The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case-control study

PURPOSE

Variations in total knee arthroplasty (TKA) joint line height may lead to complications such as pain and altered joint mechanics, while posterior condylar offset (PCO) can influence knee stability.

METHODS

Single-centre, single-surgeon retrospective analysis from December 2019 to May 2023 investigated primary unilateral TKA (Nexgen Legacy, Zimmer Biomet) in patients with knee osteoarthritis, using ROSA robotic system (raTKA) or conventional manual technique (mTKA). Joint line height and PCO were measured and compared in 182 raTKA and 144 mTKA patients.

RESULTS

The groups were matched in age (p = 0.847) and sex distribution (p = 0.2). Excellent interobserver agreement (ICC ≥ 0.9). RaTKA mean joint line height difference was - 0.0001 mm (± 3.48, 95% CI - 0.509, 0.509) (p = 0.523), - 0.951 mm for mTKA (± 4.33, 95% CI - 1.664, - 0.237) (p = 0.009). RaTKA mean PCO difference was 0.52 mm (± 2.45, 95% CI 0.160, 0.880) (p = 0.005), 1.15 mm for mTKA (± 4.01, 95% CI - 1.496, 1.818) (p < 0.001). Mean difference in joint line height of 0.95 mm between groups was significant (p = 0.027), and for PCO, it was 0.63 mm, demonstrating tendency towards significance (p = 0.08). Mean absolute value in joint line height difference between groups was not significant (p = 0.235) but highly significant for PCO (p < 0.001).

CONCLUSION

The ROSA knee robotic system can more accurately restore joint line height and PCO compared to conventional manual TKA. The improved degree of precision raTKA offers may be a vehicle for better Patient-Reported Outcome Measures, but further correlational studies are required.

Effectiveness of virtual reality compared to video training on acetabular cup and femoral stem implantation accuracy in total hip arthroplasty among medical students: a randomised controlled trial

PURPOSE

Virtual reality (VR) training effectiveness in improving hip arthroplasty surgical skills requires further evaluation. We hypothesised VR training could improve accuracy and the time taken by medical students compared to a control group with only video teaching.

METHODS

This single-centre randomized controlled clinical trial collected data from March to June 2023. Surgically naïve volunteer undergraduate medical students performed three sessions on a VR training platform, either cup (VR-Cup=Control-Stem) or stem (VR-Stem=Control-Cup) implantation. The primary outcome was the mean difference between predefined cup inclination (60°) and stem anteversion (20°) compared to the actual implanted values in sawbones between VR and control groups. Secondary outcomes were task completion time and mistake number between the groups.

RESULTS

A total of 101 students participated (VR-Cup 47, VR-Stem 54). Groups did not significantly differ concerning age (p = 0.879), gender (p = 0.408), study year (p = 0.938), previous VR use (p = 0.269) and baseline medical and procedural knowledge. The VR-Cup implanted the cup closer to the intended target (p < 0.001) and faster than the Control-Cup group (p = 0.113). The VR-Stem implanted the stem closer to the intended target (p = 0.008) but not faster than the Control-Cup group (p = 0.661). Stem retroversion was commoner in the Control-Stem than in the VR-Stem group (p = 0.016).

CONCLUSIONS

VR training resulted in higher rates of accurate procedure completion, reduced time and fewer errors compared to video teaching. VR training is an effective method for improving skill acquisition in THA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05807828.

Collared versus collarless hydroxyapatite-coated stems for primary cementless total hip arthroplasty; a systematic review of comparative studies. Is there any difference in survival, functional, and radiographic outcomes?

INTRODUCTION

This systematic review aims to critically assess the literature comparative studies investigating collared and collarless Corail stem in primary total hip arthroplasty (THA) to find differences in revision rates, radiographic and clinical outcomes, and postoperative complications between these two types of the same stem.

METHODS

Eligible studies were found by searching PubMed, Science Direct/Scopus, and the Cochrane Database of Systematic Reviews from conception till May 2023. The PRISMA guidelines were followed. The investigation encompassed randomized controlled trials, case series, comparative, cohort, and observational studies that assessed at least one comparative outcome or complication between collared and collarless Corail stems.

RESULTS

Twelve comparative studies with 90,626 patients undergoing primary THA were included. There were 40,441 collared and 58,543 collarless stems. The follow-up ranged from 12 to 360 months. Our study demonstrated no significant difference in stem revision relative risk (RR = 0.68; 95% confidence interval (CI), 0.23, 2.02; p = 0.49), number of radiolucent lines (RR = 0.3; 95% CI, 0.06, 2.28; p = 0.29) and overall complication risk (RR = 0.62; 95% CI, 0.22, 1.76; p = 0.37) between collared and collarless stems. The collared stems demonstrated significantly lesser subsidence (mean difference: 1.01 mm; 95% CI, -1.77, -0.25; p = 0.009) and risk of periprosthetic fractures (RR = 0.52; 95% CI, 0.29, 0.92; p = 0.03).

CONCLUSION

The comparative studies between collared and collarless stem groups showed similar survival and overall complication rates and functional outcomes. The similar revision rates between groups make the impact of higher subsidence for collarless stems uncertain. The lower risk of periprosthetic fractures in the collared stems group must be clarified further but could be related to increased rotational stability.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Primary Staged Bilateral Total Hip Arthroplasty in a Patient With Short Stature and Hartofilakidis Type I Developmental Dysplasia of the Hip

Syndromes associated with osteochondrodysplasia, short stature, and DDH are rarely reported in the literature. Total hip arthroplasty (THA) in such cases is a complex procedure with a high rate of complications and difficulties. In this case report, we describe the staged bilateral complex primary THA of a patient with the rare occurrence of a syndrome involving osteochondrodysplasia and DDH, highlighting the surgical challenges and importance of the right prosthesis selection.

The learning curve to ROSA: cases needed to match the surgery time between a robotic-assisted and a manual primary total knee arthroplasty

PURPOSE

Limited published data regarding the ROSA (Robotic Surgical Assistant) learning curve exist. This study evaluated the number of cases needed for an expert orthopaedic surgeon to master the ROSA system and match the operative time of robotic (raTKAs) and manual primary total knee arthroplasties (mTKAs).

METHODS

This retrospective comparative cohort study included two hundred patients with primary knee osteoarthritis. The study group consisted of an expert surgeon's first 100 raTKAs. The control group included 100 patients that underwent mTKAs from the same surgeon during the same period. The consecutive cases in each group were divided into ten subgroups, each of 10 cases. The groups were comparable concerning age, sex, BMI and Kellgren-Lawrence classification. We compared each subgroup's operative time and complications in mTKA and raTKA groups. We performed a cumsum analysis to construct the ROSA learning curve.

RESULTS

The first non-significant difference between the mTKAs and raTKAs operative times was observed in the subgroup of 62 to 71 cases. Till then, the operative time has been significantly lower for the mTKA than the raTKA group. The following groups of tens analysis (8th, 9th and 10th) showed no operative time difference between groups. The learning curve analysis demonstrated that the surgeon switched to the mastering phase from case 73 onwards. The two groups had no complication rate differences.

CONCLUSION

Our study demonstrated that about 70 cases are necessary for a senior surgeon to balance operative time between mTKAs and raTKAs using the ROSA system.

Bisphosphonates' use and risk of aseptic loosening following total hip arthroplasty: a systematic review

Purpose

The main indication of bisphosphonates (BPs) is osteoporosis treatment. However, there is growing interest in the peri- and postoperative use of BPs to mitigate total hip arthroplasty (THA) aseptic loosening (AL) risk. This systematic review aimed to evaluate the implant survival and the AL rate in patients with elective THA receiving BPs compared to those that do not receive BPs. Secondary outcomes included the comparison of revision rate, postoperative complications, and patients' functional scores.

Methods

This systematic review was conducted under the PRISMA 2020 guidelines with a pre-registered PROSPERO protocol. Three engines and grey literature were searched up until May 2022. Randomized and nonrandomized controlled trials and comparative cohort studies assessing BP and control therapy impact on THA survival were included.

Results

Twelve studies embraced the inclusion criteria. A total of 99 678 patients and 99 696 THAs were included; 10 025 patients received BPs (BP group), and 89 129 made up the control group. The overall revision and AL rates were lower in the BP group (2.17% and 1.85%) than in the control group (4.06% and 3.2%). Periprosthetic fracture (PPF) cases were higher in the BP group (0.24%) than in the control group (0.04%); however, the majority of PPF cases were derived from a single study. Further complication risk was similar between groups. Most studies reported comparable functional scores between groups.

Conclusion

BP treatment after elective THA seems to reduce the overall revision and AL risk. Other complications' risk and functional scores were similar between groups. Further high-quality studies are needed to validate the results due to the multifactorial AL pathogenesis.

Complex Primary Total Knee Arthroplasty in a Young Patient With Neurofibromatosis Type One and Multidirectional Knee Instability: Technical Tips and Outcome

Neurofibromatosis is an inherited disorder that causes skin discoloration and tumors. The musculoskeletal symptoms are specific, including bone deformities, dysplasia, joint instability, and osteoporosis. We present a rare case of a young patient with neurofibromatosis and multidirectional knee instability who underwent a successful complex primary knee replacement surgery. Stress right knee radiographs showed global joint instability with permanent anterior knee dislocation, excessively hypoplastic femoral condyles and patella, joint surfaces incongruency, and hypoplastic varus tibia, with intraluminal midshaft bone bridge causing severe stenosis. The patient could not walk, had an unstable recurvatum right knee, and used a wheelchair for her professional activities. The surgery involved a fully cemented rotating-hinged total knee arthroplasty with tibial and femoral stems. After three years of follow-up, the patient remains pain-free, fully ambulatory with no walking aids, a stable knee, a full range of motion, and no signs of aseptic loosening. This case highlights the decision-making difficulties and the significant surgical challenges faced during the operation.

A Rare Case of Staphylococcus caprae-Caused Periprosthetic Joint Infection Following Total Hip Arthroplasty: A Literature Review and Antibiotic Treatment Algorithm Suggestion

In this study, we discuss a case of a 59-year-old male who developed a periprosthetic joint infection (PJI) three months after a total hip arthroplasty (THA). The patient complained of groin and buttock pain, swelling, and high temperature. A palpable fluid collection, discomfort, edema, and elevated local temperature were present in the clinical examination. Laboratory analysis revealed elevated white blood cells, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). The preoperative joint aspiration came up positive for Staphylococcus caprae (S. caprae) infection. Diagnosis and pathogen identification were confirmed by histological examination of six tissue samples obtained during surgery. We initially performed early debridement, antibiotics, and implant retention (DAIR) followed by antibiotic therapy suggested by an infectious disease specialist. DAIR failed two months later, and we proceeded to a two-stage revision. Following surgery, the patient was treated with intravenous antibiotic combination therapy for three weeks and thereafter with oral antibiotics for three months. Four months down the line, the patient is free of symptoms, and the inflammatory markers are normal. Finally, we will proceed with the second stage of revision. This study highlights a very rare case of PJI infection by S. caprae, reviews the limited literature, and provides the available evidence for surgical and antibiotic management.

Is thyroid disease associated with post-operative complications after total joint arthroplasty? A systematic review of the literature

Background

This comprehensive systematic review aims to assess the literature regarding the risk of postoperative complications in patients undergoing total joint arthroplasty (TJA) with concomitant thyroid dysfunction.

Methods

Studies were identified by searching PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and ClinicalTrials.gov (end of search: May 2022).

Inclusion criteria

Randomized control and case-control studies, cohort and observational clinical studies were included, which focused on postoperative complications and outcomes of patients undergoing TJA operations of major joints (knee, hip, ankle, elbow). All studies were assessed according to their level of evidence, the number and age of patients, and treatment complications.

Analysis

Nine studies were included in this review that demonstrated a higher risk of postoperative anemia, perioperative blood loss, hemoglobin decrease, and transfusion rates in hypothyroid patients after TJA.

Results

Hypothyroidism has been identified as a potential but modifiable risk factor for increased rates of deep venous thrombosis, acute kidney injury, pneumonia, and non-specified cardiac complications among hypothyroid patients who underwent TJA as well as increased rates of periprosthetic joint infection. No significant differences in the prosthesis-related mechanical complication rates have been calculated when comparing hypothyroid and euthyroid patients.

Constrained liners revisited: favourable mid-term results in patients with high-risk of dislocation: technical considerations for the optimal outcome

BACKGROUND

The outcomes of constrained liners (CLs) in total hip arthroplasty (THA) remain inconclusive. We evaluated the mid-term performance of CLs in a consecutive series of high-risk dislocation patients undergoing primary or revision THA performed by a single surgeon. The survival, dislocation rate, complications, and functional patients' scores were assessed. Surgical tips to enhance outcomes were reviewed.

METHODS

45 patients who received the Trident Tripolar CL between 2010 to 2019 were retrospectively evaluated from Arthroplasty Registry Thessaloniki. There were 17 primary and 28 revision THAs. The primary indications for using CL were severe abductor insufficiency or comorbidities, increasing the dislocation risk in primary, and recurrent dislocation or abductor insufficiency in revision THAs. The mean patient's age was 68.5 (±14.5) years, and the mean follow-up 3.81 (±1.66) years.

RESULTS

There were 2 dislocations and 1 deep infection in the revision group. For any reason, the cumulative 6-year survival rate was 93.3%, 100% for primary, and 89.3% for revision THAs. The mean overall CL survival was 76.3 months for any reason (95% CI, 68.1-84.5) and 80.5 months for dislocation (95% CI, 75.8-85.2). The mean postoperative functional scores were significantly improved (p < 0.001) at the latest follow-up.

CONCLUSIONS

CLs can provide hip stability and durable fixation in selected low-demand patients with high-risk for dislocation after primary and revision THA at mid-term follow-up. Careful patient selection and the refined surgical technique aiming at the neutral liner position and considering the high CLs' offset relative to stem-neck impingement are necessary to maximise outcomes.

Superior Transverse Atraumatic Reconstruction (STAR) approach provides a better-compared outcome to standard Direct Superior Approach (DSA): a matched, prospective comparative single-surgeon study

INTRODUCTION

The Direct Superior Approach (DSA) is a muscle-sparing hip approach that does not protect the piriformis and the other short external rotators. We present a DSA modification we named STAR (Superior Transverse Atraumatic Reconstruction), which has DSA advantages but always preserves piriformis. Our study compared the early postoperative, radiological, and functional results of patients undergoing primary total hip arthroplasty (THA) through the STAR approach with a matched DSA group performed by a senior surgeon.

METHODS

Each group, DSA, and STAR included 200 elective primary unilateral THAs performed by the surgeon between 2016-2017 and 2020-2021, respectively. Patients were included in both groups using the same inclusion criteria. Both groups were matched for age and sex. The same postoperative pain management, chemoprophylaxis, and physiotherapy protocols were followed in both groups. Two independent orthopaedic surgeons performed the clinical and radiological follow-up.

RESULTS

The STAR group had significantly lower mean incision length (p = 0.042) and hospital stay (p = 0.002) than the DSA group. The mean intraoperative blood loss (p = 0.085) and the need for blood transfusion (p = 0.228) were less for the STAR than the DSA group. The mean postoperative functional scores improvement was significantly higher for the STAR than the DSA group at the end of the first and third postoperative months.

CONCLUSIONS

The STAR approach offers earlier functional improvement, shorter hospital stay and less transfusion need than DSA for patients undergoing primary THA. Both approaches showed a limited complication risk and an outstanding acetabular and femoral access enabling the procedure.

Comparative outcomes between a new robotically assisted and a manual technique for total knee arthroplasty in patients with osteoarthritis: a prospective matched comparative cohort study

PURPOSE

Studies comparing clinical outcomes between manual (mTKA) and robotic-assisted TKA (raTKA) are limited. This prospective comparative cohort study aimed to compare early postoperative outcomes, satisfaction, and patient-reported outcome measures (PROMS) between patients undergoing mTKA and ROSA raTKA (Zimmer Biomet, Warsaw, IN) performed by one surgeon.

METHODS

Thirty ROSA raTKAs and 30 mTKAs performed by one surgeon during 2020-2021 were prospectively evaluated. Groups were matched for age, sex, and body mass index. All procedures were primary unilateral TKAs using the same posterior-stabilized prosthesis (Nexgen Legacy, Zimmer Biomet, Warsaw, IN). Length of hospital stay (LOS) and blood transfusion rate were recorded. Complications, visual analogue scale score (VAS), and Oxford Knee Score (OKS) were assessed preoperatively and for six postoperative months. The Forgotten Joint Score (FJS) and patient satisfaction were evaluated 6 months postoperatively.

RESULTS

No complications and similar blood transfusion rate were recorded between groups (p = 0.228). The LOS was non-significantly shorter in raTKA than in the mTKA group (p = 0.120). Mean preoperative and third-month OKS and VAS scores were comparable between groups. However, the mean 6-month OKS (p = 0.006) and VAS score (p = 0.025) were significantly better for the raTKA group. The 6-month FJS was significantly greater for raTKA than the mTKA group (p < 0.001). One patient was unhappy in raTKA, and three in the mTKA group (p = 0.301). Significantly more raTKA patients answered that they would undergo surgery again (p = 0.038).

CONCLUSION

raTKA was associated with the same complication risk, less pain level, better patient satisfaction, and PROMs on 6-month follow-up than the mTKA group.

Earlier functional recovery and discharge from hospital for THA patients operated on via direct superior compared to standard posterior approach: a retrospective frequency-matched case-control study

BACKGROUND

The direct superior hip approach (DSA) has been less researched than other approaches in the literature. We retrospectively compared the early postoperative and functional outcomes of patients with hip osteoarthritis undergoing total hip arthroplasty (THA) via DSA with a matched control group using a standard posterior approach (SPA).

METHODS

The DSA group comprised 100 THAs performed via DSA by a senior surgeon between January 2018 and May 2019. Patients with primary osteoarthritis and ASA score ⩽3 who were eligible for surgery were included. The DSA group was compared to a matched cohort of 100 patients operated on with a SPA in the same period by another chief surgeon. Patients were matched for age, sex, and ASA score. All patients received the same postoperative chemoprophylaxis, pain management and physiotherapy. 2 independent attending arthroplasty surgeons assessed the incision length, operative time, blood loss, hospital stay, and complications. VAS, HHS, and HOOS scores were also evaluated for a year postoperatively.

RESULTS

Mean incision length and hospital stay were significantly lower in the DSA group. DSA patients had non-significantly lower intraoperative blood loss, transfusion needs, and postoperative pain than SPA patients. Mean operation time and complication rate did not differ between groups. The DSA group demonstrated significantly greater functional scores than the SPA group at the first postoperative month. No differences in scores were recorded following the third month.

CONCLUSIONS

The DSA approach may provide earlier functional recovery and hospital discharge for THA patients compared with SPA. DSA was equivalent to SPA concerning pain and blood loss, showing minimal complication rates.

The impact of stem fixation method on Vancouver Type B1 periprosthetic femoral fracture management

INTRODUCTION

Our understanding of the impact of the stem fixation method in total hip arthroplasty (THA) on the subsequent management of periprosthetic femoral fractures (PFF) is still limited. This study aimed to investigate and quantify the effect of the stem fixation method, i.e., cemented vs. uncemented THA, on the management of Vancouver Type B1 periprosthetic femoral fractures with the same plate.

METHODS

Eight laboratory models of synthetic femora were divided into two groups and implanted with either a cemented or uncemented hip prosthesis. The overall stiffness and strain distribution were measured under an anatomical one-legged stance. All eight specimens underwent an osteotomy to simulate Vancouver type B1 PFF's. Fractures were then fixed using the same extramedullary plate and screws. The same measurements and fracture movement were taken under the same loading conditions.

RESULTS

Highlighted that the uncemented THA and PFF fixation constructs had a lower overall stiffness. Subsequently, the mechanical strain on the fracture plate for the uncemented construct was higher compared to the cemented constructs.

CONCLUSION

PFF fixation of a Vancouver type B1 fracture using a plate may have a higher risk of failure in uncemented THAs.

Differences between two sequential uncemented stem sizes in total hip arthroplasty: A comparative biomechanical study and potential clinical implications

Background: Early failure of uncemented femoral stems associated with incorrect sizing is a known postoperative complication. Surgeons are often faced with the question of whether an uncemented stem of adequate stability or a larger-sized stem should be implanted, especially when the proximal femoral cancellous bone is adequate. The biomechanical effect of sub-optimal stem sizing in the femur remains unclear. This study investigated the mechanical behaviour of two sequential sized uncemented stems of the same type. Methods: Six laboratory models of synthetic non-osteoporotic femora were randomly divided into two groups and implanted with either a nominal or oversized uncemented hydroxyapatite-coated nonporous titanium collarless stem. Stiffness, uniaxial strain, and pattern of strain distribution were measured under an anatomical one-legged stance. Results: Oversized stems demonstrated a higher overall stiffness compared to nominal; however, this was not statistically significant. The nominal stem showed a higher strain in the neck and the proximal medial diaphyseal region. The oversized stem showed higher strains in the distal region around the implant tip. Conclusion: Opting to use a larger stem may potentially increase primary stability, thus allowing safer early mobility. However, higher stiffness may lead to stress shielding, bone loss, and thigh pain in the long term. In addition, strains in the diaphysis and the tip of the stem may predispose to periprosthetic fractures, especially in osteoporotic bones, making this a relatable aspect for users and biomechanical loading. Given the wide range of complex factors that need to be considered when choosing stem size in uncemented THA surgery, this study’s results should be interpreted cautiously.

A Rare Case of Traumatic Bilateral Elbow Dislocation Without a Fracture in a Seven-Year-Old Female Child

Pediatric bilateral elbow dislocation is an infrequent injury. This is a report of a seven-year-old girl, the youngest patient ever reported, with simultaneous isolated bilateral traumatic elbow dislocation without fracture, treated with closed reduction under sedation.

Gluteus maximus tendon transfer for chronic abductor insufficiency: the Geneva technique

INTRODUCTION

The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon.

METHODS

We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months.

RESULTS

The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported.

CONCLUSIONS

This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.

Survival of monoblock RM vitamys compared with modular PINNACLE cups: mid-term outcomes of 200 hips performed by a single surgeon

INTRODUCTION

Monoblock cups have theoretical advantages over modular cups; however, their superiority in terms of survival has not been confirmed in comparative studies.

METHODS

We compared the mid-term survivorship of 107 RM Pressfit vitamys monoblock cups (Mathys Ltd., Bettlach, Switzerland) with 93 modular pressfit Pinnacle cups (DePuy Synthes, Warsaw, IN, USA). All cases were registered in the Arthroplasty Registry Thessaloniki and performed by a senior surgeon through the same approach between 2013 and 2014. The groups were comparable in sex distribution, preoperative diagnosis, follow-up, cup diameter, head diameter, type and use of screws, HOOS and HSS preop scores; the recipients of RM cup were significantly younger.

RESULTS

3 sockets were revised. The 6-year survival for any reason was 99.1% for the RM and 97.8 % for the PINNACLE group. There was no difference in survival for aseptic loosening and any reason between groups (log-rank test p = 0.921 and p = 0.483, respectively). The age (95% CI, 0.79-1.1), sex (95% CI, 0.2-45.0), cup diameter (95% CI, 0.18-1.1), head diameter (95% CI, 0.004-6.2), preoperative diagnosis and use of screws (95% CI, 0.02-4.3), did not influence hazard ratio for revision between groups. HHS and HOOS were comparable at the last follow-up.

CONCLUSIONS

Our study demonstrated that both cup designs had similar revision rates at mid-term follow-up, regardless the fact that the RM vitamys was used in a cohort of younger patients; which according to the literature would have led to earlier failures. Further long-term data are needed to evaluate the superiority of RM vitamys in the clinical setting, especially in the young.

Molecular sequencing technologies in the diagnosis and management of prosthetic joint infections

INTRODUCTION

Prosthetic joint infections (PJIs) can be challenging to eradicate and have high morbidity and mortality. Current microbiology culture methods can be associated with a high false-negative rate of up to 50%. Early and accurate diagnosis is crucial for effective treatment, and negative results have been linked to a greater rate of reoperation.

AREAS COVERED

There has been increasing investigation of the use of next-generation sequencing (NGS) technology such as metagenomic shotgun sequencing to help identify causative organisms and decrease the uncertainty around culture-negative infections. The clinical importance of the organisms detected and their management, however, requires further study. The polymerase chain reaction (PCR) has shown promise, but in recent years multiple studies have reported similar or lower sensitivity for bacteria detection in PJIs when compared to traditional culture. Furthermore, issues such as high cost and complexity of sample preparation and data analysis are to be addressed before it can move further toward routine clinical practice.

EXPERT OPINION

Metagenomic NGS has shown results that inspire cautious optimism - both in culture-positive and culture-negative cases of joint infection. Refinement of technique could revolutionize the way PJIs are diagnosed, managed, and drastically improve outcomes from this currently devastating complication.

Efficacy of parathyroidectomy compared with active surveillance in patients with mild asymptomatic primary hyperparathyroidism: a systematic review and meta-analysis of randomized-controlled studies

OBJECTIVE

Parathyroidectomy (PTx) has an established benefit in patients with symptomatic primary hyperparathyroidism (PHPT). However, its efficacy in mild asymptomatic PHPT has not been proven. This study aimed to systematically review and meta-analyze the best available evidence from randomized-controlled trials comparing the efficacy of PTx over conservative management (non-PTx) on skeletal outcomes [fractures and bone mineral density (BMD)], nephrolithiasis risk and quality of life (QoL) in patients with mild asymptomatic PHPT.

METHODS

A comprehensive literature search was conducted in PubMed, Scopus and Cochrane databases, from conception to February 23, 2020. Data were extracted from the studies that fulfilled the eligibility criteria and were synthesized quantitatively (fixed or random effects model) as relative risks and percentage mean differences (MD) with 95% confidence intervals (CI). I² index was employed for heterogeneity.

RESULTS

Four studies were included in the meta-analysis. There was no difference in fracture risk between PTx and active surveillance. The PTx group demonstrated higher BMD [MD 3.55% (95% CI 1.81, 5.29) in lumbar spine and 3.44% (95% CI 1.39, 5.49) in total hip, without difference in femoral neck and forearm] and lower calcium concentrations (MD - 13.26%, 95% CI - 7.10, - 19.43) compared with the non-PTx group. No difference was observed between groups regarding nephrolithiasis or QoL indices, except for general health (higher in PTx group).

CONCLUSIONS

In patients with mild asymptomatic PHPT, PTx increases BMD and reduces serum calcium concentrations. However, its superiority over active surveillance in terms of fracture risk, nephrolithiasis and QoL cannot be supported by current data.

A roadmap to develop clinical guidelines for open surgery of acute and chronic tears of hip abductor tendons

PURPOSE

Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm.

METHODS

Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips.

RESULTS

A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%.

CONCLUSION

The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments.

LEVEL OF EVIDENCE

IV.

Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA.

METHODS

A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I²-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies.

RESULTS

Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I² 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I² 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I² 42.99%).

CONCLUSION

Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.

The effect of vitamin D plus protein supplementation on sarcopenia: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

The exact effect of vitamin D supplementation, either as monotherapy or in combination with protein, on musculoskeletal health in patients with sarcopenia is currently unknown. This study aimed to determine the effect of vitamin D alone or with protein supplementation on muscle strength, mass, and performance in this population.

METHODS

A comprehensive search was conducted in Medline, Cochrane Central and Scopus databases, up to March 31^st, 2020. Data were expressed as standardized mean difference (SMD) with 95 % confidence intervals (CI). I² index was employed for heterogeneity.

RESULTS

The initial search identified 1164 studies, eight of which met the eligibility criteria for qualitative and quantitative analysis, yielding a total of 776 patients. Vitamin D (100-1600 IU/day) plus protein (10-44 g/day) supplementation exhibited a beneficial effect on muscle strength, as demonstrated by an improvement in handgrip strength (SMD 0.38 ± 0.07, 95 % CI 0.18-0.47, p = 0.04; I² 76.2 %) and a decrease in the sit-to-stand time (SMD 0.25 ± 0.09, 95 % CI 0.06-0.43, p = 0.007; I² 0%) compared with placebo. However, the effect on muscle mass, assessed by skeletal muscle index, was marginally non-significant (SMD 0.25 ± 0.13, 95 % CI -0.006-0.51, p = 0.05; I² 0%). No effect on appendicular skeletal muscle mass or muscle performance (assessed by walking speed) was observed with vitamin D plus protein.

CONCLUSIONS

Vitamin D supplementation, combined with protein, improves muscle strength in patients with sarcopenia, but has no effect on muscle mass or performance.

Use of tourniquet does not increase serum concentration of inflammatory mark-ers following total knee arthroplasty during the first 24 postoperative hours

BACKGROUND

The literature on the systemic inflammatory reaction following tourniquet-induced ischemia and reperfusion in elective orthopedic surgery is limited.

METHODS

This prospective comparative study compared the levels of clinically relevant cytokines and peripheral blood counts and major complications in patients undergoing total knee arthroplasty (TKA) with or without a tourniquet during the first postoperative day. Forty-three patients undergoing primary TKA for degenerative osteoarthritis were divided into two groups; 21 patients were operated on using (TG group) and 22 (NTG group) without using a tourniquet. Proinflammatory cytokines interleukin-1b, interleukin-6, anti-inflammatory cytokine interleukin-10, intercellular and vascular adhesion molecules, C-reactive protein, and full blood count were evaluated preoperatively and at one, three, six, and 24 hours postoperatively in both groups.

RESULTS

Demographics, American Society of Anesthesiologists score, surgery duration, osteoarthritis grade, and other preoperative variable values were comparable between groups. The average tourniquet time was 67.8 minutes. The majority of testing variables did not demonstrate significant postoperative differences between groups. However, the mean IL-6 value was non-significantly higher for the TG than the NTG group during the first six postoperative hours. It demonstrated a trend to significance at the end of the first postoperative day. The mean hemoglobin and hematocrit levels were significantly higher for the NTG group at the sixth postoperative hour.

CONCLUSIONS

The tourniquet use may affect the systemic inflammatory response. Patients undergoing TKA with or without a tourniquet demonstrated a similar systemic inflammatory response. However, reperfusion following approximately 70 minutes of tourniquet ischemia is a safe practice. HIPPOKRATIA 2021, 25 (1):31-37.

Total hip arthroplasty in patients with slipped capital femoral epiphysis: a systematic analysis of 915 cases

There is limited evidence on the outcomes of Total Hip Arthroplasty (THA) in Slipped Capital Femoral Epiphysis (SCFE) patients. This systematic review aims to evaluate the current literature in terms of survival rate, functional outcomes, complications and types of implants of THA in SCFE patients. Following the established methodology of PRISMA guidelines, PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE were systematically searched from inception to September 2018. The search criteria used were: (“total hip arthroplasty’’ OR ‘’total hip replacement’’ OR “hip arthroplasty’’ OR ‘’hip replacement’’) AND (‘’slipped capital femoral epiphysis’’ OR ‘’slipped upper femoral epiphysis’’ OR ‘’femoral epiphysis’’). Ten studies were finally included in the analysis and were qualitatively appraised using the Newcastle-Ottawa tool. Variables were reported differently between studies. The sample size varied from 12 to 374 THAs. A total of 877 patients undergone 915 THAs. The mean reported follow-up ranged from 4.4 to 15.2 years and the mean patients’ age at the time of THA from 26 to 50 years. Four studies specified the type of implants used, with 62% being uncemented, 24% hybrid (uncemented cup/cemented stem) and 14% cemented. All but three studies reported the mean survival of implants that ranged from 64.9% to 94.8%. A limited number of complications were mentioned. There was a tendency for more favorable functional outcomes in modern studies. Modern THA-studies in SCFE patients showed improvement of survivorship, clinical outcomes and patient satisfaction. Future higher-quality studies are necessary to estimate long-term postoperative outcomes better.

Clinical outcomes in elective total hip arthroplasty in Parkinson's disease: a systematic review of the literature

Parkinson’s disease (PD) poses a significant challenge for the arthroplasty surgeon, owing to excessive muscle tone, higher fracture risk and poor bone quality. Several studies have reported high mortality, early failure and perioperative complications associated with hip fracture surgery in PD; however, no higher-level evidence exists regarding elective hip arthroplasty.

The aim of our study was to perform a systematic review to evaluate the evidence basis and clinical outcomes pertaining to patients with underlying Parkinson’s disease undergoing elective total hip arthroplasty (THA).

We searched MEDLINE, EMBASE and The Cochrane Central Register of Controlled Trials to identify studies evaluating the safety and clinical outcomes of THA in patients suffering from Parkinson’s. Our review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Ten studies encompassing 49,730 patients were included in our systematic review. Qualitative synthesis demonstrated comparable results between PD patients and controls with respect to one-year mortality and surgical site infections. PD patients experienced more medical complications, had a longer hospital stay and worse long-term implant survival. Some studies also reported a higher rate of dislocation, periprosthetic fractures and aseptic loosening.

Decisions about the optimal articulation, the utilization of cemented components, dual-mobility cups or constrained liners were not uniform among included studies.

THA in patients with Parkinson’s disease can offer significant functional gains and pain relief. Surgical considerations pertain to the approach and ways to address instability, whereas emphasis should be placed on appropriate counselling and exploring whether potential improvement of life quality outweighs the risks.

Cite this article: EFORT Open Rev 2020;5:856-865. DOI: 10.1302/2058-5241.5.200034

Type 2 Diabetes Mellitus is Associated with Increased Risk of Sarcopenia: A Systematic Review and Meta-analysis

Diabetes mellitus (DM) is associated with an increased risk of fractures, mainly due to impaired bone architecture and microvascular complications. Whether DM is also associated with increased risk of sarcopenia is not yet known, with studies yielding inconclusive results. The aim of this study was to systematically review and synthesize the best available evidence regarding the association between DM and sarcopenia risk. A comprehensive search was conducted in PubMed, CENTRAL and Scopus databases. Data are expressed as odds ratio (OR) with 95% confidence intervals (CI). The I² index was employed for heterogeneity. Only studies which had implemented at least two of the three criteria for sarcopenia diagnosis (low muscle mass, muscle strength and/or muscle performance), as defined by the international studying groups, were included. Fifteen studies fulfilled eligibility criteria, yielding a total of 1832 patients with type 2 DM (T2DM) and 1159 cases of sarcopenia. Patients with T2DM demonstrated a higher risk of sarcopenia compared with euglycemic subjects (OR 1.55, 95% CI 1.25-1.91, p < 0.001; I² 34.6%). This risk remained significant when analysis was restricted to studies matched for age and sex. Sarcopenia risk was independent of disease definition or study design. Notably, T2DM patients presented lower muscle performance and strength compared with euglycemic subjects, whereas no difference in muscle mass was observed between groups. Patients with T2DM have an increased risk of sarcopenia compared with euglycemic subjects.

The Effect of Perioperative Vitamin D Levels on the Functional, Patient-Related Outcome Measures and the Risk of Infection Following Hip and Knee Arthroplasty: A Systematic Review

Introduction

The aim of this study was to evaluate the effect of perioperative vitamin D levels in terms of functional results, patient-related outcome measures (PROMs) and infection risk after hip or knee replacement.

Materials and Methods

A systematic search in PubMed, Cochrane library, ScienceDirect and ClinicalTrials.gov was conducted according to the PRISMA guidelines from inception to January 2020.

Results

Eighteen studies with more than 8000 knee and 1500 hip joint arthroplasties were included. The mean follow-up ranged from 6 weeks to 1 year and mean patients’ age from 59.4 to 76 years. Hypovitaminosis was diagnosed in 26.7% of cases. Most studies did not find significant differences in pre- and postoperative functional results, PROMs and length of hospital stay between hypovitaminosis and euvitaminosis groups. Deficient patients may be at higher risk of postoperative joint stiffness. Patients suffering from hip and knee periprosthetic joint infection seem to have lower vitamin D levels compared to those with aseptic loosening of implants.

Conclusion

The necessity of pre-operative correction of vitamin D levels to achieve better functional results and minimize the risk of infection following hip and knee arthroplasty remains inconclusive. Extend of exposure to low vitamin D levels and comparison between outliers needs further evaluation.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Direct superior approach with standard instrumentation for total hip arthroplasty: safety and efficacy in a prospective 200-case series

INTRODUCTION

Direct Superior Approach (DSA) is a muscle sparing approach for total hip arthroplasty (THA) implemented using special instrumentation. There is a lack of information in the literature concerning DSA with standard instrumentation.

MATERIALS AND METHODS

238 patients were recruited for primary THA by a single surgeon from January 2016 until May 2017. 209 patients underwent THA through DSA approach with non-offset acetabular reamers and femoral broaches. We evaluated accuracy of implantation, complications and early functional results. Independent orthopaedic surgeons performed the clinical and radiographic assessments.

RESULTS

200 patients were followed for a year. 3 different implants were used. No sciatic nerve palsies, hip dislocations or fractures were recorded. There was one acute deep and superficial wound infection. The mean functional score was significantly improved at all follow-ups (p < 0.001). 97% of stems were inserted into the neutral coronal and 96% in neutral sagittal alignment. All cups fell within a safe zone of inclination and 91% of anteversion. 2 hips demonstrated heterotopic ossification, Brooker class I. Obese patients had no increased risk of complications.

CONCLUSIONS

DSA with standard instrumentation is safe and efficacious for THA. It offers fast recovery and facilitates correct implantation of different implants, can be useful even for hip dysplasia and obese patients with minimal complication rates.

A Catastrophic Cascade of Postoperative Complications Following Hemiarthroplasty for Femoral Neck Fracture in a Middle-Aged Patient With Schizophrenia

The treatment of a patient with schizophrenia suffering a subcapital hip fracture may be challenging, mainly due to the high risk of postoperative medical and surgical complications. Mechanical complications from the implant are also frequently encountered following hip arthroplasty in patients with schizophrenia. We report the case of a 57-year-old male patient with schizophrenia who underwent hip hemiarthroplasty for a displaced femoral neck fracture. During the initial postoperative period, the patient developed a cascade of surgical and mechanical complications, leading to multiple revision procedures and a suboptimal outcome. The ideal type of treatment of patients with schizophrenia with subcapital hip fracture is still missing. It is, therefore, important to highlight the high risk of postoperative complications in patients with schizophrenia who present with subcapital fractures subsequently treated with hemiarthroplasty. 

Vitamin D supplementation and fracture risk: Evidence for a U-shaped effect

During the last decade, a cascade of evidence has questioned the anti-fracture efficacy of vitamin D supplementation. In general, vitamin D status, reflected by serum 25-hydroxy-vitamin D [25(OH)D] concentrations, seems to predict fracture risk and bone mineral density (BMD). Despite the well-documented detrimental effect of vitamin D deficiency on bones, vitamin D monotherapy does not seem to reduce the risk of fractures. On the other hand, high vitamin D doses, either at monthly (60,000-100,000 IU) or daily intervals (>4000 IU), appear to be harmful with regard to falls, fracture risk and BMD, especially for people without vitamin D deficiency and at low fracture risk. Therefore, a U-shaped effect of vitamin D on the musculoskeletal system may be supported by the current evidence. Vitamin D supplementation could be of value, at daily doses of at least 800 IU, co-supplemented with calcium (1000-1200  mg/day), in elderly populations, especially those with severe vitamin D deficiency [25(OH)D <25-30  nmol/L (<10-12  ng/mL)], although its anti-fracture and anti-fall efficacy is modest. Good compliance and at least 3-5 years of therapy are required.

Quality of the femoral cement mantle in total hip arthroplasty using the direct anterior hip approach

Background

Limited literature exists concerning the femoral cement mantle quality that can be achieved through an anterior approach in total hip arthroplasty (THA). We radiologically evaluated the quality and thickness of the femoral cement mantle in patients undergoing THA utilizing the direct anterior approach (DAA).

Methods

Immediate postoperative anteroposterior and lateral radiographs of 116 consecutive patients who underwent hybrid or fully cemented THA using the DAA and cemented Quadra-C stem (Medacta, International, SA, Switzerland) were assessed by 2 arthroplasty surgeons blinded to the study. Surgical indications were hip osteoarthritis or subcapital hip fracture. The cement mantle and stem alignment were evaluated using the Barrack classification and Khalily methods, respectively. After calibration of radiographs, the thinnest part of the cement mantle per Gruen zone was recorded. Parameters were compared between obese and nonobese patients.

Results

Agreement between raters was substantial for the cement quality in anteroposterior (k = 0.707, P ≤ .001) and moderate for lateral radiographs (k = 0.574, P ≤ 001). The cement mantle was graded A in 39.25%, B in 53.0%, and C in 7.75% of anteroposterior radiographs and similarly for lateral radiographs (40.1% A, 51.75% B, 9.5% C). 93% of stems had neutral alignment. The mean thinnest cement mantle (P = .237) and incidence of inadequate cement mantle (<2 mm) per zone (P = .431) were comparable between Gruen zones. The cement mantle quality (P = .174) and inadequacy (P > .05) and stem alignment (P = .652) were comparable between obese and nonobese patients.

Conclusions

DAA enables correct implantation and effective cementation of straight femoral stems. A high-quality cement mantle can be achieved using DAA even in obese patients.

Organizing an Orthopaedic Department During COVID-19 Pandemic to Mitigate In-Hospital Transmission: Experience From Greece

The new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging in Wuhan city of China, was the cause of a rare type of pneumonia evolving rapidly in pandemic early at the beginning of 2020. The rapid human-to-human transmission of SARS-CoV-2 increases the risk of in-hospital transmission, requiring re-definement of musculoskeletal trauma management and postoperative care. Following the review of the existing literature on COVID-19 and similar infectious diseases, National and Hospital Board instructions for Infectious Diseases, as well as the consensus for surgical care by the consortium of the Orthopaedic Department Directors, we present the outline of the implemented principles in the orthopaedic departments of a tertiary academic hospital in Greece to operate during COVID-19 pandemic. Our overall objectives were to decrease the admission load and mitigate the risk of in-hospital transmission of SARS-CoV-2. The principles involve the management of the Orthopaedic medical and nursing personnel, alterations of the workflow in the wards, operating rooms and outpatient clinics from the admission to the discharge of an orthopaedic patient. In addition, we present the recommended principles of management of traumatic orthopaedic injuries highlighting those deserving admission and in-hospital care and those that can be treated in the outpatient setting or day surgery clinics. 

Coronavirus Disease 2019 (COVID-19) Can Masquerade as Acute Postoperative Periprosthetic Joint Infection

Fever etiology during the first postoperative days following total knee arthroplasty (TKA) may be challenging to solve. Early periprosthetic joint infection is the main reason; however, other equally important causes must be excluded such as thrombosis, deep venous thrombosis, and chest or urinary tract infections. We report the case of a 70-year-old Caucasian female patient presented with high fever reaching 39°C, fatigue, and myalgia lasting for a week after a fully cemented primary TKA. Symptoms were falsely attributed to the surgical procedure, leading to erroneous early management and a complicated postoperative course. In the era of the severe acute respiratory syndrome coronavirus 2 (SARs-CoV-2) pandemic, a high index of suspicion for coronavirus disease 2019 (COVID-19) symptoms and viral chest infection must be raised, primarily in vulnerable patients.

Total hip arthroplasty in sickle cell disease: a systematic review

Total hip arthroplasty (THA) in sickle cell disease (SCD) patients can be a challenging procedure.

This systematic review evaluated the revision rate, functional outcomes and complications of THA in sicklers.

A systematic search was conducted according to the PRISMA guidelines, using four search engines from inception to May 2019.

Fifteen studies with 971 THAs were included. There were 437 cemented and 520 uncemented THAs.

There were 164 revision THAs (16.8%); 52 uncemented and 105 cemented THAs.

Forty-two infections were recorded; 16 infections for cemented and 23 for uncemented THAs.

Fifty-seven cups, 26 stems, eight cup/stem with aseptic loosening that were more frequently cemented were reported. The 28 unspecified aseptic loosening cases were more frequently uncemented THAs.

All studies demonstrated the functional improvement of patients.

There were 109 medical complications (14.3%). Sickle cell crises (SCC) and transfusion reactions were most usually recorded.

Forty-six intraoperative complications (4.7%) were reported; 18 femoral fractures, four acetabular and 18 femoral perforations. Seventeen femoral fractures occurred during uncemented THA.

THA in SCD is still related to a high risk of complications. The outcomes in properly selected sicklers have been improved. Perioperative adequate hydration, warming, oxygen supply and transfusion protocols are mandated to prevent SCC and transfusion reactions. The surgeon must be prepared to deal with a high rate of intraoperative fractures and have different implant options readily available. No definite conclusion can be made regarding the best fixation mode. Cemented implants demonstrated a higher revision rate and uncemented implants a higher risk for intraoperative complications.

Cite this article: EFORT Open Rev 2020;5:180-188. DOI: 10.1302/2058-5241.5.190038

Association of Polymorphisms in the Promoter Region of NOS2A Gene with Primary Knee Osteoarthritis in the Greek Population

Introduction

A new emerging role of nitric oxide (NO) in the aetiology of osteoarthritis (OA) has been reported. Inducible NO synthase (iNOS), produced by chondrocytes, is the major source of NO in the osteoarthritic cartilage. The aim of this study is to evaluate the potential association between the -1173C/T (rs9282799), -1026 C/A (rs 2779249) and -954G/C (rs1800482) single nucleotide polymorphisms (SNPs) in the promoter of the iNOS gene (NOS2A) and the incidence of knee OA in Greek population.

Methods

Ninety-six patients with primary knee OA were included in the study along with 44 controls. Genotypes were identified using polymerase chain reaction (PCR) and DNA sequencing techniques. Allelic and genotypic frequencies were compared between patients and controls.

Results

None of the -1173C/T, -1026 C/A and -954G/C SNPs were detected in the studied population, either in patients or controls. However, another SNP was identified at the site -1056 at the promoter region, where the initial G allele was substituted by the T allele. Interestingly, the TT genotype was completely absent in controls, but was detected in six patients with a 6.2% observed frequency. The difference between patients and controls was not statistically significant (p-value = 0.18). In male OA patients, the observed frequency of the TT genotype was higher (28.6%) in comparison to the 0% of the male controls (p-value = 0.1). The frequency of the G allele was 0.82 in controls and 0.78 in OA patients (p-value = 0.53).

Conclusions

The present study demonstrates that the 954G/C, -1026C/A, -1056G/T and -1173C/T SNPs of the NOS2A gene are not a risk factor for primary knee OA in Greek population. Moreover, -954G/C, -1026C/A and -1173C/T are rare, if not completely absent, in the Greek population. Additional research is mandatory in order to investigate the association of these SNPs with OA in different ethnic populations.

Technical Considerations of Complex Primary Total Hip Arthroplasty in a Rare Case of Combined Achondroplasia and Hereditary Multiple Exostosis Syndromes

INTRODUCTION

Combined achondroplasia and hereditary multiple exostosis (HME) syndrome is a rare autosomal dominant inherited skeletal dysplasia. We report, for the 1sttime, a complex primary hip arthroplasty in a patient with combined achondroplasia and HME syndrome. We emphasize to the femoral and acetabular surgical concerns and difficulties of the surgical exposure and soft tissue balancing for this complex procedure.

CASE REPORT

An ambulatory 66-year-old female Caucasian with achondroplasia and HME presented with the left hip pain, progressive walk disability and limited range of hip motion due to severe hip osteoarthritis. Full cemented primary total hip arthroplasty (THA) with an impaction grafting technique was performed; posterior lip augmentation device was implanted to improve stability. At 5 years follow-up, the patient remains ambulatory and pain-free with improved range of hip motion. No signs of aseptic loosening are present.

CONCLUSIONS

Cemented THA could be an efficient option to reconstruct the complex hip anatomy in patients with skeletal dysplasia.

Genetic Predisposition to Developmental Dysplasia of the Hip

BACKGROUND

The etiopathogenesis of developmental dysplasia of the hip (DDH) has not been clarified. This systematic review evaluated current literature concerning all known chromosomes, loci, genes, and their polymorphisms that have been associated or not with the prevalence and severity of DDH.

METHODS

Following the established methodology of Meta-analysis of Observational Studies in Epidemiology guidelines, MEDLINE, EMBASE, and Cochrane Register of Controlled Trials were systematically searched from inception to January 2019.

RESULTS

Forty-five studies were finally included. The majority of genetic studies were candidate gene association studies assessing Chinese populations with moderate methodological quality. Among the most frequently studied are the first, third, 12th,17th, and 20th chromosomes. No gene was firmly associated with DDH phenotype. Studies from different populations often report conflicting results on the same single-nucleotide polymorphism (SNP). The SNP rs143384 of GDF5 gene on chromosome 20 demonstrated the most robust relationship with DDH phenotype in association studies. The highest odds of coinheritance in linkage studies have been reported for regions of chromosome 3 and 13. Five SNPs have been associated with the severity of DDH. Animal model studies validating previous human findings provided suggestive evidence of an inducing role of mutations of the GDF5, CX3CR1, and TENM3 genes in DDH etiopathogenesis.

CONCLUSION

DDH is a complex disorder with environmental and genetic causes. However, no firm correlation between genotype and DDH phenotype currently exists. Systematic genome evaluation in studies with larger sample size, better methodological quality, and assessment of DDH patients is necessary to clarify the DDH heredity. The role of next-generation sequencing techniques is promising.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

BACKGROUND

No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.

METHODS

Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.

RESULTS

There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).

CONCLUSIONS

VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.

LEVEL OF EVIDENCE

Level 1.

Locking plates versus retrograde intramedullary nails in the treatment of periprosthetic supracondylar knee fractures. A retrospective multicenter comparative study

INTRODUCTION

Biomechanical studies demonstrated the superiority of retrograde supracondylar intramedullary nails (RIN) against locking plates (LP) for the treatment of periprosthetic supracondylar femoral fractures (PSFs); however, clinical results are still conflicting. This study aimed to compare LP and RIN, as well as, cemented and uncemented nails in the treatment of PSFs regarding fracture healing, complications and functional results.

MATERIALS AND METHODS

A retrospective multicenter analysis of 60 PSFs classified as Rorabeck type I or II was performed. Thirty-one cases were treated with LP while in 29 cases RIN were used. Out of the latter, 14 had nailed cementoplasty, while 15 an uncemented nail.

RESULTS

The two groups were comparable concerning gender, ASA score, operated side, follow-up time, fracture type and mechanism of injury. The LP was significantly younger than the RIN group. Forty-six cases had fracture union at an average of six months, 11 were healed between seven and twelve months (delayed unions), and three developed non-unions. There was no significant difference in the median union time between RIN and LP groups (six vs five months, p = 0.707) or cemented and uncemented nailing groups (5.5 vs six months, p = 0.354). The RIN group had fewer delayed unions or non-unions than LP group; however, not reaching significance (4 vs 10, p = 0.190). Complications were fewer but non-significantly different between cemented and uncemented nails (one vs five, p = 0.481). The mean postoperative flexion was comparable between RIN and LP groups (99.1° vs 94.9°, p = 0.547) or cemented and uncemented nails (102° vs 96.3°, p = 0.4). The mean Oxford Knee Score did not differ between LP and RIN groups (30.8 vs 31.3, p = 0.93) as well as between cemented and uncemented nails (31.5 vs 30.6, p = 0.801).

DISCUSSION

PSFs with good bone stock can be treated equally with LP or RIN. Nails demonstrated advantages concerning the fracture healing potential. Orthopaedic surgeons need to be trained in both treatment options to manage PSFs. Cemented nails may increase stability and healing capacity in elderly osteoporotic patients; however, further studies are needed.

Mesenchymal stromal cells for bone sarcoma treatment: Roadmap to clinical practice

Over the past few decades, there has been growing interest in understanding the molecular mechanisms of cancer pathogenesis and progression, as it is still associated with high morbidity and mortality. Current management of large bone sarcomas typically includes the complex therapeutic approach of limb salvage or sacrifice combined with pre- and postoperative multidrug chemotherapy and/or radiotherapy, and is still associated with high recurrence rates. The development of cellular strategies against specific characteristics of tumour cells appears to be promising, as they can target cancer cells selectively. Recently, Mesenchymal Stromal Cells (MSCs) have been the subject of significant research in orthopaedic clinical practice through their use in regenerative medicine. Further research has been directed at the use of MSCs for more personalized bone sarcoma treatments, taking advantage of their wide range of potential biological functions, which can be augmented by using tissue engineering approaches to promote healing of large defects. In this review, we explore the use of MSCs in bone sarcoma treatment, by analyzing MSCs and tumour cell interactions, transduction of MSCs to target sarcoma, and their clinical applications on humans concerning bone regeneration after bone sarcoma extraction.