractures were unilateral, which means for the 327 patients, a 10% rate of fractures. Periprosthetic fractures increased in number with follow-up: seven fractures (1% of 654 hips) occurred within ten years of THA implantation, 20 (3%) within 20 years, 26 (4%) within 30 years, and 32 (5%) within 40 years. The risk of fracture was influenced (p < 0.001) by the bearing surfaces at the time of prosthetic implantation, low (0.3%) for ceramic on ceramic (1/32 fractures; 1/327 hips), high (10%) for ceramic on PE (31/32 fractures; 31/327 hips).

CONCLUSION

In summary, when the contralateral hip of the same patient is the control, after 40 years of follow-up, post-operative fractures occur 30 times more often on the side with PE cup than on the side with ceramic/ceramic bearing.

Talar Osteonecrosis Related to Adult Sickle Cell Disease: Natural Evolution from Early to Late Stages

BACKGROUND

Little is known about the rate of, and factors affecting, progression of talar osteonecrosis related to sickle cell disease. Adult patients with sickle cell disease who presented with hip osteonecrosis were evaluated for talar osteonecrosis with radiographs and magnetic resonance imaging (MRI). Forty-five of them (75 tali) were diagnosed with talar osteonecrosis, and this group was evaluated for factors influencing the progression of the disease.

METHODS

Forty-five patients with sickle cell disease and osteonecrosis of the talus were identified with radiographs and MRI between 1985 and 1995. Seven of these patients were homozygous for hemoglobin S (S/S genotype), 26 had hemoglobin S/hemoglobin C, and 12 had hemoglobin S/beta-thalassemia. The talar osteonecrosis was graded with radiographs and MRI. The patients were followed with clinical examination and radiographs every 6 months until talar collapse and every year after the collapse.

RESULTS

The osteonecrosis was unilateral in 15 patients and bilateral in 30 at the time of the initial examination. Forty-five ankles were asymptomatic and 30 were symptomatic at the initial evaluation. MRI performed at the time of the most recent follow-up, and compared with MRI performed at diagnosis, did not show partial or total regression of the osteonecrosis in any of the patients, even those with asymptomatic stage-I osteonecrosis. At the time of the most recent follow-up (mean, 20 years; range, 15 to 25 years), pain and collapse had developed in all except 12 ankles. The stage of the osteonecrosis at the initial visit, pain, the genotype of the sickle cell disease, and the extent and location of the lesion in the talus were risk factors for progression of the disease.

CONCLUSIONS

In the majority of the patients with sickle cell disease, osteonecrosis of the talus should be expected to show relevant clinical and radiographic evidence of progression over a long period.

LEVEL OF EVIDENCE

Prospective Level II. See Instructions for Authors for a complete description of levels of evidence.

Local transplantation of bone marrow concentrated granulocytes precursors can cure without antibiotics infected nonunion of polytraumatic patients in absence of bone defect

PURPOSE

Infected, long bone non-unions present a significant clinical challenge. New and alternative therapies are needed to address this problem. The purposes of this study were to compare the number of circulating granulocyte-macrophage colony-forming units (CFU-GM) in the peripheral blood of polytraumatic patients with infected tibial non-unions and in the peripheral blood of control patients with the hypothesis that their number was decreased in polytraumatic patients; and to treat their infection without antibiotics and with local transplantation of bone marrow concentrated granulocytes precursors.

METHODS

Thirty (18 atrophic and 12 hyperthrophic ) infected tibial non-unions (without bone defect) that occurred after open fractures in polytraumatic patients were treated without antibiotics and with percutaneous injection of autologous bone marrow concentrate (BMC) containing granulocytes precursors (CFU-GM). CFU-GM progenitors were assessed in the bone marrow aspirate, peripheral blood, and fracture site of these patients. The number of these progenitors was compared with the CFU-GM progenitors of control patient samples (healthy donors matched for age and gender). Outcome measures were: timing of union, callus formation (radiographs and CT scan), and recurrence of clinical infection.

RESULTS

As compared to control patients, the number of CFU GM derived colonies was lower at peripheral blood in patients with infected nonunions. The bone marrow graft injected in nonunions contained after concentration 42 621 ± 20 350 CFU-GM-derived colonies/cc. Healing and cure of infection was observed at six months for 25 patients and at one year follow up for 30 patients. At the median ten year follow-up (range: 5 to 15), only one patient had clinical recurrent infection after healing (between 6 months and last follow-up).

CONCLUSION

The peripheral blood of these polytraumatic patients with infected nonunions had a remarkable decrease in CFU-GM-derived colonies as compared with normal controls. Local transplantation of concentrated CFU-GM-derived colonies aspirated from bone marrow allowed cure of infection and healing without antibiotics.

Outcome of total knee arthroplasty after high tibial osteotomy: does malalignment jeopardize the results when using a posterior-stabilized arthroplasty?

BACKGROUND

The controversy regarding the outcome of total knee arthroplasties after high tibial osteotomy may relate to malalignment secondary to overcorrection after high tibial osteotomy (HTO) [1, 2] and to the type of arthroplasty itself (posterior-stabilized arthroplasty or posterior cruciate ligament-retaining prosthesis).

QUESTIONS/PURPOSE

We asked two questions: (1) Would a posterior-stabilized arthroplasty provide sufficient constrain and improve pain and function in patients with severe malalignment due to a previous HTO? (2) Will malalignment of the previous HTO jeopardize the long-term results of a total knee reconstruction with a posterior-stabilized implant?

PATIENTS AND METHODS

We retrospectively reviewed 25 posterior-stabilized TKAs in 25 patients with severe valgus deformity after HTO (ranging from 10° to 20° of valgus) and compared the results with a series of matched 25 posterior-stabilized TKAs in 25 patients with normocorrection after HTO ranging from 5° of valgus to 5° of varus. Clinical, operative, and radiographic data were reviewed. Minimum follow-up was 10 years after the arthroplasty (average, 15 years; range, 10-20 years).

RESULTS

All the knees had standard posterior-stabilized total knee arthroplasty implants. Patients with an overcorrected HTO were more likely to require a soft tissue release to balance the knee. However, Average Knee Society and Function Score improved, respectively, from 48 to 85 and from 50 to 90 points in the severely overcorrected group, versus, respectively, 50 to 89 and 52 to 97 in the normocorrected group, but the range of mobility was superior for patients with normal alignment. Fifteen-year survivorship after the arthroplasty comparison showed no significant difference between the two groups (one revision in each group).

CONCLUSIONS

Patients with an overcorrected HTO are more likely to require a soft tissue release to balance the knee. However, both groups show improvements in function and pain. With a posterior-stabilized arthroplasty, the degree of deformity has no impact on the longevity of the TKA.

Computer-assisted navigation in patellofemoral arthroplasty: a new technique to improve rotational position of the trochlea

BACKGROUND

Maltracking or subluxation is one of the complications of patellofemoral arthroplasty.

QUESTIONS/PURPOSES

We questioned whether the computed navigation system can improve patellar tracking in patients with patellofemoral arthroplasty (PFA).

METHODS

Between 2007 and 2010 we performed 15 patellofemoral arthroplasties using the Ceraver PFA and navigation assistance. Fifteen other patients underwent surgery without navigation during the same period and acted as a control group. The rotation of the native trochlea as measured using the epicondylar line as a reference before surgery and the rotation of the trochlear component and the trochlear twist angle were assessed with computed tomography (CT) scan after surgery.

RESULTS

The mean follow-up was 3 years (range, 2-5 years). The group with navigation had no patellofemoral complications and better clinical scores. The group without navigation had abnormal patellofemoral tracking in 5 of the 15 patients. CT scan demonstrated excessive internal component rotation, as compared with patients without complications. This excessive internal rotation was proportional to the severity of the patellofemoral maltracking.

CONCLUSIONS

The short-term results suggest that navigation can lead to better trochlear rotation which, in our hands, is associated with fewer cases of patellar maltracking and better overall clinical scores.

Opening wedge tibial osteotomy for large varus deformity with Ceraver resorbable beta tricalcium phosphate wedges

The results in 53 knees that had been treated by proximal tibial opening-wedge osteotomy for large varus deformity and osteoarthritis of the medial compartment were evaluated after a mean length of follow-up of ten years (range, 8-12 years). We used a porous beta-tricalcium phosphate (beta-TCP) wedge because it is resorbable and osteoinductive. All osteotomies were completely consolidated and complete osseointegration of the remnant of the beta-TCP wedge took place. However, after a mean maximum follow-up of ten years none of the cases showed complete resorption. After ten years, 40 (81%) of the 53 knees had an excellent or good result, and in 13 knees there was recurrent pain for which six had an arthroplasty. Although the results deteriorated with time, time was not the only determinant of the result. Alignment, measured as the hip-knee-ankle angle on radiographs of the whole limb that were made with the patient bearing weight, was also a determinant of long-term results. The best results were obtained in the knees that had a hip-knee-ankle angle of 183-186 degrees. In these knees, there was no pain and no progression of the arthrosis in either the medial or the lateral tibiofemoral compartment. Of the three knees that had an angle of more than 186 degrees, all five had progressive degenerative changes in the lateral compartment. In the undercorrected knees (an angle of less than 183 degrees), the results were less satisfactory, and there was a tendency toward recurrence of the varus deformity and progression of the arthritis of the medial compartment. However, when the correction was insufficient the deterioration was slow. Therefore, proximal tibial osteotomy is a very suitable operation even for patients who have gonarthrosis of the medial compartment and a large varus deformity. Although, a rigidly standardised and precise operative technique is required as well as accurate radiographic measurements of the mechanical axis of the limb because exact postoperative alignment is the prerequisite for the longest possible period of relief of symptoms after osteotomy, and this exact alignment is difficult to obtain for patients with large varus deformity.

[Idiopathic tumoral calcinosis: two cases and review of the literature]

Two black patients from Africa presented idiopathic tumoral calcinosis. This rare disease, defined by the presence of calcified deposits in peri-articular tissues remains poorly elucidated. Pathogenesis is still hypothetical. The diagnosis can be established with careful physical examination and appropriate complementary exams, allowing early complete surgical resection without biopsy. Pathology examination is required for formal differential diagnosis. The present tumors were particularly large, but did not produce signs of compression. In the first patient, the tumor developed after pregnancy in the zone of antibiotic injections. The second patient presented multiple bilateral symmetrical localizations with bone invasion. Histology confirmed the nature of the lesions and revealed bony metaplasie in the first patient, an element rarely described. Prognosis is excellent with early treatment. Recurrence is the rule in the event of incomplete resection. We discuss the appropriate diagnostic and therapeutic management.