Rehabilitation Prognostic Factors following Hip Fractures Associated with Patient's Pre-Fracture Mobility and Functional Ability: A Prospective Observation Study

Low physical function is associated with poor outcomes in the elderly population suffering from hip fractures. The present study aims to evaluate the prognostic tools for predicting patient recovery after hip fractures and investigate the correlation between the pre-fracture motor and functional statuses. A prospective study was performed, including 80 patients suffering from hip fractures. Patient history, previous falls, the type of fracture and overall survival were evaluated. Patient-reported outcome measures (SF-36, EQ-5D/VAS, Charlson Comorbidity Index (CCI), Short Physical Performance Battery (SPPB), Timed Up and Go (TUG) and Harris Hip Score (HHS)) were monitored before hospital discharge at 6 weeks, and 3, 6 and 12 months postoperatively. Overall, 55% of patients experienced at least one fall, and 46% of them used crutches before the fracture. The average CCI score was 6.9. The SPPB score improved from 1.4 ± 1.3 (1 week) to 4.4 ± 2.1 (48 weeks). A one-year age increase, female sex, and prior history of falls lead to 0.1-, 0.92-, 0.56-fold lower SPPB scores, respectively, at 12 months. The HHS recorded the greatest improvement between 6 and 12 weeks (52.1 ± 14.6), whereas the TUG score continued to improve significantly from 139.1 ± 52.6 s (6 weeks) to 66.4 ± 54 s (48 weeks). The SPPB and performance test can be routinely used as a prognostic tool.

Stair Climbing Ability and Identification of the Nine Stairs Ascent and Descent Test Cut-Off Points in Hip Osteoarthritis Patients: A Retrospective Study

Objectives As the prevalence and incidence of hip osteoarthritis (hip OA) continue to rise, measuring the impact of hip OA severity on a patient's functionality is essential. Stair walking is a particularly relevant task to assess hip OA patients, as difficulty with stair ascent is one of the driving factors in deciding to undergo a total hip arthroplasty. Although stairs tests often arise in post-arthroplasty measures, there is a lack of reported stairs performance time in hip OA patients. Therefore, this retrospective study aimed to report the stair performance time of hip OA patients categorized by disease severity and determine cut-off points that differentiate between severity grades. Materials and methods The patient selection was based on the review of de-identified data from our research laboratory database. 254 hip OA patients (aged ≥ 50 years) were divided according to the Kellgren-Lawrence classification system into three groups: Grade 2 (n=68), Grade 3 (n=109), and Grade 4 (n= 68). The stair-walking ability was evaluated using the 9S-A/D test. The time taken to ascend and descend the stairs was measured separately, and the total time (9S-A/D) was also recorded. The one-way ANOVA model, Welch test, Games-Howell posthoc test, Chi-Square tests, and Two-Way ANOVA model were used for the statistical analysis of the data. The cut-off points were obtained by receiver operating curve (ROC) analysis. The statistical significance was set at p<0.05. Results Homogeneity was found between the three groups regarding demographic and clinical characteristics, except age and gender (p<0.001). The comparison of the variables (9S-ascent, 9S-descent, and 9S-A/D) between groups, adjusted for gender and age, showed significant differences: Grade 2 individuals had shorter performance times compared to those in Grade 3 and Grade 4 (p<0.005). Simultaneously, patients with Grade 3 hip OA have a shorter performance time than those with Grade 4 hip OA (p<0.005). Regarding ROC analysis of Grade 2 versus Grade 3: The AUCs of 9S-ascend, 9S-descent, and 9S-A/D were 0.742 (95%CI 0.67-0.81), 0.734 (95%CI 0.66-0.81), and 0.745 (95%CI 0.54-0.90), respectively (all p values <0.005). The cut-off points of 9S-ascend, 9S-descent, and 9S-A/D were 8.7 s (sensitivity 56%, specificity 88%), 7.1 s (sensitivity 58%, specificity 80%), and 16.25 s (sensitivity 54%, specificity 90%), respectively. Concerning ROC analysis of Grade 3 versus Grade 4: The AUCs of 9S-ascend, 9S-descent, and 9S-A/D were 0.702 (95%CI 0.62-0.78), 0.711 (95%CI 0.63-0.79), and 0.715 (95%CI 0.64-0.80), respectively (all p values <0.005). The cut-off points of 9S-ascend, 9S-descent, and 9S-A/D were 11.5 s (sensitivity 66%, specificity 65%), 8.3 s (sensitivity 71%, specificity 62%), and 19.05 s (sensitivity 71%, specificity 61%), respectively. Conclusions The study provides evidence that the progression of hip OA affected stair walking; the performance time of 9S-ascent, 9S-ascent, and 9S-A/D tests was significantly longer as the severity of hip OA worsened. ROC analysis results show tests' ability to distinguish the cut-off point between different hip OA grades. However, further research is required for the reporting and classification of stair performance time values in hip OA patients and to further investigate the ability of 9S-ascent, 9S-descent, and 9S-A/D tests to predict the grade of hip OA.

The Effect of Postoperative Physical Therapy Following Hip Fracture: A Literature Review

Hip fractures in the elderly have become a major public health concern as the population ages. Post-operative rehabilitation is associated with improved outcomes and a greater likelihood of returning to pre-operative functional capacity. Several studies have been conducted to investigate various post-operative recovery pathways. However, little is known about which post-operative rehabilitation pathways for hip fractures are most effective in improving patient outcomes. No clear evidence-based guidelines for a standard mobilization protocol for patients are currently available. This review aims to investigate post-operative recovery pathways to help patients suffering from hip fracture return to pre-fracture condition and to quantify pre-operative and post-operative scores for objective rehabilitation evaluation. Measuring pre-operative activity and comparing it to post-operative follow-up values can help predict post-operative rehabilitation functional outcomes.

The modern Burch-Schneider antiprotrusio cage for the treatment of acetabular defects: is it still an option? A systematic review

BACKGROUND

A number of papers have been published about the clinical performance of modern rough-blasted titanium Burch-Schneider antiprotrusio cages (BS-APCs) for the treatment of acetabular bone defects. However, no systematic review of the literature has been published to date.

METHODS

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications using keywords pertinent to Burch-Schneider antiprotrusio cage, revision THA, and clinical outcomes.

RESULTS

8 articles were found to be suitable for inclusion in the present study in which 374 cases (370 patients) had been treated with modern BS-APCs. Most acetabular bone defects were type 3 according to the Paprosky classification (type 2C: 18.1%, 3A: 51%, and 3B: 28.9%). The overall re-revision rate for the 374 acetabular reconstructions with modern BS-APCs was 11.5% (43 cases). The short-term survival rate of the modern BS-APC construct was 90.6% (339 out of 374 cases), while the mid-term survival rate was 85.6% (320 out of 374 cases), and the long-term survival rate 62% (54 out of 87 cases). The most common reasons for revision were aseptic loosening (5.6%), periprosthetic joint infection (3.8%), dislocation (2.7%), and acetabular periprosthetic fracture (1.9%).

CONCLUSIONS

There was moderate quality evidence to show that the use of modern rough blasted titanium BS-APCs in cases of acetabular bone loss has an unacceptably high failure rate (38%). Given that antiprotrusio cages do not provide any biological fixation, we would not recommend the routine use of modern BS-APCs in complex revision THA cases. By contrast, the satisfactory short- to mid-term outcome of modern BS-APCs in combination with their low cost compared to highly porous acetabular implants, make us feel that BS-APCs might still be used in selected elderly or low-demand patients without severe superomedial acetabular bone loss.

Sonication Fluid Isolation of Peptoniphilus asaccharolyticus After Total Hip Arthroplasty

Peptoniphilus asaccharolyticus is a gram-positive anaerobic coccus found on the skin, vagina, and gut, where it acts as an opportunistic pathogen or as part of polymicrobial infections of chronic wounds or diabetic ulcers. We present a case of a 68-year-old woman who was diagnosed with a late prosthetic hip arthroplasty infection caused by P. asaccharolyticus and isolated from sonication fluid cultures. Despite the fact that evidence is scarce, its role and pathogenicity in more severe infections should not be underestimated.

Total hip arthroplasty through the direct anterior approach in morbidly obese patients

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.

Methods

Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m² who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m². Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed.

Results

No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041).

Conclusion

Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons.

Cite this article: Bone Jt Open 2022;3(1):4–11.

Direct anterior approach vs Hardinge in obese and nonobese osteoarthritic patients: A randomized controlled trial

BACKGROUND

The increased prevalence of obesity has resulted in orthopedic surgeons being likely to face many patients with a high body mass index (BMI) who warrant total hip arthroplasties (THAs) over the coming years. Studies' findings considered the postoperative clinical, and functional outcomes in these patients are controversial, and selecting the most appropriate surgical approach remains debatable.

AIM

To compare pain-levels, functionality, and quality-of-life in obese and nonobese osteoarthritic patients who have undergone primary total hip arthroplasty through either direct-anterior-approach (DAA) or Hardinge-approach.

METHODS

One hundred and twenty participants (> 50 years) were divided into four groups according to the surgical approach (DAA or Hardinge) and patients' BMI (nonobese < 30 kg/m² vs obese ≥ 30 kg/m²). Outcomes were measured preoperatively and postoperatively (6^th and 12^th week). Pain was measured with Face Pain Scale-Revised (FPS-R). Functionality was measured with Timed Up & Go (TUG) test and Modified Harris Hip Score-Greek version (MHHS-Gr). Quality-of-life was evaluated with the 12-item-International Hip Outcome Tool-Greek version (iHOT12-Gr) (Clinical Trial Identifier: ISRCTN15066737).

RESULTS

DAA vs Hardinge: (week 6) DAA-patients showed 12.2% less pain, more functionality (14.8% shorter TUG-performance time, 21.5% higher MHHS-Gr), and 38.16% better quality-of-life (iHOT12-Gr) compared to Hardinge-patients (all P values < 0.001). These differences were further increased on week 12 (all P values ≤ 0.05)]. DAA-obese vs Hardinge–obese: (week 6) DAA-obese patients had less pain, shorter TUG-performance time, better MHHS-Gr and iHOT12-Gr scores than Hardinge-obese (all P values < 0.01). (Week 12) Only the TUG-performance time of DAA-obese was significantly shortened (22.57%, P < 0.001). DAA-nonobese vs DAA-obese: no statistically significant differences were observed comparing the 6^th and 12^th weeks' outcomes.

CONCLUSION

DAA-groups reported less pain, more functionality and better quality-of-life, compared to the Hardinge-groups. The DAA benefited obese and nonobese patients, similarly yet faster, suggesting that it should be the more preferred choice for obese patients, instead of Hardinge. However, more comparative studies with more extended follow-up periods are needed to confirm our results and better evaluate all patients' long-term outcomes.

Acute Total Hip Arthroplasty for the Treatment of Acetabular Fractures: A Retrospective Study With a Six-Year Follow-Up

Objectives

While open reduction and internal fixation is considered the gold standard for the treatment of acetabular fractures, it is associated with significant complications due to prolonged immobilization for elderly patients. The aim of this study was to investigate the clinical and radiological outcomes in elderly patients treated with an acute total hip arthroplasty (THA).

Patients and methods

This retrospective study included 16 patients (10 women and 6 men) with a mean age of 80.1 years suffering from a displaced acetabular fracture after a low-energy trauma. Primary THA was performed in all cases, by the same surgeon, within a three-week period after the fracture. The Burch-Schneider reinforcement ring with a cemented cup was used in 10 patients and a jumbo acetabular cup was used in 6 patients, whereas autologous bone graft was used in all cases.

Results

With a mean follow-up of 72 months, one dislocation occurred that was treated with close reduction, and one patient developed superficial site infection that was managed conservatively with antibiotics. No periprosthetic fractures, deep infections, or other adverse events were observed. One case of asymptomatic radiographic loosening was reported and treated conservatively. And autologous bone graft was well incorporated. Clinical scores were significantly improved, and all patients were able to walk independently.

Conclusions

Acute THA for the treatment of displaced acetabular fractures in elderly patients seems to be a safe option with good functional and radiological outcomes and low complication rates, offering early mobilization and weight-bearing ability to elderly patients.

Glutamate uptake in Purkinje cells in rat cerebellar slices

We have described how whole-cell clamping of neurons in brain slices has allowed a characterization of postsynaptic transporters, probably a mixture of EAAC1 and EAAT4, in cerebellar Purkinje cells. Similar experiments have been carried out on transporters (mainly GLAST) in cerebellar Bergmann glia, and have revealed an uptake current occurring as these carriers remove glutamate released at the parallel fiber synapses. As more transporters are cloned and their regulation is characterized in heterologous expression systems, it will be increasingly important to use methods similar to those outlined above to investigate to what extent the behavior of the carriers is similar in situ in the nervous system.

The role of glutamate transporters in glutamate homeostasis in the brain

Glutamate transporters in neurones and glia, four of which have been cloned from mammals, play a crucial role in controlling the extracellular glutamate concentration in the brain. In normal conditions, they remove glutamate from the extracellular space and thereby help to terminate glutamatergic synaptic transmission and to prevent the extracellular glutamate concentration from rising to neurotoxic values. Glutamate transport on these carriers is thought to be driven by the cotransport of Na+, the counter-transport of K+, and either the cotransport of H+ or the counter-transport of OH-. Activating the transporters also activates an anion conductance in their structure, the anion flux through which is not coupled to glutamate movement and varies widely for the different transporters. During hypoxia or ischaemia, glutamate transporters can run backwards, releasing glutamate into the extracellular space, triggering the death of neurones and thus causing mental and physical handicap. The rate of glutamate release by this process is slowed by the acid pH occurring in hypoxia/ischaemia, which may help protect the brain during transient, but not sustained, ischaemia.

Postsynaptic glutamate uptake in rat cerebellar Purkinje cells

1. Whole-cell clamp experiments on Purkinje neurons in rat cerebellar slices were used to test whether glutamate transporters, detected immunocytochemically in the somata and dendrites of the cells, are functional in the cell surface membrane, and to investigate their role in terminating synaptic transmission. 2. A membrane current was detected with the pharmacology, voltage and ion dependence of a glutamate uptake current. Part of the current was generated by an anion conductance activated when uptake occurs. 3. With sodium and glutamate inside the cell, raising the external potassium concentration generated an outward current attributable to reversed operation of glutamate transporters. 4. The magnitude of the uptake current suggested that Purkinje cell transporters could help to terminate transmission at the climbing and parallel fibre to Purkinje cell synapses. Reducing postsynaptic glutamate uptake with intracellular D-aspartate prolonged the climbing fibre EPSC. 5. These data establish the existence of functional postsynaptic glutamate transporters, show that they contribute to terminating synaptic transmission, and suggest that they may play a role in the preferential death of Purkinje cells in ischaemia.

Arachidonic acid depresses non-NMDA receptor currents

Arachidonic acid has been proposed as an intercellular messenger in the nervous system. It is released when glutamate acts on postsynaptic receptors, potentiates NMDA receptor currents and depresses glutamate uptake. Here we report the effects of arachidonic acid on non-NMDA receptor currents, studied by whole-cell clamping isolated neurons and neurons in tissue slices. In cultured cerebellar granule cells and in freshly isolated hippocampal pyramidal cells arachidonic acid decreased the current produced by iontophoresed AMPA. This depression was not due to increased desensitization of the AMPA receptor. In cerebellar slices, arachidonic acid depressed the non-NMDA component of the synaptic current at the mossy fibre to granule cell and the parallel fibre to Purkinje cell synapses. However, this depression was not always seen, possibly because the lipophilic arachidonic acid is absorbed by superficial cells in the slice and does not reach the synapse being studied. Depression of non-NMDA receptor currents by arachidonic acid may reflect the presence of an arachidonic acid binding site on the non-NMDA receptor, but non-NMDA receptor subunits show much less sequence homology with fatty acid binding proteins than does the NMDA receptor.

Glutamate uptake from the synaptic cleft does not shape the decay of the non-NMDA component of the synaptic current

To study the role of glutamate uptake at central glutamatergic synapses, we used the uptake blocker L-transpyrrolidine-2,4-dicarboxylate (PDC). The effects of PDC on the glutamate uptake current in salamander retinal glia indicated that PDC competes with glutamate for transport on the uptake carrier and that 300 microM PDC should significantly reduce the uptake of glutamate during the synaptic current. In isolated rat hippocampal neurons, 300 microM PDC did not affect non-N-methyl-D-aspartate (NMDA) receptor currents, but reduced NMDA receptor currents by 30%. In hippocampal and cerebellar slices, whereas 300 microM PDC reduced the NMDA component of excitatory synaptic currents by 50%, it reduced the non-NMDA component only slightly with no change in its decay time constant. Thus, the decay rate of the non-NMDA component is not set by the rate of glutamate uptake from the synaptic cleft into the presynaptic terminal.

The spatial relationship between Müller cell processes and the photoreceptor output synapse

Glutamate is the neurotransmitter released by photoreceptors in the retina. The postsynaptic action of glutamate is terminated partly by uptake into glial (Müller) cells. The anatomical distribution of Müller cell processes around the synaptic terminals of photoreceptors was investigated electron microscopically in the tiger salamander retina. Müller cells wrap around the synaptic terminals of both rods and cones and come within 1-3 microns of the sites of glutamate release, close enough to contribute to terminating the synaptic action of glutamate.

Potentiation of NMDA receptor currents by arachidonic acid

Arachidonic acid is released by phospholipase A2 when activation of N-methyl-D-aspartate (NMDA) receptors by neurotransmitter glutamate raises the calcium concentration in neurons, for example during the initiation of long-term potentiation and during brain anoxia. Here we investigate the effect of arachidonic acid on glutamate-gated ion channels by whole-cell clamping isolated cerebellar granule cells. Arachidonic acid potentiates, and makes more transient, the current through NMDA receptor channels, and slightly reduces the current through non-NMDA receptor channels. Potentiation of the NMDA receptor current results from an increase in channel open probability, with no change in open channel current. We observe potentiation even with saturating levels of agonist at the glutamate- and glycine-binding sites on these channels; it does not result from conversion of arachidonic acid to lipoxygenase or cyclooxygenase derivatives, or from activation of protein kinase C. Arachidonic acid may act by binding to a site on the NMDA receptor, or by modifying the receptor's lipid environment. Our results suggest that arachidonic acid released by activation of NMDA (or other) receptors will potentiate NMDA receptor currents, and thus amplify increases in intracellular calcium concentration caused by glutamate. This may explain why inhibition of phospholipase A2 blocks the induction of long-term potentiation.

Glutamate uptake in mammalian retinal glia is voltage- and potassium-dependent

Glutamate evokes an inward membrane current in glial cells from the rabbit retina, by activating high-affinity glutamate uptake. Uptake is strongly inhibited by depolarization. It is also inhibited by removing extracellular sodium or intracellular potassium and by raising the extracellular potassium concentration, suggesting that the uptake carrier transports sodium ions into and potassium ions out of the cell. The voltage- and potassium-dependence of glutamate uptake may have clinical implications: during anoxia, when [K+]0 rises, uptake will be inhibited and the extracellular glutamate concentration may then rise to neurotoxic levels.

A presynaptic action of glutamate at the cone output synapse

Neurotransmitter release from many central nervous system synapses is regulated by 'autoreceptors' at the synaptic terminal, which bind the released transmitter and alter release accordingly. The photoreceptors of lower vertebrates are thought to use glutamate as a neurotransmitter. Glutamate conveys the visual signal to postsynaptic bipolar and horizontal cells, but has been reported not to act on the photoreceptors themselves. We show here that glutamate evokes a current, carried largely by chloride ions, in cones isolated from the tiger salamander retina. This response is localized to the synaptic terminal of the cone. Removing external sodium blocks this action of glutamate. These results suggest the existence of a positive feedback loop at the cone output synapse: over most of the light-response range, glutamate released by depolarization of the cone will cause further depolarization, increasing the gain of phototransduction. Glutamate released from rods may also polarize cones, modulating the gain of the cone output synapse. This system is surprisingly different from the autoreceptor systems for most other transmitters, which act in a negative feedback way.