Long-Term Halo Follow-Up Confirms Less Invasive Treatment of Low-Grade Cartilaginous Tumors with Radiofrequency Ablation to Be Safe and Effective

Background: Radiofrequency ablation (RFA) is a minimally invasive alternative in the treatment of bone tumors. Long-term follow-up has not been described in current literature. Detailed analysis of mid- and long-term follow-up after RFA treatment for a cohort of patients with low-grade cartilaginous tumors (atypical cartilaginous tumors and enchondroma) was performed. The results, complications, and development of halo dimensions over time are presented. Methods: Data of all patients with an RFA procedure for an ACT between 2007-2018 were included. Ablation area is visible on baseline MRI, 3 months post-procedure, and is called halo. Volume was measured on MR images and compared to different follow-up moments to determine the effect of time on halo volume. Follow-up was carried out 3 months and 1, 2, 5, and 7 years after the procedure. Occurrence of complications and recurrences were assessed. Results: Of the 137 patients included, 82 were analyzed. Mean follow-up time was 43.6 months. Ablation was complete in 73 cases (89.0%). One late complication occurred, while no recurrences were seen. Halo dimensions of height, width, and depth decreased with a similar rate, 21.5% on average in the first year. Subsequently, this decrease in halo size continues gradually during follow-up, indicating bone revitalization. Conclusion: RFA is a safe and effective treatment in low-grade cartilaginous tumors with an initial success rate of 89.0%. Extended follow-up shows no local recurrences and gradual substitution of the halo with normal bone

Grip strength is strongly associated with height, weight and gender in childhood:a cross sectional study of 2241 children and adolescents providing reference values

QuestionWhat are reference values for grip strength in children and adolescents based on a large and heterogeneous study population? What is the association of grip strength with age, gender, weight, and height in this population?DesignCross-sectional study.ParticipantsParticipants were recruited from schools in the northern provinces of the Netherlands. The study included healthy children and adolescents ranging in age from 4 to 15 years.Outcome measuresAll children had their height (cm) and weight (kg) measured and were allowed a total of four attempts using the Jamar hand dynamometer: twice with each hand. Grip strength scores (kg) were recorded for the dominant and non-dominant hands.ResultsThe study population comprised 2241 children and adolescents. Reference values for both genders are provided according to age and dominance. Grip strength shows a linear and parallel progression for both genders until the age of 11 or 12, after which grip strength development shows an acceleration that is more prominent in boys.ConclusionThere is a significant difference in grip strength with each ascending year of age in favour of the older group, as well as a trend for boys to be stronger than girls in all age groups between 4 and 15 years. Weight and especially height have a strong association with grip strength in children

Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection. A retrospective single-center experience

Background: A low-grade periprosthetic joint infection (PJI) may present without specific symptoms, and its diagnosis remains a challenge. Three-phase bone scintigraphy (TPBS) and white blood cell (WBC) scintigraphy are incorporated into recently introduced diagnostic criteria for PJI, but their exact value in diagnosing low-grade PJI in patients with nonspecific symptoms remains unclear. Methods: In this retrospective study, we evaluated patients with a prosthetic joint of the hip or knee who underwent TPBS and/or WBC scintigraphy between 2009 and 2016 because of nonspecific symptoms. We reviewed and calculated diagnostic accuracy of the TPBS and/or WBC scintigraphy to diagnose or exclude PJI. PJI was defined based on multiple cultures obtained during revision surgery. In patients who did not undergo revision surgery, PJI was ruled out by clinical follow-up of at least 2 years absent of clinical signs of infection based on MSIS 2011 criteria. Results: A total of 373 patients were evaluated, including 340 TPBSs and 142 WBC scintigraphies. Thirteen patients (3.5 %) were diagnosed with a PJI. TPBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were 71 %, 65 %, 8 % and 98 %, respectively. Thirty-five percent of TPBS showed increased uptake. Stratification for time intervals between the index arthroplasty and the onset of symptoms did not alter its diagnostic accuracy. WBC scintigraphy sensitivity, specificity, PPV and NPV were 30 %, 90 %, 25 % and 94 %, respectively. Conclusion: Nuclear imaging does not have clear added value in patients with low a priori chance of periprosthetic joint infection

Should all hip and knee prosthetic joints be aspirated prior to revision surgery?

Aims It is essential to exclude a periprosthetic joint infection (PJI) prior to revision surgery. It is recommended to routinely aspirate the joint before surgery. However, this may not be necessary in a subgroup of patients. The aim of our study was to investigate if specific clinical and implant characteristics could be identified to rule out a PJI prior to revision surgery. Methods We retrospectively evaluated clinical and implant characteristics of patients who underwent a hip or knee revision surgery between October 2015 and October 2018. Patients were diagnosed with a PJI according to the MSIS diagnostic criteria. Results A total of 156 patients were analyzed, including 107 implants that were revised because of prosthetic loosening and 49 because of mechanical failure (i.e. instability, malalignment or malpositioning). No PJI was diagnosed in the group with mechanical failure. In the prosthetic loosening group, 20 of 107 were diagnosed with a PJI (19%). Although there was a significantly lower chance of having a PJI with an implant age of > 5 years combined with a CRP < 5 mg/L, an infection was still present in 3 out of 39 cases (8%). Conclusion Implants with solely mechanical failure without signs of loosening and low inflammatory parameters probably do not require a synovial fluid aspiration. These results need to be confirmed in a larger cohort of patients. In case of prosthetic loosening, all joints need to be aspirated before surgery as no specific characteristic could be identified to rule out an infection

The push-through total femoral prosthesis offers a functional alternative to total femoral replacement:a case series

PURPOSE: Oncologic resections or complications of segmental femoral prostheses can result in severe bone loss of the femur for which a total femoral prosthesis (TFP) is required. This study assesses whether the loss of stability and function caused by the loss of muscle attachments can be improved by using a push-through total femoral endoprosthesis (PTTF), because it saves parts of the femur and its muscle attachments. METHODS: In this retrospective case series, ten patients aged 25-77 (mean 54) who received a PTTF between 2005 and 2014 were included for baseline, complications and survival analysis with a mean follow-up of 5.3 (1.1-9.6) years. Functional outcome was assessed in six patients using the Musculoskeletal Tumor Society (MSTS) score, WHO performance scale, Toronto Extremity Salvage Score (TESS), SF36, EQ-5D, NRS pain score, fatigue score and satisfaction score. RESULTS: The mean MSTS score was 64% (23-93%). Five patients had a WHO performance scale of 1, one patient of 3. Mean TESS was 69% (13-90%). SF36 was most notably limited by physical functioning (mean 48), vitality (68) and general health (67). NRS score was 1.9, 1.8 and 8.3 for pain, fatigue and satisfaction, respectively. There were four failures: two infections (one resulting in amputation and one in a minor revision) and two mechanical failures (which required one revision to a TFP and one minor revision). Patient survival was 100%, limb survival 90%, and prosthesis survival 80%. CONCLUSION: The push-through total femoral endoprosthesis allows preservation of muscle attachments and offers a good alternative to total femoral prostheses

F-18-FDG-PET uptake in non-infected total hip prostheses

Background and purpose - F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) can be used in the diagnostic work-up of a patient with suspected periprosthetic joint infection (PJI) but, due to a lack of accurate interpretation criteria, this technique is not routinely applied. Since the physiological uptake pattern of FDG around a joint prosthesis is not fully elucidated, we determined the physiological FDG uptake in non-infected total hip prostheses. Patients and methods - Patients treated with primary total hip arthroplasty (1995-2016) who underwent a FDG-PET/CT for an indication other than a suspected PJI were retrospectively evaluated. Scans were both visually and quantitatively analyzed. Semi-quantitative analysis was performed by calculating maximum and peak standardized uptake values (SUVmax and SUVpeak) by volume of interests (VOIs) at 8 different locations around the prosthesis. Results - 58 scans from 30 patients were analyzed. In most hips, a diffuse heterogeneous uptake pattern around the prosthesis was observed (in 32/38 of the cemented prostheses, and in 16/20 of the uncemented prostheses) and most uptake was located around the neck of the prosthesis. The median SUVmax in the cemented group was 2.66 (95% CI 2.51-3.10) and in the uncemented group 2.87 (CI 2.65-4.63) (Median difference = -0.36 [CI -1.2 to 0.34]). In uncemented prostheses, there was a positive correlation in time between the age of the prosthesis and the FDG uptake (r(s) = 0.63 [CI 0.26-0.84]). Interpretation - Our study provides key data to develop accurate interpretation criteria to differentiate between physiological uptake and infection in patients with a prosthetic joint.</p

The Influence of Hand Preference on Grip Strength in Children and Adolescents; A Cross-Sectional Study of 2284 Children and Adolescents

Introduction In adults the preferred hand is often considered to be around 10% stronger than the non-preferred hand. Whether the same is true for children and adolescents remains unclear. The objective of this study is therefore to determine whether there is a difference in grip strength between the preferred and non-preferred hand in developing children, to establish whether this difference is similar for children of a different gender or hand preference, and whether there is a difference in grip strength of the preferred hand of left-preferent (LP) and right-preferent (RP) children. Design Cross-sectional study. Participants Participants were recruited from schools in the northern provinces of the Netherlands. The study included healthy children and adolescents in the age range of 4-17 years. Outcome Measures Each child was allowed a total of four attempts using the JAMAR hand dynamometer, two attempts with each hand. All individual attempts were scored. Hand preference was determined by asking which hand was used to write, or in the case of 4- and 5-year-olds, which hand was used to draw a shape. Results The study population comprised 2284 children and adolescents. RP boys and girls scored significantly higher with their preferred hand, the difference amounting to 9.5 and 10.1% respectively. LP girls scored significantly higher with their preferred hand, but this difference was only 3.0%. For LP boys no significant difference was found in favor of either hand. LP children score higher with the non-preferred hand and tie scores on both hands more often than RP children. Conclusion The 10% rule of hand preference is applicable to RP children ranging in age between 4 and 17 years, but not to LP children. In contrast to LP boys, LP girls are generally significantly stronger with their preferred hand

The effects of pelvic ring injuries on quality of life, physical, and mental health:results of a 2-year prospective cohort study

PURPOSE: Pelvic ring injuries are known to affect the patients' daily life in terms of physical functioning and quality of life (QoL). Still, prospective studies on the patient's perception over the first 2 years of rehabilitation are lacking. Therefore, patients cannot be properly informed about whether or when they will return to their pre-existing level of physical functioning and QoL. METHODS: A prospective longitudinal cohort study was performed over a 4-year period including all consecutive patients above 18 years who sustained a pelvic ring injury in a level 1 trauma center. Validated patient-reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D) at baseline (recalled pre-injury score), 6 weeks, 3 months, 6 months, 1 year and 2 years after the injury. It was assessed whether patients had fully recovered by comparing follow-up scores to baseline PROMs. Binary logistic regression analysis was used to identify independent predictors for patients who did not fully recover. Most experienced difficulties at 3 months and 1 year were identified by analyzing the highest reported scores on individual items of the SMFA. RESULTS: A total of 297 patients with a pelvic ring injury were identified of which 189 were eligible for follow-up and 154 (82%) responded. Median SMFA function score at 3 months, 1 and 2 years was 70, 78 and 88, respectively, compared to 96 out of 100 before the injury. Median SMFA bother score was 67, 79 and 88, respectively. Median EQ-5D score at 3 months, 1 and 2 years was 0.61, 0.81 and 0.85, respectively, compared to 1 (maximum achievable) before the injury. After 1 and 2 years of follow-up, 61% and 75% of the patients fully "recovered" in physical functioning and 52% and 71% fully recovered in terms of QoL. Female gender and high-energy trauma were independent predictors for not fully recovering after 1 year. After 3 months of follow-up, 54% of patients reported severe difficulties with recreational activities, whereas after 1 year, most experienced difficulties (31% of patients) concerned heavy house or yard work. Moreover, after 3 months and 1 year, 44% and 27% of patients reported feeling physically disabled. CONCLUSION: Pelvic ring injuries have a large impact on the patients' daily life in the first 2 years of rehabilitation. Directly after the injury, physical functioning and QoL decrease strongly but then gradually improve over a 2-year period with about 75% of patients fully recovering. Female gender and high-energy trauma are shown to be independent predictors for not fully recovering. After 3 months, patients experience difficulties with both the physical and mental effects of the injury which continue to be present after 1 year

A Second Surgical Debridement for Acute Periprosthetic Joint Infections Should Not Be Discarded

Background: In acute periprosthetic joint infections (PJIs), a second surgical debridement (debridement, antibiotics, and implant retention [DAIR]) is generally not recommended after a failed first one. We identified the failure rate of a second DAIR and aimed to identify patients in whom an additional debridement might still be beneficial. Methods: Patients with acute PJI of the hip or knee and treated with DAIR between 2006 and 2016 were retrospectively evaluated. A second DAIR was routinely performed provided that the soft tissue was intact. Failure of a second DAIR was described as (1) the need for additional surgical intervention to achieve infection control, (2) the need for antibiotic suppressive therapy due to persistent clinical and/or biochemical signs of infection, or (3) PJI related death. Results: From the 455 cases treated with DAIR, 144 cases underwent a second debridement (34.6%). Thirty-seven cases failed (37/144, 25.7%). The implant needed to be removed in 23 cases (23/144, 16%). Positive cultures during the second DAIR (odds ratio 3.16, 95% confidence interval 1.29-7.74) and chronic renal insufficiency (odds ratio 13.6, 95% confidence interval 2.03-91.33) were independent predictors for failure in the multivariate analysis. No difference in failure was observed between persistent infection with the same microorganism and reinfection with a new microorganism (failure rate 31.6% vs 34.6%, P =.83). Conclusion: A second DAIR had a low failure rate in our cohort of patients and the implant could be retained in the majority of them. Therefore, a second DAIR should not be discarded in acute PJIs