Increasing grades of frontal deformities in knee osteoarthritis are not associated with ligamentous ankle instabilities

Purpose: Varus or valgus deformities in knee osteoarthritis may have a crucial impact on ankle subtalar range of motion (ROM) and ligamentous stability. The purpose of this study was to assess whether the grade of ankle eversion and inversion rotation stability was influenced by frontal deformities of the knee joint. Methods: Patients who were planned to undergo total knee arthroplasty (TKA) were prospectively included in this study. Patients were examined radiologically (mechanical tibiofemoral angle (mTFA), hindfoot alignment view angle (HAVA), anterior distal tibia angle (ADTA)) and clinically (ROM of the knee and ankle joint, foot function index, knee osteoarthritis outcome score). Ankle stability was assessed using an ankle arthrometer (AA) to test inversion/eversion (ie) rotation and anterior/posterior (ap) displacement stability of the ankle joint. Correlations were calculated using Pearson's coefficient, and differences between two independent groups of nonparametric data were calculated using a two-sided Wilcoxon signed rank test. Results: Eighty-two (varus n = 52, valgus n = 30) patients were included. The preoperative mTFA significantly correlated with the HAVA (Pearson's correlation = - 0.72, p < 0.001). Laxity testing of the ankle demonstrated that in both varus and valgus knee osteoarthritis, higher grades of mTFA did not correlate with the inversion or eversion capacity of the ankle joint. The ADTA significantly correlated with the posterior displacement of the ankle joint (cor = 0.24, p = 0.049). Conclusions: This study could not confirm that higher degrees of frontal knee deformities in osteoarthritis were associated with increasing grades of ligamentous ankle instabilities or a reduced ROM of the subtalar joint

Cure rate of infections is not an argument for spacer in two-stage revision arthroplasty of the hip

Introduction A devastating complication after total hip arthroplasty (THA) is chronic periprosthetic joint infection (PJI). Most frequently spacers (Sp) with or without antibiotics are implanted in a two-stage procedure even though not always indicated due to unknown pathogen, femoral and acetabular defects or muscular insufficiency. Materials and methods A retrospective analysis of a prospectively collected database was conducted, analyzing the treatment of 44 consecutive cases with chronic PJI undergoing two-stage revision using a Girdlestone situation (GS) in the interim period between 01/2015 and 12/2018. Diagnostics included intraoperative microbiological cultures, histological analysis, sonication of the initial implant, analysis of hip aspiration, as well as laboratory diagnostics and blood cultures. We analyzed the general and age-group-specific success rate of treatment using GS. Furthermore, we compared our data with the current literature on spacer implantation regarding common complications. Results In total, 21 female and 23 male patients at a mean age of 59.3 +/- 9.6 years were included. Age groups were divided into young, mid-age, and elderly. In most patients, microbiology revealed Staphylococcus epidermidis in 39.1% of cases, following Staphylococcus lugdunensis and Staphylococcus aureus in 10.9% after THA explantation. For histology, Krenn and Morawietz type 2 (infectious type) was diagnosed in 40.9%, type 3 (infectious and abrade-induced type) in 25.0%. With GS, the total cure rate was 84.1% compared to 90.1% (range 61-100%) using Sp as described in the literature. Among age-groups, cure rate varied between 77.8 and 100%. Other complications, which only occurred in the mid-age and elderly group, included the necessity of transfusion in 31.1%, and in total, one periprosthetic fracture was identified (2.3%). Conclusion GS shows an acceptable cure rate at a minimum of 2 years when compared to the cure rate reported in the literature for Sp without major complications. For patients with increased risks for treatment failure using spacer, GS seems to be an alternative for chronic PJI when looking at the success rate of treatment

Mechanical failure of total hip arthroplasties and associated risk factors

Introduction Mechanical failure of total hip arthroplasties is a rare but devastating complication. With increasing numbers in primary arthroplasty implantation, revision surgeries are indicated more often. Therefore, understanding the mechanism and the location of failure is essential in determining proper treatment. Aim of this study was to identify mechanical failures of all total hip arthroplasties performed in a major academic center as well as the associated risk factors such as BMI and sports. Methods A retrospective trial was conducted using our prospective arthroplasty database. Database was searched for all patients presenting with mechanical failures of total hip arthroplasty (THA) to the emergency department between 2011 and 2019. All medical charts and radiographs as well as surgical reports were analyzed to identify demographics, implant choice in addition to location of failure and subsequent treatment. Results In total, 13 patients suffering from mechanical total hip implant failure were found. The femoral neck (conus) was broken in four patients, the stem in five cases, one broken inlay, two cup failures and one conus dislocation. The mean BMI was 31.42 +/- 5.29 kg/m(2) including five patients who have obesity class II. In all cases, revision surgeries were indicated. No structural causes or underlying risk factors such as repeated physical load (i.e. in sports) were identified. Conclusion Implant failure does not seem to correlate with participation in sports or BMI. Catastrophic failure of implants is a technical challenge requiring special extraction instruments that can be difficult even for experienced surgeons. It should be noted that functional outcome is often worse for this group of patients after surgery than comparing against those revised for loosening

Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction: Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure. Materials: and methods We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal-pertrochanteric, subtrochanteric-or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected. Results: A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 +/- 13.5 years and in the PO group was 65.6 +/- 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure. Conclusion: Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site

The Impact of the Laterality on Radiographic Outcomes of the Bernese Periacetabular Osteotomy

The purpose of this study was to compare the pre and postoperative radiographic findings and analyze the complication rate with respect to the laterality in periacetabular osteotomy in right-handed surgeons. Satisfaction rate and radiographic findings were prospectively collected between 2017 and 2019 and retrospectively reviewed. For analysis, all measurements of the CT scans were performed by a musculoskeletal fellowship-trained radiologist. Complications were classified into two categories: perioperative or postoperative. All surgeries were performed by three right-hand dominant hip surgeons. A total of 41 dysplastic hips (25 right and 16 left hips) in 33 patients were included. Postoperatively, a significantly lower acetabular index angle on the left side was observed at -2.6 +/- 4.3 as compared to the right side at 1.6 +/- 6.5 (p < 0.05). The change in Center edge (CE) angle was significantly lower for the left side 13.7 +/- 5.5 degrees than on the right side, measured at 18.4 +/- 7.3 (p < 0.001); however, the overall CE angle was comparable at 38.5 +/- 8.9 degrees without any significant difference between the operated hips (left side at 37.8 +/- 6.1 degrees versus right side at 39.0 +/- 10.3; p = 0.340). No significant differences in other radiographic measurements or surgical time were observed. For complications, the right side was more commonly affected, which may also explain a higher satisfaction rate in patients who were operated on the left hip with 92.3%. The change in lateral CE angle was significantly lower for the left side and the right hip seems to be predisposed to complications, which correlate with a lower satisfaction rate in right-handed surgeons

Rotational abnormalities in dysplastic hips and how to predict acetabular torsion

Objectives: The aim of this study was to investigate the degree to which conventional radiography can represent the acetabular and femoral rotational alignment profile between dysplastic and borderline-dysplastic hips. Methods: A retrospective trial was conducted including 56 borderline-dysplastic and dysplastic hips at a mean age of 28.9 years (range from 18 to 46). Inclusion criteria consisted of symptomatic patients with hip dysplasia undergoing 2-dimensional radiography as well as computed tomography. On radiography, the lateral center edge angle, acetabular hip index, hip lateralization index, acetabular index angle, and the Sharp angle were measured, and the presence of a crossover sign was noted. In computed tomography, the full rotational profile of the lower limb was measured. Results: Significant correlations were observed in the overall analysis between the anteversion of the acetabulum and the hip lateralization index (mean 0.56, coefficient of regression (CoR) -32.35, p = 0.011) as well as the acetabular index angle with a mean of 11.50 (CoR 0.544, p = 0.018). Similar results were found in the subgroup of dysplastic hips with an acetabular index angle of 13.9 (p = 0.013, CoR 0.74). For the borderline-dysplastic group, no significant correlations between the pelvis radiography and rotational CT were seen. Conclusion: Although the femoral and acetabular torsion cannot be predicted from x-rays, the anteversion of the acetabulum correlates with the acetabular index angle, the hip lateralization index, and eventually the beta angle in dysplastic hips. For borderline-dysplastic hips, such results did not show up, which strongly illustrates the need for computed tomography in these cases

The Impact of Hip Dysplasia on CAM Impingement

Predisposing factors for CAM-type femoroacetabular impingement (FAI) include acetabular protrusion and retroversion; however, nothing is known regarding development in dysplastic hips. The purpose of this study was to determine the correlation between CAM-type FAI and developmental dysplastic hips diagnosed using X-ray and rotational computed tomography. In this retrospective study, 52 symptomatic hips were included, with a mean age of 28.8 +/- 7.6 years. The inclusion criteria consisted of consecutive patients who suffered from symptomatic dysplastic or borderline dysplastic hips and underwent a clinical examination, conventional radiographs and rotational computed tomography. Demographics, standard measurements and the rotational alignments were recorded and analyzed between the CAM and nonCAM groups. Among the 52 patients, 19 presented with CAM impingement, whereas, in 33 patients, no signs of CAM impingement were noticed. For demographics, no significant differences between the two groups were identified. On conventional radiography, the acetabular hip index as well as the CE angle for the development of CAM impingement were significantly different compared to the nonCAM group with a CE angle of 21.0 degrees +/- 5.4 degrees vs. 23.7 degrees +/- 5.8 degrees (p = 0.050) and an acetabular hip index of 25.6 +/- 5.7 vs. 21.9 +/- 7.3 (p = 0.031), respectively. Furthermore, a crossing over sign was observed to be more common in the nonCAM group, which is contradictory to the current literature. For rotational alignment, no significant differences were observed. In dysplastic hips, the CAM-type FAI correlated to a lower CE angle and a higher acetabular hip index. In contrast to the current literature, no significant correlations to the torsional alignment or to crossing over signs were observed

App-based rehabilitation program after total knee arthroplasty: a randomized controlled trial

Introduction: New app-based programs for postoperative rehabilitation have been developed, but no long-term study has been published to date. Thus, a prospective randomized control trial with 2-year follow-up was performed to evaluate the effectiveness of app-based rehabilitation (GenuSport) compared to a control group after total knee arthroplasty (TKA). Methods: Between April and October 2016, 60 patients were enrolled in the study. Twenty-five patients were lost to follow-up, leaving 35 patients undergoing TKA for inclusion. In this group, twenty patients received app-based exercise program and 15 were randomized to the control group. The mean age was 64.37 +/- 9.32 years with a mean follow-up of 23.51 +/- 1.63 months. Patients in the app group underwent an app-based knee training starting on the day of surgery; whereas, patients in the control group underwent regular physiotherapy. Functional outcome scores using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and VAS of pain were analyzed. Results: In the short term, significant differences between the app group and control group in time of 10-m walk (19.66 +/- 7.80 vs. 27.08 +/- 15.46 s; p = 0.029), VAS pain at rest and activity (2.65 +/- 0.82 vs. 3.57 +/- 1.58, respectively 4.03 +/- 1.26 vs. 5.05 +/- 1.21; p < 0.05) were observed. In the long term, a variety of different tendencies was found, highest in KSS Function with 76.32 +/- 16.49 (app group) vs. 67.67 +/- 16.57 (control group) (p = 0.130). Additionally, patients in the app group required less painkillers (10.0% vs. 26.7%) and more likely to participate in sports (65.0% vs. 53.3%). Conclusions: An app-based knee trainer is a promising tool in improving functional outcomes such as KSS function score and VAS after TKA

КЛАССИФИКАЦИЯ И АЛГОРИТМ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ПЕРИПРОТЕЗНОЙ ИНФЕКЦИИ ТАЗОБЕДРЕННОГО СУСТАВА

Prosthetic joint infection (PJI) is the second common reason for revision surgery of the hip joint prosthesis. The rate of hip PJI is about 1% after primary surgery and it goes up to 4% or higher after revision surgery. In most cases, the main cause of this complication is an intraoperative bacterial contamination, rarer is a haematogenic one. An up-to-date diagnostic approach and clearly defined treatment strategy are required for the successful therapy of PJI. Based on the analysis of the scientific literature and own experience, an algorithm for diagnosis and treatment of this complication is proposed. A thoroughly obtained case history plays a predominant role in the diagnosis of PJI. Lack of the increased serum C-reactive protein cannot be considered as an exclusion criterion because in some cases, especially chronic infection, it can be within the normal range. Bacteriology lab tests of periprosthetic tissue biopsies and synovial fluid is the gold standard for the diagnosis. Novel methods such as ultrasound debridement of the removed prosthetic components have allowed to substantially increase the diagnostic sensitivity of bacteriology tests. This led to the discovery of PJI in some cases which before that were regarded as aseptic loosening. Visualization methods including MRI and scintigraphy play only a secondary role. The authors propose the classification of PJI for further determination of the treatment strategy which takes into account parameters such as biofilm maturity, prosthesis stability, the type of pathogen and soft tissue state for the decision on the treatment strategy. While desire to retain the implant is only justified in case of the immature biofilm, in most cases the infection can be cured only after the replacement of endoprosthesis. According to the proposed algorithm, patients undergo one- or two-stage procedure with a short or long interval. Antibiotics that are active against biofilm pathogens play an important role in the efficacy of the therapy. Selection of these antibiotics should be based on the results of bacteriology tests, preferably in collaboration with specialists in infectious diseases and microbiology.Перипротезная инфекция (ППИ) является второй по частоте причиной ревизии эндопротезов тазобедренного сустава. Частота ППИ тазобедренного сустава составляет около 1% после первичных вмешательств и возрастает до 4% и выше после ревизионных операций. Причиной развития данного осложнения в большинстве случаев является интраоперационное инфицирование, реже - гематогенное. Для успешной терапии ППИ необходимы своевременная диагностика и четкая стратегия лечения. На основе анализа научной литературы и собственного опыта лечения ППИ предлагается алгоритм диагностики и лечения данного осложнения. Большое значение в диагностике ППИ имеет подробно собранный анамнез. Отсутствие повышения С-реактивного белка нельзя рассматривать как критерий исключения, так как в ряде случаев, особенно при хроническом течении инфекции, он может быть в пределах нормальных значений. «Золотым стандартом» диагностики является бактериологическое исследование образцов перипротезных тканей и синовиальной жидкости. Новые методы, такие как ультразвуковая обработка удаленных компонентов эндопротеза, позволили значительно повысить диагностическую значимость бактериологических исследований и в ряде случаев, ранее идентифицируемых как асептическое расшатывание эндопротеза, была диагностирована ППИ. Методы визуализации, такие как МРТ или сцинтиграфия, имеют лишь второстепенное значение. Авторы предлагают классификацию перипротезной инфекции для дальнейшего определения тактики лечения, которая учитывает такие параметры, как зрелость микробной биоплёнки, стабильность протеза, вид возбудителя и состояние мягких тканей. Стремиться сохранить протез можно только при незрелой биоплёнке, в большинстве случаев санация инфекции возможна только путем замены эндопротеза. В соответствии с предложенным алгоритмом пациентам назначается одноэтапный или двухэтапный метод лечения с коротким или длинным интервалом. Значимую роль в эффективности терапии отводят активным в отношении биоплёнки антибиотикам, выбор которых должен осуществляться с учетом результатов бактериологического исследования, желательно в междисциплинарном сотрудничестве со специалистами в области антимикробной химиотерапии и микробиологи