ARCHIVES OF BONE AND JOINT SURGERY
Year:2018 | Volume:6 | Issue:5|Papers Count:13

Background: Periprosthetic infection is the most serious joint replacement complication, occurring in 0. 8-1. 9% of total knee arthroplasties (TKAs). This review aims to define the role of preoperative aspiration culture (PAC) for diagnosis of TKA infection. Methods: A PubMed (MEDLINE) search related to TKA infection and PAC was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question. Results: Twenty articles were found, but only fourteen were selected and reviewed because they were deeply focused on the topic. PAC has shown an average sensitivity of 67. 6% (range, 28% to 100%) and an average specificity of 98. 4% (range, 96% to 100%). Conclusion: PAC has moderate to high sensitivity and very high specificity for diagnosing TKA infection.

Background: Adult degenerative disorders of hip and spine are common. The recent studies inconsistently have discussed about the influence of spinal disorders on total hip arthroplasty (THA). In this review, we discussed clearly about these relationships and their effects on the most appropriate position of the acetabular component. Methods: We searched on databases and evaluated the articles about spinopelvic parameters in patients with spinal disorders who needed THA. Results: The literature search showed a prevalence of 21. 2 % to 60. 4% of low back pain (LBP) in patients, who are candidates for primary THA. The coexistence of degenerative disease of hip and spine or other diseases can significantly alter spinopelvic alignment. Accordingly, pain management or any other treatment in these patients requires proper understanding about the biomechanics of the hip and the spinal and their corresponding interactions. In this review article, we discussed about these interactions and their effects on the most appropriate position of the acetabular component. Conclusion: We concluded that counseling sessions among patients, orthopedic surgeons and spine surgeons can result in obtaining the best outcome for these individuals.

Background: The Global Unite Shoulder System is the next generation of implant from the Depuy Global Shoulder line. The primary feature of the Global Unite is adaptability through the interchangeable modular bodies, modular suture collars, and stems. Short-term functional and radiographic outcomes of the Global Unite Platform Shoulder System were assessed as well as complication and revision rates. Methods: 95 subjects were enrolled prospectively between 2013 and 2015 that underwent anatomic or reverse shoulder arthroplasty utilizing the DePuy Global Unite Anatomic Platform Shoulder System. Functional outcome data (ASES and SANE) as well as radiographic data was collected on these patients pre-operatively, and at 6 months, 1 year and 2 years post-operatively. Results: The cohort consisted of 97 shoulders in 95 patients of which 54 (56. 8%) are males and 41 (43. 2%) are female. There were 55/97 (56. 7%) were primary anatomic total shoulder arthroplasties, 37/97 (38. 1%) primary reverse shoulder arthroplasties, and 3/97 (3. 1%) revision procedures to a reverse shoulder arthroplasty. Outcome scores demonstrated an increase in ASES score from a mean of 33. 00 to 79. 56 and SANE score of 21. 30 to 84. 08. Conclusion: The Depuy Global Unite shoulder system demonstrated very good short-term results in this two-year outcome study. Functional outcome scores are similar to current literature for anatomic and reverse primary cases. Radiographic measures at two years are promising with only 2 cases of grade 1 scapular notching and one case of grade 2 scapular notching. Overall the Depuy Global Unite is a versatile shoulder system with very good early outcomes.

Background: The purpose of this study was to evaluate the value of perioperative tests for the diagnosis of infection in revision shoulder arthroplasty. Methods: A retrospective analysis was performed on 537 shoulder arthroplasties (429 patients) that underwent revision shoulder arthroplasty at our institution. Periprosthetic tissue cultures were positive in 169/537 surgeries. Results: White-blood cell count (WBC) was elevated in 3. 8% revision arthroplasties. Erythrocyte sedimentation rate (ESR) was elevated in 23. 1% revision arthroplasties. The C-reactive protein (CRP) was elevated in 20. 8% revision arthroplasties. Bone scans (technetium, indium) were performed on 9. 9% patients and it was positive for osteomyelitis in just one revision arthroplasty. Intra-operative pathology was read as consistent with acute inflammation in 11. 9% revision arthroplasties. The positive and negative predictive values for intra-operative pathology were 56. 7% and 71. 6% respectively. Conclusion: All of the perioperative tests had a high specificity and negative predictive value, but low sensitivity and positive predictive value.

fractures is still under controversy. Common treatment methods for these fractures include open reduction and internal fixation (ORIF) as well as radial head excision. In this study, we compared long-term outcomes of both methods in treatment of patients with Mason type III fractures of radial head. Methods: Fifteen men and five women with Mason type III radial head fractures were evaluated retrospectively. Ten patients had undergone excision whereas the other ten patients had been treated with ORIF. Outcomes were assessed based on stability and range of motion of the elbow joint, grip strength, and pain. Data were gathered using Mayo elbow performance index (MEPI), Oxford elbow score, and disability of arm-shoulder-hand (DASH), along with the short form (SF)-36 questionnaire. Results: The mean age of the subjects was 36. 25± 9. 22 years and the mean follow-up time was 25. 05± 11. 43 months. The ranges of extension and supination, and frequency of pain reporting was significantly different between the groups. The average grip strength in the operated side was significantly higher in the ORIF group, compared with the excision (P= 0. 03). Ten (100%) patients of ORIF group and 5 (50%) patients of excision group had elbow joint stability (P=0. 01). Mean MEPI and DASH scores were significantly higher in ORIF group (P<0. 001 and =0. 04, respectively). Conclusion: The results are in favor of ORIF method. Therefore, this method is recommended and preferred over excision in treating radial heads with Mason type III frac ture.

Background: There are a number of different implant choices for surgical treatment of distal radius fractures, often determined by surgeon preference or availability. Although no one volar plate demonstrates superior outcomes, there are significant cost differences absorbed by hospitals and surgical centers. This purpose of this study is to characterize the economic implications of implant selection in the surgical management of distal radius fractures. Methods: A retrospective review of billing records at a mid-size community surgicenter was conducted for CPT codes 25607, 25608, and 25609 between 1/1/2014 and 6/1/2014, and associated implant costs and facility reimbursements were collected. A unique stochastic simulation model was developed from derived probabilities, reimbursements, and costs, and analyzed by Monte Carlo simulation. Results: Reimbursement to the facility for distal radius ORIF cases ranged from $1, 102. 20 to $7, 393. 86, with an average of $3, 824. 56. Per case operating costs to the facility ranged from $1, 250 to $7, 270, with an average of $2, 817. 42. In the US, variations in implant cost 25% above or below the mean translates to annual operating profits realized by facilities ranging from a loss of $57, 047, 720 to profits of $55, 189, 729. On average, per case operating costs for distal radius fractures need to be less than $2956 fo r facilities to realize a per case profit. Conclusion: Value based purchasing is by necessity becoming integrated into clinical decision making by orthopaedic surgeons. Variations of 25% around the mean per case operating cost can vary facility operating margins by $112, 237, 450 annually. Arming the orthopaedic surgeon with the realities of the cost of implant selection in the operative management of distal radius fractures will lead to better value based decision making, substantial cost savings to the US hospital system, and ultimately payers and patients.

Background: Presentation of proximal tibia stress fracture is not infrequent among elderly patients due to their poor bone stock. Optimal management of patients with severe gonarthrosis of the knee and concurrent tibial stress fracture is not known yet. In this study we report the outcome of primary total knee arthroplasty (TKA) using stemmed components in elderly patients. Methods: Between 2009 and 2014, a total of 16 elderly patients with proximal tibial stress fractures and concurrent gonarthrosis were treated with TKA using long stemmed components. The diagnosis of stress fractures was confirmed based on the radiographic changes. A standing alignment view was obtained for all patients preoperatively. Union of the fracture site was investigated using plain anteroposterior (AP) and lateral leg x-rays. Results: All patients experienced significant relieve of symptoms. The Knee Society score and Knee Society functional score averaged 86± 4 and 85± 6, respectively. The mean arc of motion of the knee was 118° ± 2° at the latest follow-up. All stress fractures resolved at a mean of 8. 3± 1. 1 weeks. The medial proximal tibial angle was increased from 74. 7° ± 5. 7° preoperatively to 90. 3° ± 1. 1° (P<0. 05) postoperatively. Tegner activity scale was increased from 2. 1± 1. 3 to 3. 4± 0. 9 (P<0. 05). Conclusion: According to our findings, patients with stress fracture of proximal tibia and concurrent gonarthrosis can be treated with primary TKA using stemmed components that may bypass the stress fracture and allow healing of the fracture.

Background: No scientific evidence exists regarding the amount of bone cement used and discarded in primary cemented Total knee arthroplasty (TKA). The aim of this study was to identify the exact amount of bone cement utilized for component fixation in primary TKA. Methods: In a prospective study carried out at five centers, 133 primary cemented TKAs were performed. One pack of 40g Palacos bone cement (PBC 40) was hand mixed and digitally applied during the surgery. After fixation of the TKA components, the remaining bone cement was methodically collected and weighed on a digital weighing scale. The actual quantity of cement utilized for component fixation was calculated. Results: On an average, 22. 1 g of bone cement was utilized per joint, which accounted to 39 % of 57 g, the solidified dry weight of PBC 40. Among 133 knees, the cement usage was 20 % to 50% in 109 knees, more than 50% in 20 knees and less than 20% in 4 knees. Knees which received larger sized femoral implant required more cement compared to medium and small sizes. Knees which had pulse lavage had more cement utilization compared to knees which had simple syringe lavage before implantation. Conclusion: Large quantity of bone cement was handled than actual requirements in primary TKA when a standard 40g pack was used with the digital application technique, resulting in sizeable discard of bone cement. Customizing cement pack according to the implant size can potentially avoid this cement wastage. Future research is required to study the utility and economic impact of smaller packs (20 g or 30 g) of bone cement in primary TKA.

Background: Hip fracture is one of the most common problems in elderly that needs surgical repair. As, the majority of these patients have chronic diseases, they are at increased risk of peri-operative mortality and morbidity. The purpose of this study was to evaluate spinal anesthesia with bupivacaine vs bupivacaine in combination with lidocaine in terms of hemodynamic changes in patients undergoing hip fracture surgery. Methods: This double-blind clinical trial was conducted on 292 patients undergoing surgery for hip fracture under spinal anesthesia. Patients were allocated into two groups of B (10 mg of hyperbaric 0. 5% Bupivacaine) and BL (5 mg hyperbaric Bupivacaine 0. 5% plus 50 mg Lidocaine 5%). Sensory and motor block and hemodynamic changes were consecutively measured before spinal anesthesia (T0), immediately after spinal injection (T1), every 5 minutes for half an hour (T2-T7), and at 45 minutes (T8) and 60 minutes (T9) after injection. Results: Patients in the two groups were homogeneous in demographic characteristics including age, sex, BMI, ASA Class, baseline blood pressure and heart rate. The onsets of sensory and motor blocks in group BL were faster than group B (P=0. 0001). Also, the durations of sensory and motor blocks in group B were significantly longer than group BL (P=0. 0001). The BL group had a significantly lower systolic blood pressure in all periods (P<0. 05). Although the heart rate in the BL group was lower than group B at all time points, this difference was only significant during T2-T3 (P=0. 033 and P=0. 0001, respectively). Group BL had significantly more episodes of hypotension, bradycardia, nausea and vomiting (P=0. 0001, P=0. 023, P=0. 003, and P=0. 033, respectively). Conclusion: According to our findings, using Lidocaine 50 mg in combination with Bupivacaine 5 mg, compared with Bupivacaine 10 mg alone for spinal anesthesia in hip fracture fixation surgeries was associated with more hypotension and bradycardia. As a result, combination of Bupivacaine with Lidocaine at this dose is not recommended for induction of anesthesia in these patients.

Background: Revision discectomy is the principal procedure for recurrent lumbar disk herniation (RLDH). The clinical outcomes after this procedure are as good as or slightly poorer than those produced by primary discectomy. In this study, the clinical outcomes of patients treated with microsurgical discectomy for RLDH were analyzed. Methods: We examined 179 patients undergoing lumbar microdiscectomy surgery for RLDH. The visual analogue scale (VAS), Prolo scoring system, and Oswestry Disability Index (ODI) were used for evaluating the improvement of symptoms and functional outcomes. Results: Among 179 patients, 101 (56%) obtained good and excellent Prolo scores (group 1), while 78 (44%) obtained fair or poor results (group 2). There was no significant difference between the groups regarding age (P=0. 515), gender (P=0. 545), body mass index (P=0. 523), diabetes mellitus (P=0. 074), smoking (P=0. 100), interval between primary and revision surgeries (P=0. 749), and surgical outcomes (P=0. 749). However, significant improvements were achieved in VAS scores for back (P=0. 197) and radicular pain (P=0. 606), as well as ODI scores (P= 0. 000). Based on the findings, only ODI scores showed a significant inter-group difference in the 12-month follow-up (P=0. 038). Conclusion: Limited microsurgical discectomy could be considered as the main surgical method in patients with RLDH without overt instabilities.

Background: Flexible idiopathic flatfoot is the most common form of flatfoot. First line treatments are parental reassurance and conservative measures; however, surgical treatment may be needed in some cases. A number of surgical techniques with varying results have been described in the literature. Here, we present our clinical and radiological outcomes of calcaneal lengthening osteotomy for pediatric idiopathic flexible flatfoot. Methods: Calcaneal lengthening osteotomy was performed in 20 patients, 30 feet, with idiopathic flexible flatfoot that were resistant to conservative treatment between 2007 and 2011. Patients were evaluated according to ACFAS universal evaluation scoring scale and radiographic indexes. The mean follow up duration was 23. 1 ± 9. 9 months. Results: The average age was 10. 4 ± 0. 9 years. Achilles tendon lengthening was performed in 28 feet. ACFAS score at the final follow up had improved significantly compared to pre-operative score (37 to 88, P<0. 0001). Radiographic parameters also showed significant improvement after surgery ((P<0. 0001)). Distal segment displacement and hardware irritation as postop complications were observed in 2 and 3 cases, respectively, with no long-term clinical impact. Conclusion: Calcaneal lengthening osteotomy is an appropriate and safe operation in symptomatic idiopathic flexible flat foot that is resistant to conservative treatment.

Background: Pilon fracture is one of the challenging injuries in orthopedic surgery. Associated soft tissue injury is an important factor in choosing treatment options. Two major methods of treatment are considered as one-stage open reduction internal fixation (ORIF) and two-stage treatment (primary external fixation and secondary ORIF). The latter is most accepted in literature. In the current study, we compared the results of these two methods. Methods: In a retrospective study, 41 patients were assigned to two groups containing one-stage primary ORIF (21 patients) group, and two-stage group included external fixation and secondary ORIF (20 patients). The rate of infection (superficial or deep infection, osteomyelitis), malunion, nonunion, duration of hospital stay, neurovascular injury, pain intensity, and patients’ satisfaction with AOFAS score, were compared between the two groups. Results: There was no significant difference between the two groups in measured variables except hospital stay which was significantly longer for the two-stage group. Conclusion: Based on our findings, we recommend using one stage ORIF for a patient with Pilon fract

Dear Editor: The popliteal cyst, as first described by William Baker in 1877, is defined as a fluid-filled mass that is a benign swelling of bursa in the popliteal fossa, usually the gastrocnemio-semimembranosus bursa (1). Popliteal cysts nearly always have a cause, normally being a reaction to loose bodies formed in conditions such as osteoarthritis (OA), rheumatoid arthritis or in the presence of meniscal tears (1). More recently, popliteal cysts have been seen in relation to wear particles following knee arthroplasty, mostly from the polyethylene liner (1, 2).