The Impact of Epidural Analgesia on Immobility and extended Hospital Stay After Periacetabular Osteotomy

AIMS

Early mobilisation after periacetabular osteotomy (PAO) represents an important goal after surgery. The purpose of this study was to determine whether the use of epidural aznalgesia (EA) is associated with prolonged immobility and an increased length of stay (LOS) after PAO surgery.

METHODS

From January 2022 to July 2023, the study included a cohort of 150 PAO procedures all performed by the same surgeon (SSA). Patients were categorized into two distinct groups: those who received epidural analgesia (EA) (79 PAOs) and those who did not receive EA (71 PAOs). "Ready for discharge" was defined as the ability to ascend and descend a standardized flight of stairs independently. Multivariable linear regression was used to identify additional factors influencing LOS after PAO.

RESULTS

Patients in the EA group were ready for discharge 5.95 ± 2.09 days after surgery which was significantly longer than in the No EA group´s average of 4.18 days ± 2.5, (p < 0.001). While the reduction in the number of patients experiencing pulmonary embolism in the No EA group did not reach statistical significance, it still demonstrated a relevant decrease from two patients within the EA group (2.53%) to 0 (0%) in the No EA group. The active engagement of the surgeon in mobilising patients led to a substantial reduction in LOS, decreasing it from 5.81 ± 2.18 days to 2.2 ± 0.77 days (p < 0.001). Multivariable analysis revealed five independent factors influencing the LOS following PAO which included absence of EA, surgeon-led mobilisation within 24 h after surgery, postoperative hemoglobin levels, BMI, and prior experience with PAO surgery on the contralateral side.

CONCLUSIONS

Opting against the use of EA in patients undergoing PAO is advisable, as it will result in extended postoperative immobility and the associated risks. Additionally, the active participation of the surgeon in the mobilisation process is strongly recommended.

Unveiling the learning curve of periacetabular osteotomy

Aims

Periacetabular osteotomy (PAO) is widely recognized as a demanding surgical procedure for acetabular reorientation. Reports about the learning curve have primarily focused on complication rates during the initial learning phase. Therefore, our aim was to assess the PAO learning curve from an analytical perspective by determining the number of PAOs required for the duration of surgery to plateau and the accuracy to improve.

Methods

The study included 118 consecutive PAOs in 106 patients. Of these, 28 were male (23.7%) and 90 were female (76.3%). The primary endpoint was surgical time. Secondary outcome measures included radiological parameters. Cumulative summation analysis was used to determine changes in surgical duration. A multivariate linear regression model was used to identify independent factors influencing surgical time.

Results

The learning curve in this series was 26 PAOs in a period of six months. After 26 PAO procedures, a significant drop in surgical time was observed and a plateau was also achieved. The mean duration of surgery during the learning curve was 103.8 minutes (SD 33.2), and 69.7 minutes (SD 18.6) thereafter (p < 0.001). Radiological correction of acetabular retroversion showed a significant improvement after having performed a total of 93 PAOs, including anteverting PAOs on 35 hips with a retroverted acetabular morphology (p = 0.005). Several factors were identified as independent variables influencing duration of surgery, including patient weight (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p < 0.001), learning curve procedure phase of 26 procedures (β = 34.0 (95% CI 24.3 to 43.8); p < 0.001), and the degree of lateral correction expressed as the change in the lateral centre-edge angle (β = 0.7 (95% CI 0.001 to 1.3); p = 0.048).

Conclusion

The learning curve for PAO surgery requires extensive surgical training at a high-volume centre, with a minimum of 50 PAOs per surgeon per year. This study defined a cut-off value of 26 PAO procedures, after which a significant drop in surgical duration occurred. Furthermore, it was observed that a retroverted morphology of the acetabulum required a greater number of procedures to acquire proficiency in consistently eliminating the crossover sign. These findings are relevant for fellows and fellowship programme directors in establishing the extent of training required to impart competence in PAO.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on scientific evidence and expert opinion to improve the diagnosis, preoperative planning, indication and surgical strategy in Anterior Cruciate Ligament revision.

METHODS

Part 2, presented herein, followed exactly the same methodology as Part 1: the so-called ESSKA formal consensus derived from the Delphi method. Eighteen questions were ultimately asked. The quality of the answers received the following grades of recommendation: Grade A (high level scientific support), Grade B (scientific presumption), Grade C (low level scientific support) or Grade D (expert opinion). All answers were scored from 1 to 9 by the raters. Once a general consensus had been reached between the steering and rating groups, the question-answer sets were submitted to the peer-review group. A final combined meeting of all the members of the consensus was then held to ratify the document.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the surgical strategy in cases of ACL reconstruction failure. Of the 18 questions, only 1 received a Grade A rating; 5, a Grade B rating; and 9, grades of C or D. The three remaining complex questions received further evaluations for each portion of the question and were looked at in more detail for the following grades: B and D; A, C and D; or A, B, C and D. The mean rating of all questions by the rating group was 8.0 + - 1.1. The questions and recommendations are listed in the article.

CONCLUSION

ACL revision surgery, especially the surgical strategy, is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardization. Therefore, this international European consensus project is of great importance and clinical relevance for guiding the management of ACL revision in adults.

LEVEL OF EVIDENCE

Level II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning

PURPOSE

The aim of this ESSKA consensus is to give recommendations based on evidence and expert opinion to improve diagnosis, preoperative planning, indication and surgical strategy in ACL revision.

METHODS

The European expert surgeons and scientists were divided into four groups to participate in this consensus. A "literature group" (four surgeons); "steering group" (14 surgeons and scientists); "rating group" (19 surgeons) and finally "peer review group" (51 representatives of the ESSKA-affiliated national societies from 27 countries). The steering group prepared eighteen question-answer sets. The quality of the answers received grades of recommendation ranging from A (high-level scientific support), to B (scientific presumption), C (low level scientific support) or D (expert opinion). These question-answer sets were then evaluated by the rating group. All answers were scored from 1 to 9. The comments of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the question-answer sets were submitted to the peer review group. A final combined meeting of all the members of the consensus was held to ratify the document.

RESULTS

The literature review for the diagnosis and preoperative planning of ACL revision revealed a rather low scientific quality. None of the 18 questions was graded A and six received a grade B. The mean rating of all the questions by the rating group was 8.4 ± 0.3. The questions and recommendations are listed below.

CONCLUSION

ACL revision surgery is a widely debated subject with many different opinions and techniques. The literature reveals a poor level of standardisation. Therefore, this international consensus project is of great importance.

LEVEL OF EVIDENCE

II.

Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method

PURPOSE

The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev).

METHODS

The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate').

RESULTS

The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III).

CONCLUSION

This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications.

LEVEL OF EVIDENCE

II.

Increased asphericity of the femoral head-neck junction in professional breakers compared to hobby athletes - a retrospective case-control study

OBJECTIVE

Breaking has gained public attention as a form of sports activity. The associated intense movements of the hip joints are possibly linked to the development of femoroacetabular impingement (FAI). Therefore, this study aimed to assess clinical and radiographic FAI measures in professional breakers compared to hobby athletes.

METHODS

The study cohort consisted of professional breakers with persisting hip pain who were 1:1 matched to a cohort of FAI patients without professional sports careers from our outpatient clinic. The primary endpoint assessed on standardized plain radiographs was the alpha angle (AA). Further measures were the acetabular index (AI), lateral center-edge angle (LCEA), crossover sign, ischial spine sign, and femoral head extrusion index (FHEI). The modified Harris Hip Score (mHHS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were used to obtain patient-reported measures.

RESULTS

We recruited ten professional breakers and matched them to ten hobby athletes. The median AA was significantly higher in the breakers compared with the hobby athletes (73° [IQR 66.5°, 84.2°]) vs. 61.8° [IQR 59.5°, 64.8°], p = 0.0004). There was a significant reduction in weekly training hours in breakers after diagnosis (13.0 hours [interquartile range [IQR] 9.5, 32.4] to 1.5 hours [IQR 0, 4.8], p = 0.0039). There were no inter-group differences regarding mHHS, WOMAC, and additional radiographic measurements.

CONCLUSION

Breakers have higher AA in cam-type FAI compared to nonprofessional athletes. The corresponding hip pain significantly reduced training hours and caused the end of their breaking career. The potentially high prevalence of FAI in breakers and the corresponding consequences need to be considered early when athletes present with hip pain.

Fifty percent of patients undergoing periacetabular osteotomy for hip dysplasia showed normal findings upon neonatal ultrasound screening : Symptomatic hip dysplasia in adulthood despite inconspicuous neonatal hip ultrasound

Developmental dysplasia of the hip (DDH) is characterized by the pathomorphology of inadequate acetabular coverage of the femoral head leading to increased loading of the articular surface and acetabular rim. If left untreated, this ultimately leads to osteoarthritis. Germany introduced a nationwide universal ultrasound screening program for all newborn infants in 1996. Subsequently, the incidence of undiagnosed hip dislocation was significantly reduced. In this consecutive series of patients who underwent periacetabular osteotomy for the treatment of symptomatic dysplasia of the hip between October 2014 and October 2022 data regarding the U3 screening examination were analyzed. The data included whether the examination was performed, whether the findings were positive or negative, whether the patients underwent any form of treatment in the case of a positive finding and whether a control X‑ray was performed. This study provides evidence that acetabular undercoverage cannot be ruled out based on a normal finding in ultrasonography screening. Furthermore, the study also shows that residual dysplasia may persist despite attempts of conservative treatment.

Survival of the dysplastic hip after periacetabular osteotomy: a meta-analysis

BACKGROUND

Periacetabular osteotomy (PAO) has become a popular procedure for re-orientation of the acetabulum in patients with a developmental pathomorphology. Since its first description by Reinhold Ganz in 1988, many institutions worldwide have adopted the procedure for the treatment of developmental hip dysplasia (DDH) and have subsequently reported their results. The aim of this study was to provide a meta-analysis of the likelihood of long-term survival of a dysplastic hip after PAO.

METHODS

A systematic literature review was conducted using Medline, Cochrane and "Web of Science" databases to identify articles reporting survival estimates for PAO in patients with DDH. To be included in the analysis, studies had to include patient cohorts aged <40 years, with Osteoarthritis grade < Tönnis III and no form of neuromuscular dysplasia. Adjustment for cohort overlap was performed. Quality assessment included level of evidence (LOE) according to the oxford center for LOE criteria and the "Methodological index for non-randomized studies (MINORS)". After data extraction, a random-effects meta-analytical model was applied to provide weighted mean estimates of survival at 5 years, 10 years, 15 years and 20 years.

RESULTS

Nine relevant articles included 2268 dysplastic hips that underwent PAO in 9 institutions. Of the included studies, 5 presented level III evidence and 4 presented level IV evidence. The MINORS score was 11 for 3 studies, 12 for 4 studies and 13 for 2 studies. The 5-year survival after PAO was 96.1% (95% CI, 94.9-97.3), the 10-year survival was 91.3% (95% CI, 87.7-94.8), 15-year survival 85.0% (95% CI, 78.9-91.1), 20-year survival 67.6% (95% CI, 53.9-81.3).

CONCLUSIONS

The results provide a representative survival estimate of a dysplastic hip after PAO based on global evidence. This should provide clinicians and patients with an adequate reflection of prognostic expectations after this kind of surgery.

The Female Pelvis Is Associated with a Lateralized Ischium and a Reduced Ischiofemoral Space

BACKGROUND

Pelvi-femoral conflicts are increasingly recognized for their explanatory role in the pathology of extra-articular hip impingement. Ischiofemoral impingement (IFI) is a type of impingement between the femur and the ischium that causes high femoral antetorsion and valgus femoral neck orientation. It is unknown whether obstetric adaptation of the female pelvis renders the female hip at a higher risk of sustaining IFI. The aim of this study was to determine the influence of the pelvic morphology on the ischiofemoral space (IFS).

METHODS

Plain radiographs of healthy individuals with no symptomatic hip disease were obtained in a functional standing position in a standardized manner and utilized for measurement of the interischial and ischiofemoral widths, subpubic angle, and centrum collum diaphyseal (CCD) angle. Linear regression was performed to determine the influence of morphometric measures on the ischiofemoral space.

RESULTS

Sixty-five radiographs (34 females and 31 males) were included. The cohort was stratified according to gender. Significant gender-related differences were noted regarding the ischiofemoral distance (31% increase in males, p < 0.001), pubic-arc angle (30% increased in females, p < 0.001), and the interischial space (7% increase in females, p < 0.001). CCD did not significantly differ between genders (p = 0.2). Factors influencing the IFS include the pubic-arc angle (β = -0.01 (CI -0.02--0.00), p = 0.003), interischial distance (β = -0.11 (CI -0.23--0.00), p = 0.049) and CCD (β = -0.06 (CI -0.09--0.04), p < 0.001).

CONCLUSIONS

Obstetric adaptation is associated with an increased subpubic angle that shifts the ischia laterally and away from the symphysis. The resultant reduction in the ischiofemoral space renders the female pelvis at a higher risk for a pelvi-femoral conflict, or more precisely, an ischiofemoral conflict, due to the reduced ischiofemoral space of the hip. The CCD angle of the femur was shown not to be gender specific. However, the CCD angle demonstrates an influence on the ischiofemoral space, rendering the proximal femur a target for corresponding osteotomies.

The Scientific Evolution of Periacetabular Osteotomy: A Global Review

It is well-known that hip disorders are frequently of bony origin related to an underlying pathomorphology. A fundamental understanding of morphology and biomechanics is therefore of essential importance for a targeted approach in defining treatment plans. Treatment is frequently based on altering bony morphology, for which a set of effective techniques have been proposed. Periacetabular osteotomy (PAO) allows for reorientation of the acetabulum and powerful correction of acetabular coverage. The revolutionary aspect of PAO compared to prior osteotomies lies in maintenance of the integrity of the posterior column. This allows for a substantial increase in primary stability, a larger bony surface for healing, and simple reorientation of the acetabular fragment that is free of posterior ligamentous restraints. The results for dysplasia are very promising. Indications have been refined by studies revealing that the presence of degenerative changes and age > 40 years at the time of surgery represent prognostic factors of poorer outcome. Indications have also been broadened to include acetabular retroversion (with posterolateral dysplasia) and borderline hip dysplasia. A glimpse at the future would reflect major advances related to individual planning, surgical training, and precise surgical conduction. In the era of digitalization, augmented reality may assist in performing bony cuts and act as an aid for some of the blind ischial and retro-acetabular cuts. Innovations in perioperative management will enhance recovery after the procedure and allow for early recovery programs with optimized protocols of pain management. Considering that the success of PAO in the young is comparable to the success of hip arthroplasty in the old, PAO should be considered one of the pillars of modern orthopedic surgery.

Full-length standing radiographs can be used for determination of the Femoral neck-shaft angle but not acetabular coverage

INTRODUCTION

The exact evaluation of hip morphology is essential for surgical planning. A wide range of morphometric measures of the acetabulum is deduced from conventional anterior-posterior (ap) pelvic radiographs. Full-length weight-bearing radiographs (FLWBR) also depict the acetabulum and are commonly used for osteotomy planning of the lower limb. This study aimed to determine whether FLWBR can be used to evaluate acetabular morphology.

METHODS

Radiographs of patients receiving a hip workup that included a conventional ap pelvic X-ray and FLWBR were utilized for radiographic measurements. The following parameters were measured: extrusion index of the femoral head, anterior wall index, posterior wall index, lateral center edge angle (LCE), acetabular index, pubic arc angle (subpubic angle), and centrum-collum-diaphyseal angle (CCD).

RESULTS

FLWBR depicted a significantly reduced anterior coverage (p = 0.049) and increased posterior coverage (p < 0.001), higher acetabular index (p = 0.015), and higher pubic-arc angle (p = 0.02) compared to conventional ap pelvic radiographs. There were no significant differences regarding the CCD angle (p = 0.28), extrusion index (p = 0.31), and LCE (p = 0.16).

DISCUSSION

The CCD angle of the femur can be measured on conventional ap radiographs and full-length weight-bearing X-rays for lower limb deformity analysis. However, FLWBR will depict an anteverted acetabular morphology, rendering conventional ap radiographs necessary for planning pelvic osteotomies.

Evaluation of patella height in native knees and arthroplasty: an instructional review

Total knee arthroplasty (TKA) is the gold standard for treating advanced knee osteoarthritis. Among the postoperative complications of TKA are true patella infera (TPI) and pseudo patella infera (PPI), which should be differentiated since TPI exhibits significantly worse clinical outcomes. Multiple radiological patella height indices (PHI) exist; some were modified or originally designed for knees with implanted endoprostheses. However, there is no consensus on measuring and comparing patella height. Due to the lack of established, simple, reliable, and reproducible concepts for assessing patella height for arthroplasty, measuring patella height and the change of patella height by or after TKA have been challenging tasks for clinicians and researchers. This is a review of the current literature on methods for measuring patella height, with special attention to the ability to differentiate between the TPI and PPI after TKA. All literature on the topic was retrieved, and references from relevant articles were investigated until the end of April 2022.

Collagen wrapping and local platelet-rich fibrin do not improve the survival rates of ACL repair with dynamic intraligamentary stabilization: a retrospective case series after ≥5 years postoperatively

PURPOSE

Anterior cruciate ligament (ACL) repair has been recommended as a treatment principle for ACL tears. Several authors have advocated a potential role for primary repair techniques in the ACL decision tree. However, long-term results have been controversial. This study aims to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization (DIS) with and without augmentation.

METHODS

Between 2014 and 2019, 102 patients with isolated proximal ACL ruptures underwent DIS repair within 21 days from injury and were available for follow-up either clinically or telephonically after ≥5 years postoperatively. In 45 cases, DIS repair was augmented with collagen fleece wrapping, platelet-rich fibrin (PRF) or both. Failure was defined as traumatic re-rupture or conversion to ACL reconstruction. The patients being available for physical examination underwent a.-p. stability measurement with a KT-1000 device. Functional outcome was measured with the IKDC, Tegner and Lysholm scores. Kaplan-Meier survival analysis, Log-Rank Test and Binominal logistic regression were performed.

RESULTS

After a minimum 5-year follow-up, 71/102 (69.6%) DIS repairs were not re-reptured and clinically and/or subjectively stable. Augmentation did not improve survival rates (p = 0.812). The identified factors influencing failure were a younger age and a pre-injury Tegner activity level of ≥7. 95.7% of those patients with an intact ACL repair had normal or near normal knee function based on the IKDC scoring system.

CONCLUSIONS

The 5-year overall survival rate of DIS was 69.6%. Collagen fleece wrapping and local PRF application did not improve survival. Patients not suffering failure of repair demonstrated high satisfaction. Nevertheless, the results are inferior to those of established ACL reconstruction procedures.

LEVEL OF EVIDENCE

Case series, Level IV.

Tissue engineering approaches for the repair and regeneration of the anterior cruciate ligament: towards 3D bioprinted ACL-on-chip

The anterior cruciate ligament (ACL) is the most frequently injured ligament in the knee. The current method to treat the injured ligament is reconstruction using autografts and allografts. Reconstruction requires the regeneration of ligament, bone and their interface to ensure proper recovery. Recently, researchers have focused on using tissue-engineered scaffolds made of synthetic materials and biomaterials -such as collagen, decellularised tissues, silk and synthetic polymers produced following different manufacturing methods - for ACL reconstruction,. Different materials can be easily processed using various fabrication methods for mimicking the mechanical properties of the ACL. The advances in technologies play an important role in the production of constructions that can mimic native ACL.. The present review addresses integrative scaffold design, different challenges in the potential materials and manufacturing methods as well as future strategies for ACL repair. Furthermore, the review provides a road map to 3D printing combined with organ-on-chip technology to demonstrate the potential for cost-effective and user-friendly fabrication methods for ACL engineering. Finally, it underlines the potential of 3D bioprinting and organ-on-chip technologies for micro-engineering of ligaments and their associated environment.

Back to the Future with Osteotomies around the Hip

If we were to look back at the history of orthopedics only two generations ago, the intertrochanteric osteotomy was a well-established procedure for the treatment of osteoarthritis of the hip [...]

Essential concepts in the treatment of common joint fractures: A narrative review

Proximal fractures of the humerus are at high risk of osteonecrosis if the medial calcar is disrupted and the metaphyseal extension of the head fragment is <8mm. Risk factors for failure of osteosynthesis include: poor bone stock, varus dislocation, head dislocation and medial comminution. During surgical treatment of distal humerus fractures, one should aim to restore the arc and stabilize the columns. Several technical rules have been outlined by O´Driscoll and are mentioned in this article in detail. In fractures of the distal radius, the length, the joint surface, and joint angles (palmar inclination ca. 11°, radial inclination ca. 22°) should be reconstructed. Several surgical factors are associated with the development of radiocarpal osteoarthritis including the sagittal depth of the articular cavity and the anterior-posterior diameter of the fossa lunata of the distal radius. When managing fractures of the proximal tibia, a four- or more column classification system should be used to plan the surgical steps and choose the appropriate approach(es). In ankle fractures, intraoperative 3-D-Scan should be considered especially in the case of syndesmotic involvement or involvement of the posterior malleolus.

Microbiological Advantages of Open Incisional Biopsies for the Diagnosis of Suspected Periprosthetic Joint Infections

Background: Periprosthetic joint infection (PJI) represents a serious complication following total hip (THA) and knee arthroplasty (TKA). When preoperative synovial fluid cultures remain inconclusive, open incisional joint biopsy (OIB) can support causative microorganism identification. Objective: This study investigates the potential benefit of OIB in THA and TKA patients with suspected PJI and ambigious diagnostic results following synovial fluid aspiration. Methods: We retrospectively assessed all patients treated from 2016 to 2020 with suspected PJI. Comparing the microbiology of OIB and the following revision surgery, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the number needed to treat (NNT). Results: We examined the diagnostic validity of OIB in 38 patients (20 female) with a median age of 66.5 years. In THA patients (n = 10), sensitivity was 75%, specificity was 66.67%, PPV was 60%, NPV was 80%, and NNT was 2.5. In TKA patients (n = 28), sensitivity was 62.5%, specificity was 95.24%, PPV was 83.33%, NPV was 86.96%, and NNT was 1.42. Conclusions: Our results indicate that OIB represents an adequate diagnostic tool when previously assessed microbiological results remain inconclusive. Particularly in TKA patients, OIB showed an exceptionally high specificity, PPV, and NPV, whereas the predictive validity of the diagnosis of PJI in THA patients remained low.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Therapeutic anticoagulation complications in the elderly: a case report

Background

The demographic transition leads to a continuously growing number of elderly patients who receive therapeutic anticoagulation by reason of several comorbidities. Though therapeutic anticoagulation may reduce the number of embolic complications in these patients, major complications such as bleeding complications need to be kept in mind when considering such therapy. However, evidence regarding the choice of anticoagulation agents in chronic kidney disease patients of higher age is limited. In this report, a guideline-based anticoagulation treatment which led to a fulminant atraumatic bleeding complication is discussed.

Case presentation

We present the case of an 85-year-old female stage V chronic kidney disease patient who suffered from a diffuse arterial, subcutaneous bleeding in her lower left leg due a therapeutic anticoagulation using low molecular weight heparin (LMWH). Anticoagulation was started in accordance with general recommendations for patients with atrial fibrillation, and the dosage was adapted for the patient’s renal function. Nevertheless, the above-mentioned complication occurred, and the bleeding led to a hemorrhagic shock and an acute kidney injury on top of a chronic kidney disease. The hematoma required surgical evacuation and local coagulation in the operating room. In the further course, the patient underwent additional four surgical interventions due to a superinfected skin necrosis, including skin grafting. Furthermore, the patient needed continuous renal replacement therapy, as well as intensive care unit treatment, for a total of 47 days followed by 36 days of geriatric rehabilitation. Afterwards, she was discharged from the hospital to her previous nursing home.

Discussion and conclusions

Although therapeutic anticoagulation may sufficiently protect patients at cardiovascular risk, major complications such as bleeding complications may occur at any time. Therefore, physicians need to regularly re-evaluate any prior indication for therapeutic anticoagulation. With this case report, we hope to draw attention to the cohort of geriatric patients and the need for more and well differentiated study settings to preferably prevent any potentially avoidable complications.

Iatrogenic ischiofemoral impingement due to high tibial osteotomy with overvalgization: a case report

Background

Open wedge high tibial osteotomy is a standard procedure for frontal realignment. It is indicated in varus knee with reduced mechanical medial proximal tibia angle. Overcorrection producing a mechanical medial proximal tibia angle out of the normal range (85–90°) is not recommended because this would lead to unphysiological joint-line orientation. Osteotomies around the knee also influence the adjacent ankle and hip joints. For the hip, it is known that frontal alignment of the leg influences the ischiofemoral space. A decreased ischiofemoral space can lead to painful impingement between the ischial bone and the lesser trochanter.

Case presentation

A 53-year-old German woman presented with severe ischiofemoral impingement symptoms and valgus malalignment of the left leg after open wedge high tibial osteotomy, which was indicated and performed by an orthopedic surgeon with intention to treat medial knee pain due to degenerative arthritis of the medial compartment years after medial meniscectomy. The mechanical medial proximal tibia angle was 100.5°. We performed closed wedge high tibial osteotomy producing a mechanical medial proximal tibia angle of 90.0° and normal joint-line orientation. The hip pain was gone immediately after the surgery, and the patient had no signs of ischiofemoral impingement or hip pain at last follow-up 12 months after closed wedge high tibial osteotomy.

Conclusions

Frontal realignment osteotomy around the knee can create problems at adjacent joints. Overvalgization of the proximal tibia made the patient compensate by hyperadduction of the hip to enable full foot sole contact with the floor. Hyperadduction of the hip decreased the ischiofemoral space, leading to severe impingement. Therefore, meticulous planning of osteotomies is important not to produce unphysiological situations or unwanted negative effects at the level of an adjacent joint.

Rotation osteotomy of the distal femur influences coronal femoral alignment and the ischiofemoral space

INTRODUCTION

Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the remaining planes and adjacent joints are still to be defined. It was, therefore, the aim of this study to determine the influence of a distal femoral rotation osteotomy on the coronal limb alignment and on the ischiofemoral space of the hip joint.

MATERIALS AND METHODS

Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar rotational osteotomies of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip-knee-ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), and the ischiofemoral space were measured. Comparison between means was performed using the Wilcoxon-Mann-Whitney test.

RESULTS

Twenty-seven patients underwent isolated supracondylar external rotation osteotomy to reduce the overall antetorsion of the femur. The osteotomy resulted in a 2.4° ± 1.4° mean increase in HKA and 2.4 mm ± 1.7 mm increase in the ischiofemoral space (p < 0.001).

CONCLUSION

Supracondylar external rotation osteotomy of the femur leads to valgisation of the coronal limb alignment and increases the ischiofemoral space. This is resultant to the reorientation of the femoral antecurvature and the femoral neck. When planning a rotational osteotomy of the lower limb, this should be appreciated and may also aid in the decision regarding osteotomy site.

The Association between Constitutional Knee Alignment and the Horizontal Orientation of the Ankle Joint Line

PURPOSE OF THE STUDY To characterize constitutional frontal alignment of the ankle in genua vara, valga, and norma. MATERIAL AND METHODS Long-leg standing radiographs of 589 patients presenting between 2011 and 2020 for knee-complaints because of any reason were chosen from our database. Cases with fractures or history of bony-realignment-surgeries were excluded. The Hip-Knee-Ankle angle (HKA), the mechanical Lateral Distal Tibia Angle (mLDTA), and the Tibia-Plafond-Horizontal-Orientation angle (TPHA) were measured in 354 patients. For this study, neutral frontal alignment of the leg was defined as HKA between -3.0° and +4.0°. HKA-values <-3.0° were defined as genua valga and values >4.0° were defined as genua vara. According to these cutoffs, data was categorized into the following three patient groups: genua vara (n=157), genua norma (n=106), genua valga (n=91). For each group, the ankle alignment in the frontal plane was compared to the HKA. Finally, the three groups were compared to each other. RESULTS In the varus-group, the HKA-value was 6.9°±2.4°, the TPHA-value was 4.7°±3.5°, and the mLDTA-value was 87.4°±4.8°. In the neutral-group, the HKA-value was 1.8°±2.0°, the TPHA-value was 2.5°±2.9°, and the mLDTA-value was 87.2°±4.6°. In the valgus-group, the HKA-value was -6.0°±2.7°, the TPHA-value was -0.2°±4.7°, and the mLDTA-value was 85.0°±4.7°. DISCUSSION The frontal alignment of the ankle joint line depends on the overall frontal alignment of the leg. The TPHA correlates with varus or valgus alignment of the knee, but the mLDTA does not. In patients with valgus-aligned long-leg axis, the TPHA demonstrated less valgus alignment than in patients with varus-aligned long-leg axis. This knowledge is especially useful when planning osteotomies for correction of lower extremity malalignment. CONCLUSIONS During the planning process of osteotomies around the knee, the TPHA should be appreciated because it correlates with the constitutional knee alignment. Key words: valgus, varus, frontal alignment, coronal alignment, osteotomy.

Frontal knee alignment influences the vertical orientation of the femoral neck in standing position

AIMS

The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck.

METHODS

Long-leg standing radiographs of patients undergoing realignment surgery around the knee were used. The hip-knee-ankle angle (HKA) and the vertical orientation of the femoral neck in relation to the floor were measured, prior to surgery and after osteotomy-site-union. Linear regression was performed to determine the influence of knee alignment on the vertical orientation of the femoral neck.

RESULTS

The cohort included 147 patients who underwent knee realignment-surgery. The mean age was 51.5 years (SD 11). Overall, 106 patients underwent a valgisation-osteotomy, while 41 underwent varisation osteotomy. There was a significant association between the orientation of the knee and the coronal neck-orientation. In the varus group, the median orientation of the femoral neck was 46.5° (interquartile range (IQR) 49.7° to 50.0°), while in the valgus group, the orientation was 52.0° (IQR 46.5° to 56.7°; p < 0.001). Linear regression analysis revealed that HKA demonstrated a direct influence on the coronal neck-orientation (β = 0.5 (95% confidence interval (CI) 0.2 to 0.7); p = 0.002). Linear regression also showed that realignment surgery was associated with a significant influence on the change in the coronal femoral neck orientation (β = 5.6 (95% CI 1.5 to 9.8); p = 0.008).

CONCLUSION

Varus or valgus knee alignment is associated with either a more horizontal or a more vertical femoral neck orientation in standing position, respectively. Subsequently, osteotomies around the knee alter the vertical orientation of the femoral neck. These aspects are of importance when planning osteotomies around the knee in order to appreciate the effects on the adjacent hip joint. The concept may be of even more relevance in dysplastic hips. Cite this article: Bone Jt Open 2021;2(12):1057-1061.

"How to measure the outcome in the surgical treatment of vertebral compression fractures? A systematic literature review of highly cited level-I studies"

Background

The economic burden of vertebral compression fractures (VCF) caused by osteoporosis was estimated at 37 billion euros in the European Union in 2010. In addition, the incidence is expected to increase by 25% in 2025. The recommendations for the therapy of VCFs (conservative treatment versus cement augmentation procedures) are controversial, what could be partly explained by the lack of standardized outcomes for measuring the success of both treatments. Consensus on outcome parameters may improve the relevance of a study and for further comparisons in meta-analyses. The aim of this study was to analyze outcome measures from frequently cited randomized controlled trials (RCTs) about VCF treatments in order to provide guidance for future studies.

Material and methods

We carried out a systematic search of all implemented databases from 1973 to 2019 using the Web of Science database. The terms “spine” and “random” were used for the search. We included: Level I RCTs, conservative treatment or cement augmentation of osteoporotic vertebral fractures, cited ≥50 times. The outcome parameters of each study were extracted and sorted according to the frequency of use.

Results

Nine studies met the inclusion criteria. In total, 23 different outcome parameters were used in the nine analyzed studies. Overall, the five most frequently used outcome parameters (≥ 4 times used) were the visual analogue scale (VAS) for pain (n = 9), European Quality of Life–5 Dimensions (EQ-5D; n = 4) and Roland–Morris Disability Questionnaire (RMDQ, n = 4).

Conclusion

With our study, we demonstrated that a large inconsistency exists between outcome measures in highly cited Level I studies of VCF treatment. Pain (VAS), followed by HrQoL (EQ-5D) and disability and function (RMDQ), opioid use, and radiological outcome (kyphotic angle, VBH, and new VCFs) were the most commonly used outcome parameters.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04305-6.

Osteotomies around the knee lead to corresponding frontal realignment of the ankle

Introduction

Despite the fact that osteotomies around the knee represent well-established treatment options for the redistribution of loads and forces within and around the knee joint, unforeseen effects of these osteotomies on the ankle are still to be better understood. It was therefore the aim of this study to determine the influence of osteotomies around the knee on the coronal alignment of the ankle. We hypothesize that osteotomies around the knee for correction of genu varum or valgum lead to a change of the ankle orientation in the frontal plane by valgisation or varisation.

Materials and methods

Long-leg standing radiographs of 154 consecutive patients undergoing valgisation or varisation osteotomy around the knee in 2017 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy site. The hip knee ankle angle (HKA), the mechanical lateral distal femur angle (mLDFA), the mechanical medial proximal tibia angle (mMPTA) and five angles around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test.

Results

One hundred fifty-four patients (96 males, 58 females) underwent osteotomies around the knee for coronal realignment. The mean age was 51 ± 11 years. Correction osteotomies consisted of 73 HTO, 54 DFOs, and 27 double level osteotomies. Of all osteotomies, 118 were for valgisation and 36 for varisation. For valgisation osteotomies, the mean HKA changed from 5.8° ± 2.9° preoperatively to − 0.9° ± 2.5° postoperatively, whereas the mMPTA changed from 85.9° ± 2.7° to 90.7° ± 3.1° and the malleolar-horizontal-orientation-angle (MHA) changed from 16.4° ± 4.2° to 10.9° ± 4.2°. For varisation osteotomies, the mean HKA changed from − 4.3° ± 3.7° to 1.1° ± 2.2° postoperatively, whereas the mLDFA changed from 85.7° ± 2.2° to 89.3° ± 2.3° and the MHA changed from 8.8° ± 5.1° to 11.2° ± 3.2°.

Conclusion

Osteotomies around the knee for correction of coronal limb alignment not only lead to lateralization or medialization of the weight-bearing line at the knee but also lead to a coronal reorientation of the ankle. This can be measured at the ankle using the MHA. When planning an osteotomy around the knee for correction of genu varum or valgum, the ankle should also be appreciated—especially in patients with preexisting deformities, ligament instabilities, or joint degeneration around the ankle.

Follow-up definitions in clinical orthopaedic research : a systematic review

AIMS

The follow-up interval of a study represents an important aspect that is frequently mentioned in the title of the manuscript. Authors arbitrarily define whether the follow-up of their study is short-, mid-, or long-term. There is no clear consensus in that regard and definitions show a large range of variation. It was therefore the aim of this study to systematically identify clinical research published in high-impact orthopaedic journals in the last five years and extract follow-up information to deduce corresponding evidence-based definitions of short-, mid-, and long-term follow-up.

METHODS

A systematic literature search was performed to identify papers published in the six highest ranked orthopaedic journals during the years 2015 to 2019. Follow-up intervals were analyzed. Each article was assigned to a corresponding subspecialty field: sports traumatology, knee arthroplasty and reconstruction, hip-preserving surgery, hip arthroplasty, shoulder and elbow arthroplasty, hand and wrist, foot and ankle, paediatric orthopaedics, orthopaedic trauma, spine, and tumour. Mean follow-up data were tabulated for the corresponding subspecialty fields. Comparison between means was conducted using analysis of variance.

RESULTS

Of 16,161 published articles, 590 met the inclusion criteria. Of these, 321 were of level IV evidence, 176 level III, 53 level II, and 40 level I. Considering all included articles, a long-term study published in the included high impact journals had a mean follow-up of 151.6 months, a mid-term study of 63.5 months, and a short-term study of 30.0 months.

CONCLUSION

The results of this study provide evidence-based definitions for orthopaedic follow-up intervals that should provide a citable standard for the planning of clinical studies. A minimum mean follow-up of a short-term study should be 30 months (2.5 years), while a mid-term study should aim for a mean follow-up of 60 months (five years), and a long-term study should aim for a mean of 150 months (12.5 years). Level of Evidence: Level I. Cite this article: Bone Jt Open 2021;2(5):344-350.

Supracondylar rotation osteotomy of the femur influences the coronal alignment of the ankle

Purpose

Osteotomies represent well-established treatment-options for the redistribution of loads and forces within and around the knee-joint. Effects of these osteotomies on the remaining planes and adjacent joints are not fully understood. The aim of this study was to determine the influence of a distal-femoral-rotation-osteotomy on the coronal alignment of the ankle. It was hypothesized that supracondylar-external-rotation-osteotomy of the distal femur leads to a change in the coronal orientation of the ankle joint.

Methods

Long-leg standing radiographs and CT-based torsional measurements of 27 patients undergoing supracondylar-rotational-osteotomy of the femur between 2012 and 2019 were obtained and utilized for the purpose of this study. Postoperative radiographs were obtained after union at the osteotomy-site. The hip-knee-ankle-angle (HKA), the mechanical-lateral-distal-femur-angle (mLDFA), and Tibia-Plafond-Horizontal-Orientation-Angle (TPHA) around the ankle were measured. Comparison between means was performed using the Wilcoxon-Mann–Whitney test.

Results

Twenty-seven patients with high femoral antetorsion (31.3° ± 4.0°) underwent supracondylar-external-rotation-osteotomy. The osteotomy led to a reduced antetorsion (17.4 ± 5.1; p < 0.001) and to a valgisation of the overall limb-alignment. The HKA decreased by 2.4° ± 1.4° (p < 0.001). The TPHA decreased by 2.6° (p < 0.001).

Conclusions

Supracondylar external rotation osteotomy of the femur leads to lateralization of the weight bearing line at the knee and ankle due to valgisation of the coronal limb alignment. The mobile subtalar joint has to compensate (inversion) for the resulting valgus orientation of the ankle to ensure contact between the foot and the floor. When planning a rotational osteotomy of the lower limb, this should be appreciated – especially in patients with a preexisting valgus alignment of the lower extremities or restricted mobility in the subtalar joint.

Molecular evidence and hematological alterations associated with the occurrence of coronavirus in domestic dogs in Pakistan

Canine Enteric Coronavirus (CCoV) is one of the major enteric pathogen affecting dogs. This study aims to investigate the molecular prevalence, phylogenetic analysis, associated risk factors, and haemato-biochemical alterations in Canine Coronavirus in dogs in district Lahore, Pakistan. 450 fecal samples were collected from symptomatic dogs originating from various pet-clinics and kennels during 2018-2019. Samples were initially analyzed by sandwich lateral flow immunochromatographic assay and then further processed by RT-PCR (reverse transcriptase polymerase chain reaction) targeting the M gene followed by sequencing. RT-PCR based positive (n=20) and negative (n=20) dogs were samples for their blood for the haemato-biochemical analysis. A questionnaire was used to collect data from pet owners, in order to analyze the data for risk factors analysis by chi square test on SPSS. The prevalence of CCoV was 35.1%, and 23.8 % through Sandwich lateral flow immunochromatographic and RT-PCR respectively. Various risk factors like breed, age, sex, vomiting, diarrhea, sample source, body size, cohabitation with other animals, living environment, food, deworming history, contact with other animals or birds feces, and season were significantly associated with CCoV. The CCoV identified in Pakistan were 98% similar with the isolates from China (KT 192675, 1), South Korea (HM 130573, 1), Brazil (GU 300134, 1), Colombia (MH 717721, 1), United Kingdom (JX 082356, 1) and Tunisia (KX156806). Haematobiochemical alterations in CCoV affected dogs revealed anaemia, leucopenia, lymphopenia, neutrophilia, and decreased packed cell volume, and a significant increase in alkaline phosphate and alanine transaminase. It is concluded that infection with canine coronavirus appears widespread among dog populations in district Lahore, Pakistan. This study is the first report regarding the molecular detection and sequence analysis of CCoV in Pakistan.

The ischiofemoral space of the hip is influenced by the frontal knee alignment

PURPOSE

The ischiofemoral distance (IFD), defined as the distance between the ischial tuberosity and the lesser trochanter of the femur, is gaining recognition as an extra-articular cause of hip pain. It is unknown whether the IFD is influenced by the frontal knee alignment. The aim of this study was to determine the influence of realignment surgery around the knee on the IFD. It was hypothesized that valgisation osteotomy around the knee is associated with reduction of the IFD.

METHODS

A consecutive series of 154 patients undergoing frontal realignment procedures around the knee in 2017 were included in this study. Long-leg standing radiographs were obtained before surgery and postoperatively. The IFD was measured between the ischium and the lesser trochanter at three different levels (proximal, middle and distal margins of the lesser trochanter parallel to the horizontal orientation of the pelvis) on standardized long-leg radiographs with the patient in upright standing position. The knee alignment was determined by measuring the hip knee ankle angle, mechanical lateral distal femur angle and the medial mechanical proximal tibia angle. Linear regression was performed to determine the influence of the change of frontal knee alignment on the IFD.

RESULTS

Linear regression showed a direct influence of the overall change in frontal knee alignment on the IFD of the hip, regardless of the site of the osteotomy (β-0.4, confidence-interval - 0.5 to - 0.3, p < 0.001). Valgisation osteotomy around the knee induced a significant reduction of the ipsilateral IFD (p < 0.001), while varisation osteotomy induced a significant increase (p < 0.001). The amount of ISD change was 0.4 mm per corresponding degree of change in frontal knee alignment.

CONCLUSION

These findings are relevant to both the hip and knee surgeons when planning an osteotomy or arthroplasty procedure. Correction of a malalignment of the knee may resolve an ischiofemoral conflict in the hip. The concept deserves inclusion in the diagnostic workup of both the hip and knee joints.

LEVEL OF EVIDENCE

IV.

Reliability of the Oswestry-Bristol Classification for trochlear dysplasia: expanded characteristics

Aims

The Oswestry-Bristol Classification (OBC) was recently described as an MRI-based classification tool for the femoral trochlear. The authors demonstrated better inter- and intraobserver agreement compared to the Dejour classification. As the OBC could potentially provide a very useful MRI-based grading system for trochlear dysplasia, it was the aim to determine the inter- and intraobserver reliability of the classification system from the perspective of the non-founder.

Methods

Two orthopaedic surgeons independently assessed 50 MRI scans for trochlear dysplasia and classified each according to the OBC. Both observers repeated the assessments after six weeks. The inter- and intraobserver agreement was determined using Cohen’s kappa statistic and S-statistic nominal and linear weights.

Results

The OBC with grading into four different trochlear forms showed excellent inter- and intraobserver agreement with a mean kappa of 0.78.

Conclusion

The OBC is a simple MRI-based classification system with high inter- and intraobserver reliability. It could present a useful tool for grading the severity of trochlear dysplasia in daily practice.

Cite this article: Bone Joint Open 2020;1-7:355–358.

The importance of plasmin for the healing of the anterior cruciate ligament

Aims

The anterior cruciate ligament (ACL) is known to have a poor wound healing capacity, whereas other ligaments outside of the knee joint capsule such as the medial collateral ligament (MCL) apparently heal more easily. Plasmin has been identified as a major component in the synovial fluid that varies among patients. The aim of this study was to test whether plasmin, a component of synovial fluid, could be a main factor responsible for the poor wound healing capacity of the ACL.

Methods

The effects of increasing concentrations of plasmin (0, 0.1, 1, 10, and 50 µg/ml) onto the wound closing speed (WCS) of primary ACL-derived ligamentocytes (ACL-LCs) were tested using wound scratch assay and time-lapse phase-contrast microscopy. Additionally, relative expression changes (quantitative PCR (qPCR)) of major LC-relevant genes and catabolic genes were investigated. The positive controls were 10% fetal calf serum (FCS) and platelet-derived growth factor (PDGF).

Results

WCS did not differ significantly among no plasmin versus each of the tested concentrations (six donors). The positive controls with PDGF and with FCS differed significantly from the negative controls. However, we found a trend demonstrating that higher plasmin concentrations up-regulate the expression of matrix metalloproteinase 13 (MMP13), 3 (MMP3), and tenomodulin (TNMD).

Conclusion

The clinical relevance of this study is the possibility that it is not solely the plasmin, but also additional factors in the synovial fluid of the knee, that may be responsible for the poor healing capacity of the ACL.

Cite this article: Bone Joint Res 2020;9(9):543–553.

Outcome of anterior cruciate ligament reconstruction in children and adolescents: A retrospective study

BACKGROUND

Indications and outcomes of anterior cruciate ligament (ACL) reconstruction in children and adolescents is still controversial. It was the aim of this study to analyze outcomes of anterior cruciate ligament reconstruction in this special age group.

METHODS

Retrospectively, we analyzed 62 consecutive cases of ACL reconstruction using a physis crossing technique in six to 16-year-old patients with a mean follow-up of 69 months.

RESULTS

Cases operated later than six weeks after trauma had significantly more meniscal lesions than patients operated within six weeks of trauma. At last follow-up, we found good or very good subjective and objective results in 71% of the patients.

CONCLUSION

In active and healthy children with anterior knee instability after ACL tear, ligament reconstruction is a safe and successful procedure and should be considered within six weeks of trauma because instability seems to promote secondary meniscal lesions.

Arthroscopic arthrolysis leads to improved range of motion and health-related quality of life in post-traumatic elbow stiffness

BACKGROUND

Post-traumatic elbow stiffness is a frequent and disabling complication after elbow trauma. Surgical release is needed if conservative treatment fails. In contrast to open surgical release, arthroscopic arthrolysis is a good and least invasive option to restore joint mobility. The aim of this study was to evaluate the clinical outcomes, range of motion (ROM), and function of post-traumatic elbow contracture after arthroscopic arthrolysis and to assess health-related quality of life (HRQL).

METHODS

Between 2007 and 2013, 44 patients with post-traumatic elbow stiffness were treated by arthroscopic arthrolysis and followed up in a consecutive series. Clinical (ROM) and functional analyses (Disabilities of the Arm, Shoulder, and Hand Questionnaire [DASH], Mayo Elbow Performance Index [MEPI]) were performed at final follow-up 3 (1-7) years postoperatively. Furthermore, HRQL was evaluated (EQ-5D, 36-Item Short Form Health Survey [SF-36]).

DISCUSSION

The average arc of elbow motion increased from 84° ± 28° preoperatively to 120° ± 18° postoperatively. All applied scores significantly improved pre- to postoperatively: the MEPI (59.8 ± 17.3 / 84.3 ± 14.0), DASH (43.5 ± 23.1 / 16.8 ± 15.6), EQ-5D (72.8 ± 16.6 / 84.0 ± 13.6), and SF-36 showed improved results in all categories. Univariate logistic regression revealed that preoperative pain level predicts a poorer postoperative outcome measured with the MEPI score. Revision arthroscopy was needed in 1 case because of persistent pain.

CONCLUSIONS

Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life. The complication rate as well as the revision rate is very low.

Gunshot injuries to the lower extremities: Issues, controversies and algorithm of management

Civilian gunshot violence is common and concentrated in specific geographic regions of the world, consuming a significant proportion of trauma practice in those particular regions. Unfortunately, the state of clinical evidence is scarce, and it is fair to emphasize that the field is scientifically under-represented. In the current review, the authors point out key aspects and principles requiring attention when treating low energy gunshot wounds to the lower extremity. These treatment principles include the following management concepts: 1) Conservative management of soft tissue injuries if the projectile causes no discomfort. 2) Conservative management of non-complete fractures of the tibia or femoral shaft. 3) Prophylactic fixation of non-complete peri-trochanteric fractures. 4) Fixation of allcomplete fractures. 5) Removal of all intra-articular projectiles. 6) Treating as septic arthritis if the missile passes through large bowel (not small bowel) prior to penetrating a joint capsule. The proposed concepts are based on available evidence from the literature and expert opinion. The authors also highlight challenges with conducting clinical studies in the field, given the high rate of 'loss to follow-up' and compliance issues in this particular group of patients.

Seventy percent long-term survival of the repaired ACL after dynamic intraligamentary stabilization

PURPOSE

Primary repair of the anterior cruciate ligament (ACL) is regaining popularity. Long-term results are lacking. The purpose of the current study was to determine the survival of the primarily repaired ACL after dynamic intraligamentary stabilization.

METHODS

Between 2011 and 2013, 57 patients with acute proximal ACL ruptures underwent DIS repair within 3 weeks from injury and were available for final follow-up at least 5 years postoperatively. Failure as an end point was defined as conversion to ACL reconstruction, failure to restore stability with persisting laxity side-to-side laxity of > 5 mm or a late-traumatic re-rupture or loss of stability. Kaplan-Meier survival analysis was performed.

RESULTS

Kaplan-Meier survival analysis demonstrated an overall survival of 70.0% (standard error SE 6.6%) at 74 months follow-up. Patients performing competitive sports prior to injury demonstrated an inferior long-term ACL survival of 56.4% (SE 11.6%). Patients performing recreational sport activities demonstrated a survival rate of 79.2% (SE 7.7%). The one factor demonstrating a direct influence on failure after adjustment was a high-pre-injury level of physical (odds ratio 4.0 confidence interval 1.0-15.8, p = 0.04).

CONCLUSION

The minimum 5 years survival rate after primary ACL repair using this technique was 70%. This value dropped to 56% in highly active patients performing competitive sports. Patients not suffering failure of repair demonstrated adequate restoration of knee laxity and high satisfaction. This study not only underlines the potential of ACL repair, but also highlights the danger of the procedure if strict patient selection is not appreciated.

LEVEL OF EVIDENCE

Level IV.

Surgical hip dislocation is more powerful than arthroscopy for achieving high degrees of acetabular correction in pincer type impingement

BACKGROUND

With the development of hip arthroscopy (HA), a shift away from surgical hip dislocation (SHD) is becoming a noticeable reality. It was the aim of this study to examine whether SHD provides a benefit over HA regarding its corrective power in the treatment of femoroacetabular impingement (FAI).

HYPOTHESIS

It was hypothesized that SHD provides the more powerful tool for acetabular correction in FAI surgery compared to HA.

METHOD

The examined cohort consisted of 85 hips of which 31 (36%) underwent a high degree of acetabular correction which was defined as a correction of >2 standard deviations from the population mean. A lateral center edge angle (LCE) correction>12° or an acetabular index (AI) correction>8° were therefore considered to high correction. A logistic regression model was applied to determine factors influencing high correction in FAI surgery. Subsequent adjustment was performed using a multivariate model.

RESULTS

After adjusting for pre-operative acetabular orientation, SHD showed a pronounced influence on the likelihood of achieving the adequate degree of high acetabular correction (odds ratio (OR) 10.0 confidence interval (C.I) 2.3 to 44.0, p=0.002). On the other hand, SHD showed no influence on femoral correction (p=n.s).

CONCLUSION

Surgical hip dislocation is a powerful modality for achieving high degrees of acetabular correction in the situation of a femoroactabular conflict, being defined as an LCE correction of>12° or AI correction of>8°. The reason for these results may be seen in the excellent exposure and the improved possibility of performing dynamic intra-operative examination to verify the results. The benefits are only limited to large acetabular correction. These findings should provide a helpful tool for decision making in clinical practise.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Periprosthetic Infection: Major Cause of Early Failure of Primary and Revision Total Knee Arthroplasty

Revision total knee arthroplasty (RTKA) represents an effective treatment for failed TKA, but with less favorable outcomes. Considering the technical complexity and economic burden of RTKA procedures, it is mandatory to investigate current mechanisms and predictors for RTKA failure. The objective of this study is to evaluate the survivorship and determine the predominant causes of failure of RTKA. A total of 146 patients undergoing RTKA between 2003 and 2013 were identified from the institutional database. Revision was defined as surgery in which the whole prostheses (inlay and both femoral and tibial components) required exchange. Median follow-up was 6.3 ± 2.7 years (range: 2.2-10). Patient demographics, year of primary implantation, reasons for revision surgery, implant type, pain, knee mobility, systemic or local postoperative complications, and treatment of the complications were recorded and evaluated. Infection was a major cause of failure followed by aseptic loosening, instability, pain, malalignment, and inlay wear. Following RTKA, Knee Society Score (KSS) (knee score and functional score) demonstrated a significant improvement (p < 0.05). No significant difference in flexion, extension deficit, and KSS was detected between aseptic and septic primary TKAs preoperatively and following first RTKA. Reinfection rate of the septic primary TKAs was 5%. Infection was the major cause of a second revision, reaching as high as 50% in all cases. The results of this study support that septic failure of a primary TKA is likely to occur within the first 2 years following implantation. Septic failure of primary TKA does not influence survival of the revision prosthesis.

Vertebral Body Lavage Reduces Hemodynamic Response to Vertebral Body Augmentation With PMMA

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

To assess the effect of vertebral body lavage (VBL) on (1) systemic blood pressure, (2) heart rate, and (3) oxygen saturation following cement augmentation procedures for acute vertebral compression fractures (VCFs).

METHODS

A total of 145 consecutive patients undergoing cement augmentation for acute VCF (mean age 74 ± 12 years, age range 42-96 years; 70% female; 475 levels treated) were allocated to the "lavage group" (n = 61 patients; VBL prior to cement application) and to the "control group" (n = 84 patients, no VBL). Mean arterial blood pressure (MAP), heart rate, and oxygen saturation were monitored immediately prior and 3 minutes after cement injection. Logistic regression analysis was performed with ΔMAP ≥10 mm Hg before and after cement injection as the dependent outcome variable and demographic, radiographic, and procedural factors as independent variables.

RESULTS

MAP decreased by mean 3 ± 7.3 mm Hg before and after cement injection in the "lavage group" and 9 ± 10.5 mmHg in the control group (P < .001). There were no significant differences in terms of heart rate and oxygen saturation before and after cement application within each group, or between the 2 groups. Multivariate logistic regression analyses revealed VBL as an independent factor influencing MAP (adjusted odds ratio: 3.49 [confidence interval, 1.16-10.50], P = .03).

CONCLUSION

VBL prior to cement augmentation procedures reduces the hemodynamic response, most likely resulting from decreased amounts of bone marrow substance displaced into the circulation thereby decreasing the risk of pulmonary fat embolism syndrome.

Obesity and smoking predict the results of two-stage exchange in septic revision hip arthroplasty: A cohort study

BACKGROUND

Prosthetic joint infection (PJI) is deemed to be the most serious complication following total hip arthroplasty. Obesity and smoking are known risk factors for PJI. However, the influence of these variables on infection free survival, of septic revision hip arthroplasty, is yet to be explored. The aim of this study was to determine the effect of obesity and smoking on the outcome of two-stage prosthetic exchange surgery.

PATIENTS AND METHODS

A consecutive series of 97 hips in 94 patients (69 male, 25 female, mean age 66±12 years), undergoing two-stage revision surgery for hip PJI, were investigated retrospectively, after a mean follow-up of 60 (24-170) months. Survival was estimated using Kaplan-Meyer curves. A multivariate cox-regression model was applied to test for the influence of smoking or obesity (BMI≥30) after adjusting 16 potential patient-dependant variables.

HYPOTHESIS

The study hypothesis was that smoking and high BMI are predictors for the failure of septic revision hip arthroplasty. Failure of septic revision hip arthroplasty was defined as failure to eradicate the infection or eradication of the infection but failure to preserve the arthroplasty.

RESULTS

Kaplan-Meier showed a cumulative survival proportion of 80.4%(standard error S.E 4%), of the definitive implant, at 5 years. Obese patients (BMI≥30) and smokers had a significantly lower 5-year survival of 60.9% (S.E 1%) and 50.6% (S.E 1.4%), respectively (p=0.001).

DISCUSSION

Obesity and smoking are both factors determining infection free survival in two-stage revision hip arthroplasty. Clinicians should be aware of potential complications and anticipate a higher likelihood of conversion to a Girdlestone resection or even amputation in this group of patients.

LEVEL OF EVIDENCE

III, retrospective cohort study.

The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping

PURPOSE

Most biomechanical investigations of tendon repairs were based on output measures from hydraulic loading machines, therefore, accounting for construct failure rather than true gapping within the rupture zone. It was hypothesized that the elastic capacity of a tendon-repair construct influences the force necessary to induce gapping.

METHODS

A tendon-repair model was created in 48 porcine lower hind limbs, which were allocated to three fixation techniques: (1) Krackow, (2) transosseous and (3) anchor fixation. Loading was performed based on a standardized phased load-to-failure protocol using a servohydraulic mechanical testing system MTS (Zwick Roell, Ulm, Germany). Rupture-zone dehiscence was measured with an external motion capture device. Factors influencing dehiscence formation was determined using a linear regression model and adjustment performed as necessary. A 3-mm gap was considered clinically relevant. Analysis of variance (ANOVA) was used for comparison between groups.

RESULTS

The elastic capacity of a tendon-repair construct influences the force necessary to induce gapping of 3 mm (F_3mm) [β = 0.6, confidence interval (CI) 0.4-1.0, p < 0.001]. Furthermore, the three methods of fixation did not differ significantly in terms of maximum force to failure (n.s) or F_3mm (n.s).

CONCLUSION

The main finding of this study demonstrated that the higher the elastic capacity of a tendon-repair construct, the higher the force necessary to induce clinically relevant gapping.

LEVEL OF EVIDENCE

Controlled biomechanical study.

Biologic response of human anterior cruciate ligamentocytes on collagen-patches to platelet-rich plasma formulations with and without leucocytes

Due to the poor self-healing capacities of the anterior cruciate ligament, previous primary repair attempts have failed. To enhance biologic healing, platelet rich plasma and collagen scaffold have shown promise in animal models. Platelet rich plasma (PRP) is already used in several clinical applications although outcomes are quite debated. The purpose of this study was to examine the effects of different PRP formulations during 21 days: With leucocytes and pure PRP on human anterior cruciate ligament-derived ligamentocytes grown on collagen patches in 3D cell cultures in vitro. Three experimental groups were formed: 2.5% leucocyte rich PRP, 2.5% pure PRP, 20% leucocyte rich PRP, a negative control, and a positive control. Cell proliferation, cell phenotype on mRNA transcript level, and extracellular matrix production (total collagen and glycosaminoglycan content) were evaluated. DNA content and metabolic cell activity increased significantly in all groups on day 21 compared to day 7, except in the negative control. No changes in extracellular matrix production were detected. Different catabolic genes were induced depending on the concentration of leucocyte rich PRP. PRP with and without leucocytes treated anterior cruciate ligamentocytes significantly increased cell proliferation but not extracellular matrix production. However, the specific activation of different catabolic genes was dependent on the relative content of leucocytes. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2733-2739, 2017.

Preoperative planning for redirective, periacetabular osteotomies

Redirective, periacetabular osteotomies (PAO) represent a group of surgical procedures for treatment of developmental dysplasia of the hip (DDH) in skeletally mature and immature patients. The ultimate goal of all procedures is to reduce symptoms, improve function and delay or prevent progression of osteoarthritis. During the last two decades, the understanding of the underlying pathomechanisms has continuously evolved. This is mainly attributable to the development of the femoroacetabular impingement concept that has increased the awareness of the underlying three-dimensional complexity associated with DDH. With increasing knowledge about the pathobiomechanics of dysplastic hips, diagnostic tools have improved allowing for sophisticated preoperative analyses of the morphological and pathobiomechanical features, and early recognition of degenerative changes, which may alter the long-term outcome. As redirective, PAO are technically demanding procedures, preoperative planning is crucial to avoid intraoperative obstacles and to sufficiently address the patient-specific deformity. Although conventional radiography has been used for decades, it has not lost its primary role in the diagnostic work-up of patients with DDH. Furthermore, an increasing number of modern imaging techniques exists allowing for assessment of early cartilage degeneration (biochemical magnetic resonance imaging) as well as 3D planning and computer-based virtual treatment simulation of PAO. This article reviews the literature with regard to the current concepts of imaging of DDH, preoperative planning and treatment recommendations for redirective, PAO.

Factors influencing the success of anterior cruciate ligament repair with dynamic intraligamentary stabilisation

PURPOSE

Primary repair of the anterior cruciate ligament (ACL) has regained interest of clinicians with recent development of novel repair techniques. Dynamic intraligamentary stabilisation was introduced in an attempt to promote healing by shielding cyclic loads acting upon the ACL during the healing phase. The aim of this study was to identify negative factors likely to influence success of this procedure.

METHODS

Between 2009 and 2014, 264 patients with an acute ACL rupture undergoing dynamic intraligamentary stabilisation were included in this study. Patients were evaluated for anterior/posterior laxity; range of motion and patient reported outcome measures. Adverse events and re-operations were noted. Failure was defined as AP Translation >3 mm, re-rupture or conversion to ACL reconstruction. Minimum follow-up was 24 months. Univariate and multivariate regression models were utilized to determine predictors of failure.

RESULTS

An overall complication rate of 15.1% was noted comprising 9.5% (n = 25) re-ruptures, 4.1% (n = 11) persistent instability, and 1.5% (n = 4) > 10° fixed flexion deformity. Two factors were identified as negative predictors of failure: (1) pursuit of competitive sport activities with a Tegner pre-injury score >7 (Odds Ratio (OR) 4.4, CI 1.2-15.9, p = 0.02) and (2) mid-substance ACL rupture location (OR 2.5, 1.1-5.7, p = 0.02). When neither of those risk factors occurred the failure rate was limited to 3.9%.

CONCLUSIONS

Correct patient selection and narrowing of indications are necessary to maintain high success rates of the procedure. Mid-substance ACL ruptures and a high pre-injury sports activity level are two predictors of inferior outcome.

LEVEL OF EVIDENCE

II.

Trends and Weekly Cycles in a Large Swiss Emergency Centre: A 10 Year Period at the University Hospital of Bern

Popular demand for high quality care has increased in recent years. This is also the case for medical services and support at all times of the day and night is nowadays required. During the last ten years, there has been a marked increase in the demands on hospital emergency hospitals, particularly in the Western industrialized countries. The present retrospective study investigates how the demands on a large Swiss university centre have changed over a period of 10 years. Patient numbers are differentiated by age, gender, nationality, weekday and mode of referral. A retrospective analysis was performed of the data of the patients admitted to the Emergency Centre of Bern University Medical Hospital (Inselspital) during the ten-year period from 2004 up to and including 2013 and who were treated as emergencies. A total of 264,272 patients were included in the study. It was shown that there was an uninterrupted annual increase from 23,555 patients in 2004 to 34,918 patients in 2013 (+48%). Most patients came to the Emergency Centre on Mondays, followed by Fridays. Because of the marked increase in life expectancy and the resulting demographic changes, there has been a marked increase in the number of older patients coming to the Emergency Centre for acute medical care. It was found that there were disproportionately high numbers of patients aged 20 to 49 years who were not Swiss citizens. In contrast, most patients over 60 were Swiss. In the coming years, emergency centres will have to adapt to the continued increase in patient numbers. This trend will continue, so that it is essential to consider the sociodemographic structure of a region when planning the availability of emergency medical care.

Gunshot induced injuries in orthopaedic trauma research. A bibliometric analysis of the most influential literature

A growing burden of gunshot injuries demands evidence-based ballistic trauma management. No comprehensive systematic overview of the current knowledge is available to date. This study aims to identify and analyze the most influential publications in the field of orthopedic ballistic trauma research. All databases available in the Thomson Reuters Web of Knowledge were searched to conduct this bibliometrical study. The most cited orthopedic ballistic trauma articles published between 1950 and 2015 were identified by use of a multi-step approach. Publications with ten citations and more were analyzed for citations, journal, authorship, geographic origin, area of research, anatomical site, study type, study category, and level of evidence. Citations of the 128 included studies ranged from 113 to 10. These were published in fifty different journals between 1953 and 2011. Most publications (n=106; 83%) originated from the USA, were retrospective (n=85; 66.4%), level IV studies (n=90; 70.3%), reported on spinal gunshot injuries (n=49; 38.33%) and were published between 1980 and 2000 (n=111; 86.7%). This bibliometric study provides the first comprehensive overview of influential publications in the field of orthopedic ballistic trauma research. More prospective studies and high-quality systematic reviews are needed. Centres with a high burden of gunshot injuries from the developing world need to share their experience in form of international publications, to provide a more comprehensive picture of the global gun-related orthopedic injury burden.

TYPE OF STUDY

bibliometric analysis: level III.

Open Anterior Hip Dislocation in A Child: A Rare Mechanism of Injury

Traumatic anterior dislocation of the hip is an extremely rare condition in children and open dislocation is even rarer. This isusually caused by high-energy trauma. In the current study, we present a case of an eight-year-old child suffering from an open anterior-inferior dislocation of the right hip concomitant with pelvic ring disruption and an ipsilateral open distal femoral fracture (Salter-Harris type 4, Gustilo type IIIA) caused by a traffic accident. The patient underwent successful emergent open reduction due to the buttonholed femoral head after appropriate irrigation and debridement. Successful recovery was achieved and the patient was discharged after two weeks. After nine months of follow-up, the X-ray images showed slight changes related to the osteonecrosis of the femoral head. Long-term follow-up over a period of six years showed sufficient range of motion. The patient's gait was normal and he was satisfied with the outcome. In addition, slight non-progressive osteonecrotic changes were obvious in the right hip.