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Glowalla C, Langer S, Lenze U, Lazic I, Hirschmann MT, Hinterwimmer F, von Eisenhart-Rothe R, Pohlig F. Postoperative full leg radiographs exhibit less residual coronal varus deformity compared to intraoperative measurements in robotic arm-assisted total knee arthroplasty with the MAKO™ system. Knee Surg Sports Traumatol Arthrosc 2023; 31:3912-3918. [PMID: 36964782 PMCID: PMC10435414 DOI: 10.1007/s00167-023-07386-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/09/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE Robotic arm-assisted total knee arthroplasty (raTKA), currently a major trend in knee arthroplasty, aims to improve the accuracy of implant positioning and limb alignment. However, it is unclear whether and to what extent manual radiographic and navigation measurements with the MAKO™ system correlate. Nonetheless, a high agreement would be crucial to reliably achieve the desired limb alignment. METHODS Thirty-six consecutive patients with osteoarthritis and a slight-to-moderate varus deformity undergoing raTKA were prospectively included in this study. Prior to surgery and at follow-up, a full leg radiograph (FLR) under weight-bearing conditions was performed. In addition, a computed tomography (CT) scan was conducted for preoperative planning. The hip-knee-ankle angle (HKA), mechanical lateral distal femur angle (mLDFA), mechanical medial proximal tibial angle (mMPTA) and joint line convergence angle (JLCA) were measured in the preoperative and follow-up FLR as well as in the CT scout (without weight-bearing) by three independent raters. Furthermore, the HKA was intraoperatively assessed with the MAKO™ system before and after raTKA. RESULTS Significantly higher HKA values were identified for intraoperative deformity assessment using the MAKO system compared to the preoperative FLR and CT scouts (p = 0.006; p = 0.05). Intraoperative assessment of the HKA with final implants showed a mean residual varus deformity of 3.2° ± 1.9°, whereas a significantly lower residual varus deformity of 1.4° ± 1.9° was identified in the postoperative FLR (p < 0.001). The mMPTA was significantly higher in the preoperative FLR than in the CT scouts (p < 0.001). Intraoperatively, the mMPTA was adjusted to a mean of 87.5° ± 0.9° with final implants, while significantly higher values were measured in postoperative FLRs (p < 0.001). Concerning the mLDFA, no significant differences could be identified. CONCLUSION The clinical importance of this study lies in the finding that there is a difference between residual varus deformity measured intraoperatively with the MAKO™ system and those measured in postoperative FLRs. This has implications for preoperative planning as well as intraoperative fine-tuning of the implant position during raTKA to avoid overcorrection of knees with slight-to-moderate varus osteoarthritis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Claudio Glowalla
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
- BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Severin Langer
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
- BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Ulrich Lenze
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Igor Lazic
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (BruderholzLiestalLaufen), 4101, Bruderholz, Switzerland
| | - Florian Hinterwimmer
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany.
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Nastasovic T, Lazic I, Stosic M, Ilic R, Brzanov AG. Neurogenic pulmonary edema in aneurysmal subarachnoid hemorrhage - what is next? Neurosurg Rev 2023; 46:203. [PMID: 37587381 DOI: 10.1007/s10143-023-02115-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/07/2023] [Accepted: 08/13/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Tijana Nastasovic
- Center for Anesthesiology and Resuscitation, Neurosurgery Clinic, Department of Anesthesiology and Resuscitation, University Clinical Center of Serbia, Belgrade, Serbia.
- School of Medicine, Belgrade, Serbia.
| | - Igor Lazic
- Center for Anesthesiology and Resuscitation, Neurosurgery Clinic, Department of Anesthesiology and Resuscitation, University Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, Belgrade, Serbia
| | - Mila Stosic
- Center for Anesthesiology and Resuscitation, Neurosurgery Clinic, Department of Anesthesiology and Resuscitation, University Clinical Center of Serbia, Belgrade, Serbia
| | - Rosanda Ilic
- School of Medicine, Belgrade, Serbia
- Neurosurgery Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandra Gavrilovska Brzanov
- Clinic for Anesthesia, Resuscitation and Intensive Care, University Clinical Center "Mother Teresa", Skopje, North Macedonia
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Lazic I, Stephan M, Pohlig F, Langer S, VON Eisenhart-Rothe R, Suren C. Synovial Calprotectin for Diagnosing Periprosthetic Joint Infection in Loose Hip and Knee Arthroplasties: A Prospective Cohort Study. In Vivo 2023; 37:1714-1720. [PMID: 37369505 DOI: 10.21873/invivo.13258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND/AIM Synovial calprotectin has been demonstrated as a promising biomarker for periprosthetic joint infections (PJI) in painful total hip (THA) and knee arthroplasties (TKA). However, its diagnostic utility has not been evaluated explicitly in cases with marked loosening or migration of the implant. Concerns have already been raised in cases with metallosis and severe periprosthetic osteolysis because wear-induced inflammation may yield false positive results. The purpose of this study was to evaluate calprotectin for the diagnosis of PJI in cases that preoperatively demonstrate moderate to severe periprosthetic osteolysis or implant migration as signs for implant loosening in THA and TKA. PATIENTS AND METHODS Thirty-three patients were included in this prospective study between February of 2019 and November of 2021. The extent of osteolysis was classified according to Engh et al., Paprosky et al., and the modern Knee Society Radiographic Evaluation and Scoring System. Synovial white blood cell count (WBC), percentage of polymorphonuclear neutrophils (PMC), serum C-reactive protein (CRP) and synovial calprotectin using a lateral-flow-assay were tested against the European Bone and Joint Infection Society (EBJIS) definition for PJI. Statistic quality criteria were calculated and compared using a binary classification test. RESULTS Ten patients were classified as confirmed infections according to the EBJIS definition (7 THA and 5 TKA). The calprotectin assay yielded a sensitivity of 0.60, a specificity of 0.61, a positive predictive value of 0.40, and a negative predictive value of 0.78. The calprotectin assay resulted in nine false positive and four false negative cases. No correlation between the extent of osteolysis and false classification by means of the calprotectin assay was observed. CONCLUSION The diagnostic accuracy of synovial calprotectin is impaired if moderate to severe signs of implant loosening are present. If PJI is unlikely, the calprotectin LFT can be applied as a further exclusion tool as the negative predictive value remains relatively high.
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Affiliation(s)
- Igor Lazic
- Technische Universität München, School of Medicine, Klinikum Rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Munich, Germany;
| | - Maximilian Stephan
- Technische Universität München, School of Medicine, Klinikum Rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Munich, Germany
| | - Florian Pohlig
- Technische Universität München, School of Medicine, Klinikum Rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Munich, Germany
| | - Severin Langer
- Technische Universität München, School of Medicine, Klinikum Rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Munich, Germany
| | - Rüdiger VON Eisenhart-Rothe
- Technische Universität München, School of Medicine, Klinikum Rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Munich, Germany
| | - Christian Suren
- München Klinik Bogenhausen, Zentrum für Orthopädie, Unfallchirurgie und Sportmedizin, Munich, Germany
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Suren C, Lazic I, Haller B, Pohlig F, von Eisenhart-Rothe R, Prodinger P. The synovial fluid calprotectin lateral flow test for the diagnosis of chronic prosthetic joint infection in failed primary and revision total hip and knee arthroplasty. Int Orthop 2023; 47:929-944. [PMID: 36656361 PMCID: PMC10014771 DOI: 10.1007/s00264-023-05691-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE The diagnostic criteria of prosthetic joint infection (PJI) recommended by the most commonly used diagnostic algorithms can be obscured or distorted by other inflammatory processes or aseptic pathology. Furthermore, the most reliable diagnostic criteria are garnered during revision surgery. A robust, reliable addition to the preoperative diagnostic cascade is warranted. Calprotectin has been shown to be an excellent diagnostic marker for PJI. In this study, we aimed to evaluate a lateral flow test (LFT) in the challenging patient cohort of a national referral centre for revision arthroplasty. METHODS Beginning in March 2019, we prospectively included patients scheduled for arthroplasty exchange of a total hip (THA) or knee arthroplasty (TKA). Synovial fluid samples were collected intra-operatively. We used the International Consensus Meeting of 2018 (ICM) score as the gold standard. We then compared the pre-operative ICM score with the LFT result to calculate its diagnostic accuracy as a standalone pre-operative marker and in combination with the ICM score as part of an expanded diagnostic workup. RESULTS A total of 137 patients with a mean age of 67 (± 13) years with 53 THA and 84 TKA were included. Ninety-nine patients (72.8%) were not infected, 34 (25.0) were infected, and four (2.9%) had an inconclusive final score and could not be classified after surgery. The calprotectin LFT had a sensitivity (95% confidence interval) of 0.94 (0.80-0.99) and a specificity of 0.87 (0.79-0.93). The area under the receiver operating characteristic curve (AUC) for the calprotectin LFT was 0.94 (0.89-0.99). In nine cases with an inconclusive pre-operative ICM score, the calprotectin LFT would have led to the correct diagnosis of PJI. CONCLUSIONS The synovial fluid calprotectin LFT shows excellent diagnostic metrics both as a rule-in and a rule-out test, even in a challenging patient cohort with cases of severe osteolysis, wear disease, numerous preceding surgeries, and poor soft tissue conditions, which can impair the common diagnostic criteria. As it is available pre-operatively, this test might prove to be a very useful addition to the diagnostic algorithm.
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Affiliation(s)
- Christian Suren
- Center for Orthopedics, Trauma Surgery and Sports Medicine, München Klinik Bogenhausen, Englschalkinger Str. 77, 81925, Munich, Germany.
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Artificial Intelligence and Informatics in Medicine (AIIM), Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Peter Prodinger
- Department of Trauma Surgery and Orthopedics, Norbert-Kerkel-Platz, Krankenhaus Agatharied, Hausham, Germany
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Bogdanovic I, Ristic A, Ilic R, Bascarevic V, Bukumiric Z, Miljkovic A, Milisavljevic F, Stepanovic A, Lazic I, Grujicic D. Factors associated with pre-operative and early and late post-operative seizures in patients with supratentorial meningiomas. Epileptic Disord 2023; 25:244-254. [PMID: 36939715 DOI: 10.1002/epd2.20021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/04/2022] [Accepted: 12/20/2022] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Risk factors for epilepsy in meningioma patients are not yet clearly defined, however, seizure freedom is a significant factor for quality of life after surgery. METHODS We performed a retrospective study of the 333 adult patients who received surgery for supratentorial meningioma at our centre. Various clinical, radiological, and surgical variables were included in the multivariate regression, and the outcomes measured were the occurrence of seizure(s) pre-operatively, during the hospitalization, and during the follow-up period. RESULTS A total of 89 (26,7%) patients experienced pre-operative seizures, of whom 62.9% were seizure-free after the surgery. Of 244 patients without epilepsy before surgery, 11.9% had at least one seizure post-operatively. In total, 63 of our patients (18.9%) experienced seizures after the surgery, of whom 20 had refractory epilepsy. Multivariate analysis identified the following predictors of pre-operative seizures: absence of headache (OR: 0.23, CI: 2.55-8.50), the presence of significant peritumoural oedema (OR: 4.35, CI: 2.57-7.35), and younger age (OR: 0.97 per year increase, CI: 0.95-0.99). Factors associated with early post-operative seizures were: younger age (OR: 0.96 per year increase, CI: 0.93-0.99) and presence of pre-operative seizures (OR: 2.73, CI: 1.13-6.57), while the presence of pre-operative seizures (OR: 4.73, CI: 2,05-10.92), tumour progression (OR: 5.38, CI: 2.25-12.89) and neurological worsening (OR: 5.21 CI: 1.72-15.81) were significant for late post-operative seizures. SIGNIFICANCE Our results from a single-centre meningioma cohort confirm, in general, data from some previous studies regarding patients' characteristics for both pre-operative and overall post-operative epilepsy. Besides previously described risk factors, younger age was important for pre-operative and early post-operative seizures. Epilepsy is common in patients with recurrence of meningioma, but the variables of significance for refractory seizures in these patients require further examination.
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Affiliation(s)
- Ivan Bogdanovic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia
| | - Aleksandar Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,University Clinical Center of Serbia, Clinic for Neurology Belgrade, Serbia
| | - Rosanda Ilic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladimir Bascarevic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zoran Bukumiric
- School of Medicine, University of Belgrade, Belgrade, Serbia.,University of Belgrade Faculty of Medicine, Institute for Medical Statistics and Informatics, Belgrade, Serbia
| | | | - Filip Milisavljevic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia
| | - Aleksandar Stepanovic
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Igor Lazic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia
| | - Danica Grujicic
- University Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
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Lazic I, Burdach A, Pohlig F, von Eisenhart-Rothe R, Suren C. Utility of synovial calprotectin lateral flow test to exclude chronic prosthetic joint infection in periprosthetic fractures: a prospective cohort study. Sci Rep 2022; 12:18385. [PMID: 36319727 PMCID: PMC9626574 DOI: 10.1038/s41598-022-22892-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
The diagnosis of periprosthetic joint infection (PJI) requires a combination of various clinical, laboratory, microbiological and histopathological parameters. A concomitant periprosthetic fracture (PPF) further complicates the diagnosis as it causes a confounding local inflammatory response. Synovial calprotectin has been demonstrated as a promising biomarker of PJI. The purpose of the present study was to evaluate the reliability of synovial calprotectin for the pre- or intraoperative diagnosis of PJI in PFF. 30 patients with PPF and implant loosening were included in this prospective study. Synovial fluid with white blood cells and percentage of polymorphonuclear neutrophils, serum C-reactive protein, and synovial calprotectin using a lateral-flow assay were tested against the EBJIS definition with adjusted thresholds to account for the local inflammation. 14 patients were postoperatively classified as confirmed infections (ten total hip arthroplasties and fourtotal knee arthroplasties). The calprotectin assay yielded a sensitivity of 0.71 [0.48; 0.95], a specificity of 0.69 [0.46; 0.91], a positive predictive value of 0.67 [0.43; 0.91] and a negative predictive value of 0.73 [0.51; 0.96]. Calprotectin is a promising diagnostic parameter for the detection of a PJI in a PPF. The lateral flow assay offers prompt results, which may further assist the surgeon in addition to already existing parameters of PJI diagnostics to diagnose concomitant PJI in PPF during surgery.
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Affiliation(s)
- Igor Lazic
- grid.6936.a0000000123222966Department of Orthopaedic Surgery, Technische Universität München, School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Ismaninger Str. 22, 81675 Munich, Germany
| | - Alexander Burdach
- grid.6936.a0000000123222966Department of Orthopaedic Surgery, Technische Universität München, School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Ismaninger Str. 22, 81675 Munich, Germany
| | - Florian Pohlig
- grid.6936.a0000000123222966Department of Orthopaedic Surgery, Technische Universität München, School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Ismaninger Str. 22, 81675 Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- grid.6936.a0000000123222966Department of Orthopaedic Surgery, Technische Universität München, School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Ismaninger Str. 22, 81675 Munich, Germany
| | - Christian Suren
- grid.6936.a0000000123222966Department of Orthopaedic Surgery, Technische Universität München, School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Ismaninger Str. 22, 81675 Munich, Germany
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Micheler CM, Lang JJ, Wilhelm NJ, Lazic I, Hinterwimmer F, Fritz C, Eisenhart-Rothe RV, Zäh MF, Burgkart RHH. Scaling Methods of the Pelvis without Distortion for the Analysis of Bone Defects. Current Directions in Biomedical Engineering 2022. [DOI: 10.1515/cdbme-2022-1203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
For the development of new types of hip implants for acetabulum revision, it is beneficial to analyse the acetabular defects of the indication group in advance. In order to be able to specially compare the bone defects with each other, a normalisation and accompanying scaling of the pelvis is necessary. Uniform scaling is required so that the bone structures are not distorted. In the following study, three scaling methods based on the minimal bounding box and sphere principle are compared with a method using 14 landmarks on the pelvis.The landmark method is applied to determine the true scaling factor. For the comparison of the different methods, 40 female pelvic models with an acetabular defect are analysed. In the comparison of the scaling methods, the method using minimal bounding spheres shows the least deviation from the landmark method (mean difference 3.30 ± 2.17 %). Due to the fact that no preprocessing (definition of the landmarks) is required and the fast implementation of the algorithm, the minimal bounding sphere is to be preferred to the landmark method for a fast size estimation.
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Affiliation(s)
- Carina M. Micheler
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
- Institute for Machine Tools and Industrial Management, School of Engineering and Design, Technical University of Munich, Garching near Munich , Germany
| | - Jan J. Lang
- Chair of Non-destructive Testing, School of Engineering and Design, Technical University of Munich, Munich , Germany
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
| | - Nikolas J. Wilhelm
- Munich Institute of Robotics and Machine Intelligence, Department of Electrical and Computer Engineering, Technical University of Munich, Munich , Germany
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
| | - Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
| | - Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
- Institute for AI and Informatics in Medicine, Technical University of Munich, Munich , Germany
| | - Christian Fritz
- Institute for Machine Tools and Industrial Management, School of Engineering and Design, Technical University of Munich, Garching near Munich , Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
| | - Michael F. Zäh
- Institute for Machine Tools and Industrial Management, School of Engineering and Design, Technical University of Munich, Garching near Munich , Germany
| | - Rainer H. H. Burgkart
- Department of Orthopaedics and Sports Orthopaedics, University Hospital rechts der Isar, School of Medicine, Technical University of Munich, Munich , Germany
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Lazic I, Hinterwimmer F, Langer S, Pohlig F, Suren C, Seidl F, Rückert D, Burgkart R, von Eisenhart-Rothe R. Prediction of Complications and Surgery Duration in Primary Total Hip Arthroplasty Using Machine Learning: The Necessity of Modified Algorithms and Specific Data. J Clin Med 2022; 11:jcm11082147. [PMID: 35456239 PMCID: PMC9032696 DOI: 10.3390/jcm11082147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 01/18/2023] Open
Abstract
Background: Machine Learning (ML) in arthroplasty is becoming more popular, as it is perfectly suited for prediction models. However, results have been heterogeneous so far. We hypothesize that an accurate ML model for outcome prediction in THA must be able to compute arthroplasty-specific data. In this study, we evaluate a ML approach applying data from two German arthroplasty-specific registries to predict adverse outcomes after THA, after careful evaluations of ML algorithms, outcome and input variables by an interdisciplinary team of data scientists and surgeons. Methods: Data of 1217 cases of primary THA from a single center were derived from two German arthroplasty-specific registries between 2016 to 2019. The XGBoost algorithm was adjusted and applied. Accuracy, sensitivity, specificity and AUC were calculated. Results: For the prediction of complications, the ML algorithm achieved an accuracy of 80.3%, a sensitivity of 31.0%, a specificity of 89.4% and an AUC of 64.1%. For the prediction of surgery duration, the ML algorithm yielded an accuracy of 81.7%, a sensitivity of 58.2%, a specificity of 91.6% and an AUC of 89.1%. The feature importance indicated non-linear outcomes for age, height, weight and surgeon. No relevant linear correlations were found. Conclusion: The attunement of input and output data as well as the modifications of the ML algorithm permitted the development of a feasible ML model for the prediction of complications and surgery duration.
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Affiliation(s)
- Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
- Correspondence:
| | - Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
- Institute for AI and Informatics in Medicine, Technical University of Munich, 80333 Munich, Germany;
| | - Severin Langer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
| | - Florian Pohlig
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
| | - Christian Suren
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
| | - Fritz Seidl
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany;
| | - Daniel Rückert
- Institute for AI and Informatics in Medicine, Technical University of Munich, 80333 Munich, Germany;
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, 80333 Munich, Germany; (F.H.); (S.L.); (F.P.); (C.S.); (R.B.); (R.v.E.-R.)
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Hinterwimmer F, Lazic I, Langer S, Suren C, Charitou F, Hirschmann MT, Matziolis G, Seidl F, Pohlig F, Rueckert D, Burgkart R, von Eisenhart-Rothe R. Prediction of complications and surgery duration in primary TKA with high accuracy using machine learning with arthroplasty-specific data. Knee Surg Sports Traumatol Arthrosc 2022; 31:1323-1333. [PMID: 35394135 PMCID: PMC10050062 DOI: 10.1007/s00167-022-06957-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The number of primary total knee arthroplasties (TKA) is expected to rise constantly. For patients and healthcare providers, the early identification of risk factors therefore becomes increasingly fundamental in the context of precision medicine. Others have already investigated the detection of risk factors by conducting literature reviews and applying conventional statistical methods. Since the prediction of events has been moderately accurate, a more comprehensive approach is needed. Machine learning (ML) algorithms have had ample success in many disciplines. However, these methods have not yet had a significant impact in orthopaedic research. The selection of a data source as well as the inclusion of relevant parameters is of utmost importance in this context. In this study, a standardized approach for ML in TKA to predict complications during surgery and an irregular surgery duration using data from two German arthroplasty-specific registries was evaluated. METHODS The dataset is based on two initiatives of the German Society for Orthopaedics and Orthopaedic Surgery. A problem statement and initial parameters were defined. After screening, cleaning and preparation of these datasets, 864 cases of primary TKA (2016-2019) were gathered. The XGBoost algorithm was chosen and applied with a hyperparameter search, a cross validation and a loss weighting to cope with class imbalance. For final evaluation, several metrics (accuracy, sensitivity, specificity, AUC) were calculated. RESULTS An accuracy of 92.0%, sensitivity of 34.8%, specificity of 95.8%, and AUC of 78.0% were achieved for predicting complications in primary TKA and 93.4%, 74.0%, 96.3%, and 91.6% for predicting irregular surgery duration, respectively. While traditional statistics (correlation coefficient) could not find any relevant correlation between any two parameters, the feature importance revealed several non-linear outcomes. CONCLUSION In this study, a feasible ML model to predict outcomes of primary TKA with very promising results was built. Complex correlations between parameters were detected, which could not be recognized by conventional statistical analysis. Arthroplasty-specific data were identified as relevant by the ML model and should be included in future clinical applications. Furthermore, an interdisciplinary interpretation as well as evaluation of the results by a data scientist and an orthopaedic surgeon are of paramount importance. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany. .,Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany.
| | - Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Severin Langer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Suren
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Fiona Charitou
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology-Liestal, Kantonsspital Baselland, Bruderholz, Laufen, Switzerland.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Georg Matziolis
- Orthopaedic Department Campus Eisenberg, University Hospital Jena, Eisenberg, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Fritz Seidl
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Rueckert
- Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
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10
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Lazic I, Obermeier A, Dietmair B, Kempf WE, Busch A, Tübel J, Schneider J, von Eisenhart-Rothe R, Biberthaler P, Burgkart R, Pförringer D. Treatment of vascular graft infections: gentamicin-coated ePTFE grafts reveals strong antibacterial properties in vitro. J Mater Sci Mater Med 2022; 33:30. [PMID: 35267117 PMCID: PMC8913444 DOI: 10.1007/s10856-022-06650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 01/19/2022] [Indexed: 06/14/2023]
Abstract
Vascular graft infections (VGI) are severe complications in prosthetic vascular surgery with an incidence ranging from 1 to 6%. In these cases, synthetic grafts are commonly used in combination with antimicrobial agents. Expanded polytetrafluoroethylene (ePTFE) is in clinical use as a synthetic graft material and shows promising results by influencing bacterial adhesion. However, the literature on antibiotic-bound ePTFE grafts is scarce. Gentamicin is a frequently used antibiotic for local treatment of surgical site infections, but has not been evaluated as antimicrobial agent on ePTFE grafts. In this study, we examine the antimicrobial efficacy and biocompatibility of novel types of gentamicin-coated ePTFE grafts in vitro. ePTFE grafts coated with gentamicin salt formulations with covalently-bound palmitate were evaluated in two drug concentrations (GP1.75% and GP3.5%). To investigate effects from types of formulations, also suspensions of gentamicin in palmitate as well as polylactide were used at comparable levels (GS + PA and GS + R203). Antibacterial efficacies were estimated by employing a zone of inhibition, growth inhibition and bacterial adhesion assay against Staphylococcus aureus (SA). Cytotoxicity was determined with murine fibroblasts according to the ISO standard 10993-5. Gentamicin-coated ePTFE grafts show low bacterial adherence and strong antibacterial properties in vitro against SA. Bactericidal inhibition lasted until day 11. Highest biocompatibility was achieved using gentamicin palmitate GP1.75% coated ePTFE grafts. ePTFE grafts with gentamicin-coating are effective in vitro against SA growth and adherence. Most promising results regarding antimicrobial properties and biocompatibility were shown with chemically bounded gentamicin palmitate GP1.75% coatings. Graphical abstract.
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Affiliation(s)
- Igor Lazic
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany.
| | - Andreas Obermeier
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany
| | - Bettina Dietmair
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany
| | - Wolfgang E Kempf
- School of Medicine, Klinikum rechts der Isar, Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Technical University of Munich, München, Germany
| | - Albert Busch
- School of Medicine, Klinikum rechts der Isar, Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Technical University of Munich, München, Germany
| | - Jutta Tübel
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany
| | - Jochen Schneider
- School of Medicine, Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin II, Technical University of Munich, München, Germany
| | - Rüdiger von Eisenhart-Rothe
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany
| | - Peter Biberthaler
- School of Medicine, Klinikum rechts der Isar, Klinik für Unfallchirurgie, Technische Universität München, München, Germany
| | - Rainer Burgkart
- School of Medicine, Klinikum rechts der Isar, Klinik für Orthopädie und Sportorthopädie, Technical University of Munich, Munich, Germany
| | - Dominik Pförringer
- School of Medicine, Klinikum rechts der Isar, Klinik für Unfallchirurgie, Technische Universität München, München, Germany
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11
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Glowalla C, Ertl M, Lenze U, Lazic I, Burgkart R, Lang JJ, VON Eisenhart-Rothe R, Pohlig F. Pulsatile Lavage During Cementation of Total Knee Arthroplasty - Is Fixation Impaired? A Cadaver Study. In Vivo 2022; 36:672-677. [PMID: 35241521 DOI: 10.21873/invivo.12752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Increasing economic pressure in modern healthcare necessitates an increase in efficiency in total knee arthroplasty (TKA) while maintaining high-quality outcomes. Removal of debris using pulsatile lavage (PL) during cement polymerization may considerably reduce the operative duration. However, water can penetrate the interface, resulting in impaired implant fixation. The aim of the present study was to investigate the impact of early-onset PL during bone cement polymerization on implant fixation and operative duration. MATERIALS AND METHODS Cemented implantation of tibial trays was performed in 20 fresh-frozen human tibiae from 10 donors in a matched-pair study design in two groups: 1) PL during cement polymerization; and 2) PL after completion of the polymerization process. The cement penetration depth was analysed by computed tomography (CT), and the pull-out force was measured to evaluate primary implant fixation. The duration of the procedure was recorded for both groups. RESULTS Comparable pull-out forces were observed in the experimental (2,213 N) and control groups (2,350 N; p=0.68). The mean depth of cement penetration was similar in both groups. PL during cement polymerization could decrease the operative duration by 10 min. CONCLUSION The application of PL during cement polymerization could significantly reduce operative duration and had no adverse effect on the mechanical fixation of the tibial component.
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Affiliation(s)
- Claudio Glowalla
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.,BG Unfallklinik Murnau, Murnau am Staffelsee, Germany
| | - Max Ertl
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Ulrich Lenze
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Igor Lazic
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Jan J Lang
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany.,Department of Mechanical Engineering, Chair of Nondestructive Testing, Technical University of Munich, Munich, Germany
| | | | - Florian Pohlig
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany;
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12
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Hinterwimmer F, Lazic I, Suren C, Hirschmann MT, Pohlig F, Rueckert D, Burgkart R, von Eisenhart-Rothe R. Machine learning in knee arthroplasty: specific data are key-a systematic review. Knee Surg Sports Traumatol Arthrosc 2022; 30:376-388. [PMID: 35006281 PMCID: PMC8866371 DOI: 10.1007/s00167-021-06848-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/16/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Artificial intelligence (AI) in healthcare is rapidly growing and offers novel options of data analysis. Machine learning (ML) represents a distinct application of AI, which is capable of generating predictions and has already been tested in different medical specialties with various approaches such as diagnostic applications, cost predictions or identification of risk factors. In orthopaedics, this technology has only recently been introduced and the literature on ML in knee arthroplasty is scarce. In this review, we aim to investigate which predictions are already feasible using ML models in knee arthroplasty to identify prerequisites for the effective use of this novel approach. For this reason, we conducted a systematic review of ML algorithms for outcome prediction in knee arthroplasty. METHODS A comprehensive search of PubMed, Medline database and the Cochrane Library was conducted to find ML applications for knee arthroplasty. All relevant articles were systematically retrieved and evaluated by an orthopaedic surgeon and a data scientist on the basis of the PRISMA statement. The search strategy yielded 225 articles of which 19 were finally assessed as eligible. A modified Coleman Methodology Score (mCMS) was applied to account for a methodological evaluation. RESULTS The studies presented in this review demonstrated fair to good results (AUC median 0.76/range 0.57-0.98), while heterogeneous prediction models were analysed: complications (6), costs (4), functional outcome (3), revision (2), postoperative satisfaction (2), surgical technique (1) and biomechanical properties (1) were investigated. The median mCMS was 65 (range 40-80) points. CONCLUSION The prediction of distinct outcomes with ML models applying specific data is already feasible; however, the prediction of more complex outcomes is still inaccurate. Registry data on knee arthroplasty have not been fully analysed yet so that specific parameters have not been sufficiently evaluated. The inclusion of specific input data as well as the collaboration of orthopaedic surgeons and data scientists are essential prerequisites to fully utilize the capacity of ML in knee arthroplasty. Future studies should investigate prospective data with specific and longitudinally recorded parameters. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany. .,Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany.
| | - Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, München, Germany.
| | - Christian Suren
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
| | - Michael T. Hirschmann
- Department of Orthopaedic Surgery and Traumatology-Liestal, Kantonsspital Baselland, Bruderholz, Laufen, Switzerland
| | - Florian Pohlig
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
| | - Daniel Rueckert
- Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts Der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
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13
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Lenze F, Hinterwimmer F, Fleckenstein L, Lazic I, Dammerer D, VON Eisenhart-Rothe R, Harrasser N, Pohlig F. Minimally Invasive Total Hip Arthroplasty: A Comparison of Restoring Hip Biomechanics With and Without a Traction Table. In Vivo 2022; 36:424-429. [PMID: 34972744 PMCID: PMC8765139 DOI: 10.21873/invivo.12720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The aim of the study was to analyze operative time and restoration of hip biomechanics in total hip arthroplasty (THA) via direct anterior approach (DAA) with and without the use of a traction table. PATIENTS AND METHODS We retrospectively compared 97 cases where a traction table was used to 92 cases without a table. Ninety-seven patients received THA with a traction table (AMIS® technique) and 92 patients with conventional DAA. Postoperative standard radiographs were used to analyze offset parameters and leg length. Furthermore, time for patient positioning and cut-to-suture time were evaluated. RESULTS Cut-to-suture time was statistically significantly shorter in the traction table group (p=0.001), whereas analysis of offset parameters (acetabular, femoral and combined) was comparable between the two groups (p=0.31, p=0.95, p=0.42). Postoperative leg length was statistically significantly different with and without traction table use (p=0.02). CONCLUSION Both methods enable restoration of hip biomechanics with high accuracy. Further studies with prospective study designs and larger sample sizes may be needed to confirm these results.
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Affiliation(s)
- Florian Lenze
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany;
| | - Florian Hinterwimmer
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Lisa Fleckenstein
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Dietmar Dammerer
- Department of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rüdiger VON Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norbert Harrasser
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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14
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Suren C, Lazic I, Stephan M, Lenze FW, Pohlig F, von Eisenhart-Rothe R. Diagnostic algorithm in septic total knee arthroplasty failure - What is evidence-based? J Orthop 2021; 23:208-215. [PMID: 33603316 DOI: 10.1016/j.jor.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022] Open
Abstract
Prosthetic joint infection (PJI) is among the most common differential diagnoses of total knee arthroplasty failure. It is a challenging complication, not least because of the difficulty of establishing the correct diagnosis. The fact that no single diagnostic parameter or test has been identified that can accurately rule in or out PJI has led to an evolution of similar but competing definitions of PJI on the grounds of an array of criteria. This development has had very positive effects on the scientific evaluation of various methods of PJI diagnostics and treatment because of an increased comparability. However, it can be challenging to stay abreast of the evidence these definitions are based on. Also, the definitions alone do not necessarily entail an algorithm to aid in evaluating the right criteria in a sound order to be able to use the definitions as a sensible tool. The aim of this overview is to state the most recent evidence on the diagnostic parameters included in the most established PJI definitions and to exhibit and compare the few algorithmic approaches published. Clinical symptoms of PJI are very rarely reported on in the literature, hence the evidence on their diagnostic value is poor. The only symptom that is part of the established PJI definitions is the presence of a fistula. Concerning serological markers, CRP and ESR are still the common denominator in the literature, most recently accompanied by D-Dimer as a potentially suitable marker that has been included in the most recent update of the International Consensus Meeting (ICM) criteria. Imaging plays a minor role in the diagnostic cascade because of inconsistent evidence, and no role whatsoever in the established definitions. The most important preoperative diagnostic measure is arthrocentesis and cultural and cytological analysis of the synovial fluid. The much acclaimed α-Defensin test has so far not been included in the established criteria due to inconsistent reports on its diagnostic accuracy, it is, however, in wide use and considered an optional diagnostic tool for inconclusive cases. The most diagnostic accuracy lies in the cultural and histological analysis of periprosthetic tissue biopsies, whether they are gathered in a small procedure or during arthroplasty revision. Published algorithmic approaches to PJI diagnosis are much rarer than the well-established definitions by various associations. With their PJI definition, the American Academy of Orthopedic Surgeons (AAOS) published a consensus based flowchart for PJI diagnosis. Another algorithm was proposed as part of the endeavor of the MSIS and the first consensus meeting, also based on a consensus among experts. There have been two more recent publications of flowcharts based on the current evidence, one introduced at our institution in 2013, one established in 2020 by the German Society for Arthroplasty (AE).
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Affiliation(s)
- Christian Suren
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Maximilian Stephan
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Walter Lenze
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar, Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
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15
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Lazic I, Scheele C, Pohlig F, von Eisenhart-Rothe R, Suren C. Treatment options in PJI - is two-stage still gold standard? J Orthop 2021; 23:180-184. [PMID: 33551610 PMCID: PMC7848725 DOI: 10.1016/j.jor.2020.12.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 02/07/2023] Open
Abstract
Total knee arthroplasty (TKA) is a successful treatment for osteoarthritis with good clinical outcomes 1,2. Periprosthetic joint infection (PJI) in TKA has a low incidence between 0.5 and 3% but it is nevertheless one of the most dreadful complications 3-6. Two-staged revisions are considered to be the gold standard for revision in chronic PJI with infection eradication rates of over 90% 7. Recently, similar infection eradication rates after one-staged revision arthroplasty have been reported 8-10, raising the question whether the two-staged approach can still be considered the gold standard. We therefore performed a literature review to analyse the correlation of one-staged and two-staged TKA revisions with recurrent infection rates and functional outcomes. Studies concerning PJI treated by one- or two-staged revision published between 2000 and 2020 were retrieved by searching the databases PubMed/Medline and the Cochrane Database of Systematic Reviews. 29 studies were included in this qualitative synthesis. Mean follow-up was at 4.9 ± 2.6 years. The mean infection eradication rate after one-staged revision vs. two-staged revision in TKA was 87 ± 8.8% vs. 83 ± 11.7%. The functional outcome measured by the mean Knee Society Score (KSS) of one-staged revision vs. two-staged revision in TKA was 80 ± 5.9 vs. 80 ± 3.9 points. One-staged revision arthroplasty in TKA appears to have similar infection eradication rates and functional outcomes compared to two-staged revision arthroplasty. However, these results should be interpreted with caution, since selection bias may have played a significant role. Several criteria to guide the surgeon in selecting the appropriate procedure have been described, but the current recommendations are based on poor evidence as randomized controlled trials are lacking 11,12. Two-staged revision remains a successful treatment option which is rightly the gold standard. However, there is a variety of cases in which one-staged revision is a viable alternative, where similar success rates and functional outcome can be expected 7,13.
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Affiliation(s)
- Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Christian Scheele
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
| | - Christian Suren
- Department of Orthopedics and Sports Orthopedics, Klinikum Rechts der Isar; Technical University of Munich (TUM), Ismaningerstr. 22, 81675, Munich, Germany
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16
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Lazic I, Knebel C, Consalvo S, Rechl H, von Eisenhart-Rothe R, Lenze U. [Amputations around the knee]. Orthopade 2020; 49:461-470. [PMID: 32266433 DOI: 10.1007/s00132-020-03906-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An amputation around, through or below the knee joint constitutes a "huge" change in a patient's life. In Orthopaedics, amputations are most frequently performed in cases with musculoskeletal tumours or failed total knee arthroplasty. A multidisciplinary team approach (surgeon, anaesthetist, pain specialists, orthotist, psychologist etc.) and patient-specific treatment regime from the outset as well as a meticulous surgical technique are of the outmost importance. Nowadays, prosthetic legs can be fitted for nearly any amputation level. The functional outcome of amputations below the knee is usually superior to amputations above or through the knee joint. Postoperative stump conditioning is paramount and the final prosthetic leg should not be fitted earlier than 4-6 months postoperatively. Problems with wound healing, muscle contractures and phantom limb pain represent common complications which might adversely affect patient outcomes.
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Affiliation(s)
- Igor Lazic
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Carolin Knebel
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Sarah Consalvo
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Hans Rechl
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Rüdiger von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Ulrich Lenze
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
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Scheele CB, Pietschmann MF, Schröder C, Lazic I, Grupp TM, Müller PE. Influence of bone density on morphologic cement penetration in minimally invasive tibial unicompartmental knee arthroplasty: an in vitro cadaver study. J Orthop Surg Res 2019; 14:331. [PMID: 31640733 PMCID: PMC6805553 DOI: 10.1186/s13018-019-1376-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Background Unicompartmental knee arthroplasty is an established treatment option for anteromedial osteoarthritis. However, large registry studies report higher rates of aseptic loosening compared to total knee arthroplasty. The objective of this study was to assess the impact of bone density on morphological cement penetration. Moreover, an alternative regional bone density measuring technique was validated against the established bone mineral density assessment. Methods Components were implanted on the medial side of 18 fresh-frozen cadaver knees using a minimally invasive approach. Bone density has been quantified prior to implantation using Hounsfield units and bone mineral density. Morphological cement penetration has been assessed in different areas and was correlated with local bone density. Findings A highly significant correlation between Hounsfield units and trabecular bone mineral density was detected (r = 0.93; P < 0.0001), and local bone density was significantly increased in the anterior and posterior area (P = 0.0003). The mean cement penetration depth was 1.5 (SD 0.5 mm), and cement intrusion into trabecular bone was interrupted in 31.8% (SD 23.7%) of the bone-cement interface. Bone density was correlated significantly negative with penetration depth (r = − 0.31; P = 0.023) and positive with interruptions of horizontal interdigitating (r = + 0.33; P = 0.014). Cement penetration around the anchoring peg was not significantly correlated with bone density. Interpretation Areas with high bone density were characterized by significantly lower penetration depths and significantly higher areas without cement penetration. Anchoring pegs facilitate cement intrusion mechanically. Regional quantification of bone density using Hounsfield units is a simple but valuable extension to the established determination of bone mineral density.
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Affiliation(s)
- Christian B Scheele
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany. .,Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Matthias F Pietschmann
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schröder
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Igor Lazic
- Department of Orthopedics and Sports Orthopedics, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas M Grupp
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany.,Aesculap AG Research & Development, Am Aesculap-Platz, 78532, Tuttlingen, Germany
| | - Peter E Müller
- Department of Orthopaedics, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
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Lenze U, Knebel C, Lenze F, Consalvo S, Lazic I, Breden S, Rechl H, von Eisenhart-Rothe R. [Total endoprosthetic replacement of femur, humerus and tibia]. Orthopade 2019; 48:555-562. [PMID: 31190111 DOI: 10.1007/s00132-019-03762-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Improvements in diagnostics and effectiveness of chemotherapy have resulted in most patients with primary malignant bone tumours being candidates for limb salvage surgery. Herewith, the use of modern modular tumour endoprostheses allows for the replacement of all big joints and even entire long bones such as the femur, humerus and tibia. In this article, we focus on individual prerequisites for and challenges with performing a total endoprosthetic reconstruction of the above-mentioned anatomic structures. Additionally, data from the literature with regards to functional outcome, problems and complications are presented.
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Affiliation(s)
- U Lenze
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland.
| | - C Knebel
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - F Lenze
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - S Consalvo
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - I Lazic
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - S Breden
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - H Rechl
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - R von Eisenhart-Rothe
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
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