Comparison of Mini-Midvastus and Conventional Total Knee Arthroplasty with Clinical and Radiographic Evaluation: A Prospective Randomized Clinical Trial with 5-Year Follow-up

BACKGROUND

The main objective of this prospective randomized study was to compare the clinical and radiographic outcomes of the mini-midvastus (MMV) approach with the conventional approach for total knee arthroplasty at the 5-year follow-up.

METHODS

Ninety-seven patients (100 knees) with osteoarthritis were assigned to the MMV group or to a group receiving conventional total knee arthroplasty. Intraoperative and postoperative clinical data were collected. At 6 weeks and at 1, 2, and 5 years postoperatively, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), the Knee Society Score (KSS), and the Short Form (SF)-12 were completed. Radiographs of the knee were made preoperatively and at 1 day and 1 and 5 years postoperatively. Computed tomography (CT) scans were performed 2 years postoperatively.

RESULTS

In the MMV group, the mean skin incision was 2.5 cm shorter (p < 0.001) and the mean duration of the operation was 6 minutes longer than in the conventional total knee arthroplasty group (p < 0.05). Eight patients in the conventional group had a lateral parapatellar retinacular release compared with 1 in the MMV group; the difference was significant (p = 0.01). Three intraoperative complications, including 2 small lateral femoral condylar fractures and 1 partial patellar tendon laceration, occurred in the MMV group. Seven patients in the MMV group had postoperative blisters; all of them had a relatively large femoral component and 4 of them were large men. The radiographs and CT scans of the prostheses showed no significant differences between the MMV and conventional groups except for the posterior slope of the tibial component. In addition, no significance differences were detected between the groups with respect to the KOOS, OKS, KSS, and SF-12 scores determined at the 6-week and the 1, 2, and 5-year follow-up evaluations.

CONCLUSIONS

In the rehabilitation period and at the short and mid-term follow-up, no relevant clinical and radiographic differences were found between the MMV and the conventional approach for total knee arthroplasty, making the advantage of MMV total knee arthroplasty cosmetic. We discourage the use of the MMV approach in large male patients because of the increased number of intraoperative complications and skin blisters postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury

INTRODUCTION

Much of the currently available data on the technical aspects of syndesmotic screw placement are based upon biomechanical studies, using cadaveric legs with different testing protocols, and on surgeon preference. The primary aim of this study was to investigate the effect of the level of syndesmotic screw insertion on functional outcome. Further, the effects of number of cortices engaged, the diameter of the screw, use of a second syndesmotic screw and the timing of removal on functional outcome were tested.

MATERIAL AND METHOD

All consecutive patients treated for an ankle fracture with concomitant acute distal tibiofibular syndesmotic injury that had a metallic syndesmotic screw placed, between 1 January 2004 and 31 December 2010, were included. Patient characteristics (i.e., age at injury and gender), fracture characteristics (i.e., affected side, trauma mechanism, Weber fracture type and number of fractured malleoli), and surgical characteristics (i.e., level of screw placement, screw diameter, tri- or quadricortical placement, number of syndesmotic screws used and the timing of screw removal) were recorded. Outcome was measured using validated questionnaires, which were sent by post, and consisted of the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Olerud-Molander Ankle Score (OMAS) and a single question Visual Analog Scale (VAS) for patient satisfaction with outcome.

RESULTS

During the 7-year study period, 122 patients were treated for syndesmotic injury. A total of 93 patients (76%) returned the questionnaire. The median follow-up was 51 months. The outcome scoring systems showed an overall score for the entire group of 92 points for the AOFAS, 77 for the OMAS and 8.2 for the VAS. Outcome was statistically significantly influenced by the number of fractured malleoli, age, trauma mechanism and the level of screw insertion.

CONCLUSION

Overall, the functional outcome of acute syndesmotic injuries treated with a syndesmotic screw was good and mainly influenced by patient and fracture characteristics. Most different technical aspects of placement appeared not to influence these results. Only screw placement above 41 mm negatively influenced outcome.

Delirium risk screening and haloperidol prophylaxis program in hip fracture patients is a helpful tool in identifying high-risk patients, but does not reduce the incidence of delirium

Background

Delirium in patients with hip fractures lead to higher morbidity and mortality. Prevention in high-risk patients by prescribing low dose haloperidol is currently under investigation.

Methods

This prospective cohort surveillance assessed hip fracture patients for risk of developing a delirium with the Risk Model for Delirium (RD) score. High-risk patients (score ≥ 5 points) were treated with a prophylactic low-dose of haloperidol according to hospital protocol. Primary outcome was delirium incidence. Secondary outcomes were differences between high- and low-risk patients in delirium, length of stay (LOS), return to pre-fracture living situation and mortality. Logistic regression analysis was performed with age, ASA-classification, known dementia, having a partner, type of fracture, institutional residence and psychotropic drug use as possible confounders.

Results

445 hip fracture patients aged 65 years and older were admitted from January 2008 to December 2009. The RD-score was completed in 378 patients, 173 (45.8%) high-risk patients were treated with prophylactic medication. Sensitivity was 71.6%, specificity 63.8% and the negative predictive value (NPV) of a score < 5 was 85.9%.

Delirium incidence (27.0%) was not significantly different compared to 2007 (27.8%) 2006 (23.9%) and 2005 (29.0%) prior to implementation of the RD- protocol.

Logistic regression analysis showed that high-risk patients did have a significant higher delirium incidence (42.2% vs. 14.1%, OR 4.1, CI 2.43-7.02). They were more likely to be residing at an alternative living situation after 3 months (62.3% vs. 17.0%, OR 6.57, CI 3.23-13.37) and less likely to be discharged from hospital before 10 days (34.9% vs. 55.9%, OR 1.63, CI 1.03-2.59). Significant independent risk factors for a delirium were a RD-score ≥ 5 (OR 4.13, CI 2.43-7.02), male gender (OR 1.93, CI 0.99-1.07) and age (OR 1.03, CI 0.99-1.07).

Conclusions

Introducing the delirium prevention protocol did not reduce delirium incidence.

The RD-score did identify patients with a high risk to develop a delirium. This high-risk group had a longer LOS and returned to pre-fracture living situation less often.

The NPV of a score < 5 was high, as it should be for a screening instrument. Concluding, the RD-score is a useful tool to identify patients with poorer outcome.

Cemented versus non-cemented hemiarthroplasty of the hip as a treatment for a displaced femoral neck fracture: design of a randomised controlled trial

BACKGROUND

A discussion is ongoing whether displaced femoral neck fractures in elderly patients should be treated with a non-cemented or a cemented hemiarthroplasty. A recent Cochrane analysis stresses the importance of further research into the relative merits of these techniques. We hypothesise that non-cemented hemiarthroplasty will result in at least the same technical-functional outcome and complication rate, with a shorter operation time.

METHODS AND DESIGN

A randomised controlled multicentre trial will be performed.The study population consists of 200 patients of 70 years and older. Patients with a displaced femoral neck fracture will be allocated randomly to have a cemented or a non-cemented hemiarthroplasty. Data will be collected preoperatively, immediately postoperatively, and 6 weeks, 3 months and 1 year postoperatively.The main outcome measures of this study are technical-functional results of the hemiarthroplasty, duration of surgery, complications, and mid-thigh pain. Secondary outcome measures are living conditions at final follow up, self-reported health-related quality of life, and radiological evaluation of the hemiarthroplasty.

CONCLUSION

A recent Cochrane analysis did not find arguments in favour of either non-cemented or cemented hemiarthroplasty. The forthcoming trial will compare treatment for a displaced femoral neck fracture by cemented versus non-cemented hemiarthroplasty. Our results will be published as soon as they become available.

TRIAL REGISTRATION

Trial Registration Number NTR1508.

[Diagnostic image (311). A newborn with a strange leg. Congenital knee luxation type I (genu recurvatum)]

A newborn girl's right leg was fixed in hyperextension due to congenital knee luxation type I (genu recurvatum).