JournalTOCs

Archives of Orthopaedic and Trauma Surgery
Journal Prestige (SJR): 1.146

Citation Impact (citeScore): 2
Number of Followers: 10

Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1434-3916 - ISSN (Online) 0936-8051
Published by Springer-Verlag

[2626 journals]

Evaluation of the permissible maximum angle of the tibial tunnel in
transtibial anatomic posterior cruciate ligament reconstruction by
computed tomography
- Abstract: Introduction Excessive angle of the tibial tunnel may cause breakage of the posterior cortex in transtibial anatomic posterior cruciate ligament (PCL) reconstruction. However, a few studies have determined the permissible maximum angle of the tibial tunnel. The purpose of this study was to determine the permissible maximum angle of the tibial tunnel relative to the tibial plateau in transtibial anatomic PCL reconstruction and characterize the anatomic parameters of the tibial PCL attachment position. Materials and methods Computed tomography (CT) scans of a consecutive series of 408 adult knees with normal PCL attachment were measured. The parameters measured were the permissible maximum angle (PMA) of the 10 mm-diameter tibial tunnel relative to the tibial plateau, the distance from the anterior orifice of the tibial tunnel to the tibial tuberosity (OTD), the anterior–posterior diameter (APD) of the tibial plateau, the distance from the center of PCL attachment site to the posterior edge of the tibial plateau (PPED), and the angle between the tibial plateau and the posterior tibial slope where the PCL insertion site was (PSA). Subgroup analysis was performed to determine the correlations between parameters, and sex, age, and height. The measurement reliability was evaluated by intraclass correlation coefficients (ICCs). Results The average value of PMA was 48.2 ± 5.4°, and it was not affected by sex, age, and height (P > 0.05). The values of OTD, APD, PPED, PSA, and height were significantly higher in males than females (OTD, P < 0.01; APD, P < 0.01; PPED, P < 0.01; PSA, P = 0.019; height, P < 0.01). With regard to age, we stratified the cases into three groups: the young (18–30 years old), the middle-aged (31–45 years old), and the elderly (46–60 years old). The mean value of OTD, APD, and height were significantly lower in the elderly than that in the middle-aged (P < 0.01, P < 0.01, P < 0.01, respectively). With regard to height, we stratified the cases into three groups: ~ 1.65 m (1), 1.66 ~ 1.75 m (2), and 1.76 m ~ (3). The mean value of OTD, APD, and PPED significantly increased with height, P < 0.05. The mean value of PSA was significant higher in II group than that in I group (P = 0.034). Conclusions There should be a limit to the angle of the tibial tunnel in transtibial anatomic PCL reconstruction to prevent the fracture of posterior tunnel wall. The permissible maximum angle (PMA) of the 10 mm-diameter tibial tunnel relative to the tibial plateau was 48.2°. Besides, the determination of the value of OTD, APD, PPED, and PSA could provide a clinical reference to insertion site, depth, and angle of the tibial drill guide in PCL reconstruction.
  PubDate: 2019-04-01
Retrograde fixation of the lesser trochanter in the adolescent: new
surgical technique and clinical results of two cases
- Abstract: Introduction Avulsions of the lesser femoral trochanter are rare injuries in the adolescent population. An acute avulsion causes severe functional impairment with compromised hip flexion. Recent literature reports the superiority of surgical treatment for apophyseal avulsion fractures of the pelvis in adolescents. Unfortunately, there are no guidelines for an evidence-based treatment of lesser trochanter avulsions established. We present the cases of two adolescent athletes treated operatively. Materials and methods Two adolescent males, 12 and 16 years old, suffered an avulsion of the lesser trochanter during soccer. They reported immobilizing groin pain with subjective impairment in daily activities and inability to perform sports. Surgical treatment with a new retrograde technique by applying an adapted mini-open anterior approach was performed. Intraoperatively, both cases showed an intact musculo-tendinous unit attached to the avulsed fragment. Results Both patients showed excellent postoperative results and were satisfied with the clinical outcome. In the postoperative follow-up an adequate consolidation of the lesser trochanter was visible. No complications were postoperatively reported at final follow-up. Conclusions The retrograde fixation technique has led to an excellent outcome without complications in two adolescents with acute lesser trochanter apophyseal avulsions. Further clinical use may support the value of this new surgical technique.
  PubDate: 2019-04-01
Primary stability of total hip stems: does surgical technique matter'
- Abstract: Background With this preliminary study we hypothesized a modified implantation technique may lead to higher primary stability than the conventional one. Methods In the conventional technique we used a sharp spoon to open the femoral cavity. Subsequently the opening was extended by increasing sizes of a sensing device to approve the final size. Finally, a bone compactor of the corresponding size was inserted in the cavity preparing it for implantation while compressing the surrounding cancellous bone. After initial opening of the femoral canal with a sharp spoon, the modified implantation technique was characterized by direct use of increasing sizes of bone compactors. A standardized procedure was implemented for micromotion analysis using LVDT's. Each specimen was positioned in a servo-hydraulic testing machine following a standardized test regime. A total of 1500 load cycles with a maximum hip reaction force of 1000 N were applied on each sample in three series of 500 cycles. The force was applied as a cyclic sinusoidal with a frequency of 1 Hz and a load ratio of R = 0.1. Results No significant differences of micromotion between implant and surrounding bone stock could be detected regarding conventional vs. modified implantation technique. However, independent of the surgical technique used, significant differences were observed for the operated side, i.e. backhand driving of right-handed surgeon resulted in higher interfacial micromotions at the left side. Conclusion The results did not support our hypothesis. However, the correlation found between operated side and surgeon's backhand driving as a potential risk for reduced primary stability should encourage further investigations.
  PubDate: 2019-04-01
Patient-reported quality of life and pain after permissive weight bearing
in surgically treated trauma patients with tibial plateau fractures: a
retrospective cohort study
- Abstract: Introduction A Dutch survey among orthopedic surgeons and trauma surgeons showed that almost 90% of the surgeons do not follow protocols regarding the weight bearing aftercare for tibial plateau fractures. Clinical studies comparing permissive weight bearing (PWB) versus restricted weight bearing (RWB) after surgically treated tibial plateau fractures are not available. The aim of this study was to inventory potential differences in quality of life and pain, and number of complications in patients with surgically treated tibial plateau fractures who followed a PWB regime, relative to those that followed a RWB regime. Materials and methods This retrospective cohort study included surgically treated trauma patients with tibial plateau fractures, who underwent rehabilitation according to PWB or RWB between 2005 and 2015. Data such as demographics, patient-reported quality of life and pain, and patient outcome were collected. Results This cohort study included 91 patients with a tibial plateau fracture (31 and 60 patients in the PWB and RWB groups respectively). No significant between-group differences in either age or gender were found. However, a significant difference in fracture type was found between groups, (p = 0.04). No significant differences were found in either patient-reported SF-12 or VAS scores between the PWB group and RWB group. Time to full weight bearing was significantly shorter in the PWB than in the RWB group, i.e., 14.7 versus 20.7 weeks, (p = 0.02). No significant differences were found regarding postoperative complications between the PWB and the RWB groups, i.e., 6.5% versus 10.0%, respectively. Conclusion PWB after surgically treated tibial plateau fractures is safe and is related to a significantly reduced time to full weight bearing with no significant differences in patient-reported quality of life and pain or complication rates.
  PubDate: 2019-04-01
The outcomes of total knee arthroplasty in morbidly obese patients: a
systematic review of the literature
- Abstract: Introduction The increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients. Methods A search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI ≥ 40 kg/m2) that underwent primary TKA, compared to non-obese patients (BMI ≤ 30 kg/m2). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mann–Whitney test. Statistical significance was defined as p ≤ 0.05. Results Nine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m2 (range 40–66 kg/m2) and 26.5 kg/m2 (range 11–30 kg/m2) respectively. The average follow-up time was 4.8 years (range 0.5–14.1) and 5.2 years (range 0.5–13.2) respectively, with a revision rate of 7% and 2% (p < 0.001) respectively. All functional scores improved after TKA (p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS (p = 0.78). Overall complication rates, including infection, were higher in morbidly obese patients. Conclusions This review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.
  PubDate: 2019-04-01
Surgical excision and not chemotherapy is the most powerful modality in
treating synovial sarcoma: the UK’s North East experience
- Abstract: Background and purpose We reviewed our experience of synovial sarcoma to identify factors predictive of local recurrence and overall survival, the impact of chemotherapy and outcomes after surgical excision alone. Materials and methods 81 patients were treated between 1997 and 2014 of mean age 39 years (8–78). Tumours were in the extremity in 55 (67%). 9 patients presented with metastases and 10 with unresectable disease. Mean follow-up was 3.7 years (SD 3.8). Treatment groups were palliative, surgery only, surgery and radiotherapy, or surgery with chemotherapy (with or without radiotherapy). Results Local recurrence-free survival (LRFS) was 73% at 5 years, and 68% at 10 and 15 years. In multivariate analysis, positive surgical margins were an independent predictor of LRFS. Overall survival (OS) was 50% at 5 years for all patients, and 62% at 5 years for those treated with curative intent. Larger tumour size and non-extremity locations were predictors of poorer OS. Patients who had chemotherapy did not have significantly better OS or LRS than others. Interpretation These results show that where feasible, curative resection should not be delayed for chemotherapy. Treatment with surgery only can be associated with good outcomes in selected patients with smaller extremity tumours; although our series is small.
  PubDate: 2019-04-01
Implementation of a multidisciplinary infections conference affects the
treatment plan in prosthetic joint infections of the hip: a retrospective
study
- Abstract: Introduction Establishing a systematic multidisciplinary approach in the treatment of prosthetic joint infections (PJI) of the hip and analyzing its effect on clinical decision-making. Patients and methods Forty-six patients diagnosed with PJI of the hip were included in the retrospective study. The treatment plan was either established by a single-discipline approach (n = 20) or by a weekly multidisciplinary infections conference (n = 26) consisting of at least an orthopedic surgeon, microbiologist and pathologist. Recorded data included the length of hospital stay, number and type of surgeries, medical complications, recovered organisms as well as the number of applied antibiotics. Results Patients discussed in the multidisciplinary infections conference showed a significantly shorter in-hospital stay (29 vs 62 days; p < 0.05), a significant reduction in surgeries (1.8 vs 5.1; p < 0.05) and a smaller number of antibiotics required (2.8 vs 4.2; p < 0.05). No significant difference could be found comparing inpatient complications between the two groups. Staphylococcus aureus and coagulase-negative staphylococci were the most frequently recovered organisms in both patient groups. Conclusion This study demonstrates the successful implementation of a weekly infections conference as an instrument to introduce a multidisciplinary approach to PJI of the hip. Implementation of these conferences significantly improves the treatment plan compared to a single-discipline approach, which we therefore highly recommend for other institutions. Multidiscipline may even affect clinical outcome which needs to be further investigated.
  PubDate: 2019-04-01
Prevalence and quantification of contamination of knitted cotton outer
gloves during hip and knee arthroplasty surgery
- Abstract: Introduction Knitted cotton outer gloves offer protection against surgical glove perforation and provide improved grip on instruments. These gloves absorb blood and other fluids during surgery, and may therefore also accumulate contaminating bacteria. To date, there is no published data on microbial contamination of such gloves during surgery. Methods Knitted cotton outer gloves used in primary and revision hip and knee arthroplasty from two Swiss hospitals were analysed by quantitative bacteriology. Samples were subjected to sonication and vortexing, followed by membrane filtration of the sonicate. Membranes were incubated under aerobic and anaerobic culture conditions, respectively, for 21 days. Total microbial load for each pair of gloves was determined by colony-forming units (CFU) count. Strain identification was performed with MALDI-TOF. Results A total of 43 pairs of gloves were collected from continuous series of surgeries. Under aerobic culture conditions, total CFU counts ranged 0–1103, 25 (58%) samples remaining sterile, and 4 (9%) yielding > 100 CFU. Under anaerobic culture conditions, total CFU counts ranged 0–3579, 22 (51%) samples remaining sterile, 6 (14%) yielding > 100 CFU. The only covariate significantly associated with the level of contamination was the provider hospital (p < 0.0001 for aerobic and p = 0.007 for anaerobic cultures). Strain identification revealed only skin commensals, mainly coagulase-negative staphylococci and Propionibacterium spp. Conclusion While contamination of surgical latex gloves is a well-known issue, no study has examined so far contamination of knitted cotton outer gloves. No or very low microbial contamination could be identified in the majority of the knitted cotton outer gloves assayed. However, a relevant proportion showed contamination far higher than estimated minimal thresholds for implant-associated infection. Clinical relevance of these findings remains to be established.
  PubDate: 2019-04-01
Factors predicting the 1-year outcome of collagenase treatment for
Dupuytren’s disease
- Abstract: Introduction Several studies have investigated the clinical outcome after collagenase treatment for Dupuytren’s disease in terms of range of motion of the affected finger. However, good objective clinical outcome defined by a small remaining flexion contracture does not necessarily translate into satisfactory patient-subjective hand function. The aim of the present study was to identify predictors of patient-reported as well as objective clinical outcome in patients 1 year after collagenase treatment for Dupuytren’s disease. Materials and methods Socio-demographic and disease-related data of 92 Dupuytren patients were collected prior to the intervention. Flexion contracture of the most affected finger was measured at baseline and 1 year after treatment. Patients also completed the brief Michigan Hand Outcomes Questionnaire (brief MHQ) before the intervention and at 1-year follow-up. First, univariate correlations using Pearson’s correlation coefficient of the baseline variables with the two target variables were investigated. All variables with r > 0.35 were selected for a multivariate linear stepwise backwards regression model. Results The mean brief MHQ score increased between baseline (72 ± 14) and the 1-year follow-up (85 ± 15) (p ≤ 0.001) and baseline flexion contracture decreased from 76° (± 26) to 33° (± 31) (p ≤ 0.001). Higher hand function at baseline (R2 = 0.31) and less flexion contracture (R2 = 0.46) were identified as positive predictors for the outcome 1 year after collagenase treatment for Dupuytren’s disease. Other variables such as age, gender, manual work and if the MCP or PIP joint was affected did not determine outcome in our patient series. Conclusions Collagenase treatment resulted in considerable improvement in flexion contracture as well as patient-reported hand function at the 1-year follow-up. Clinicians can expect better outcome after collagenase infiltration in patients with less flexion contracture and in patients showing good initial self-reported hand function.
  PubDate: 2019-04-01
Comparison of efficacy of shock-wave therapy versus corticosteroids in
plantar fasciitis: a meta-analysis of randomized controlled trials
- Abstract: Background Corticosteroid (CS) injections have been proven to be effective in ameliorating symptoms of plantar fasciitis. Shock-wave (SW) therapy is another common treatment of plantar fasciitis, and several meta-analyses have documented its advantages when compared to placebo treatment. Despite this, few studies have focused on comparing the use of CS and SW in the treatment of plantar fasciitis. The purpose of this meta-analysis is to assess whether SW is superior to CS in managing plantar fasciitis, both in terms of ameliorating pain as well as improving functionality. Methods A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov and OVID from the databases’ inception to July 2018. All studies comparing the efficacy of SW and CS in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3. Results Six studies were included in the current meta-analysis. A significant difference in VAS score (MD = − 0.96, Cl − 1.28 to − 0.63, P < 0.00001, I2 = 96%) was noted between the SW group and the CS group. No significant difference was seen in the Mayo CSS or FFI or HFI or 100 Scoring System score at the 3 months follow-up (Chi2 = 0.62, I2 = 0%, P > 0.05). Conclusions The clinical relevance of the present study is that both SW and CS were effective and successful in relieving pain and improving self-reported function in the treatment of plantar fasciitis at 3 months. Although inter-group differences were not significant, the VAS score was better improved in the SW group, highlighting that shock-wave therapy may be a better alternative for the management of chronic plantar fasciitis.
  PubDate: 2019-04-01
An accelerometer-based navigation did not improve the femoral component
positioning compared to a modified conventional technique of
pre-operatively planned placement of intramedullary rod in total knee
arthroplasty
- Abstract: Introduction Although the most commonly used method of femoral component alignment in total knee arthroplasty (TKA) is intramedullary (IM) guides, this method demonstrated a limited degree of accuracy. Because of the femoral anterior bowing, the tip of the guide rod will impinge on the anterior cortex if a long rod is inserted. We hypothesized that the pre-operative planned insertion depth of the rod could increase the accuracy of the femoral component positioning in conventional TKA (modified conventional technique). Accelerometer-based, portable navigation device has been postulated to have better accuracy than conventional TKA in component positioning. The purpose of this study was to compare the post-operative femoral component alignment of TKA using the modified conventional technique with the accelerometer-based navigation. Materials and methods Fifty-five knees underwent TKA using the modified conventional technique and femoral component positioning was compared with 55 knees performed using the accelerometer-based navigation device. The femoral component alignment was evaluated with a CT-based three-dimensional software. Results The mean absolute deviation from targeted alignment in the sagittal plane was significantly less in the modified conventional cohort than in the accelerometer-based navigation cohort (1.1° vs 2.6°, P < 0.001). In the modified conventional cohort, 96.4% had an alignment within 3° of a targeted angle in the coronal plane (vs 89.1% with the accelerometer-based navigation, P = 0.14), and 96.4% in the sagittal plane (vs 74.5% with the accelerometer-based navigation, P < 0.001). Conclusion The modified conventional technique is a simple and equal to or more accurate method than the accelerometer-based navigation in positioning the femoral component in TKA at a mid-volume hospital.
  PubDate: 2019-04-01
Evaluating risk factors following surgery for periprosthetic fractures
around hip and knee arthroplasties
- Abstract: Background The increasing demand for arthroplasty has resulted in an inevitable rise in the number of periprosthetic fractures around implants. Survival factors looking into patient’s comorbidities and how they influence outcome are rare. This study aims to identify correlations between survival post-injury and pre-existing comorbidities. Methods A total of 144 patients underwent operative treatment for either a hip or a knee periprosthetic fracture from January 2008 to August 2017 at our Major Trauma Hospital. The mean age at injury was 80.9 years old (SD 9.9). Each patient had a case-based analysis to ascertain injury characteristics, operative parameters and comorbidities. Results The mean survival was 12.7 months (95% CI 8.4–17.1). Survival analysis showed a correlation between age more than 75 years old (p = 0.001), ASA grade of 3 or higher (p = 0.009 Breslow’s test), history of CVA or TIA (p = 0.038 Breslow’s test), dementia (p = 0.002 log rank test), depression (p = 0.013 log rank test) and gender (p = 0.041, Breslow’s test) and survival post-periprosthetic fracture. Survival within the first year following injury was found to be affected by the presence of osteoporosis (p = 0.020) and dementia (p = 0.002). Conclusion Periprosthetic fractures are associated with a high mortality risk (34.7%). Operative risks can be minimised with careful optimisation and surgical planning. ASA, age and comorbidities (dementia, CVA or TIA, osteoporosis) have a significant correlation with survival post-injury. Hence, careful patient selection for operative treatment is advised.
  PubDate: 2019-04-01
Radial head replacement versus reconstruction for the treatment of the
- Abstract: Introduction The terrible triad injury of the elbow (TTIE) remains challenging to manage and has been associated with high complication rates and poor outcomes. There is a trend towards performing radial head replacement (REP) in preference to radial head reconstruction (REC) as arthroplasty provides early stability and may allow mobilisation sooner, potentially resulting in a better functional outcome. This systematic review compares the outcome of patients with TTIE treated with either REC or REP. Materials and methods MEDLINE, Embase, and CINAHL were searched for studies published in English involving at least ten patients exclusively with a TTIE managed operatively, including both patients with either REC or REP. Data collection was in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis protocol. The outcomes of interest were Mayo Elbow Performance Score (MEPS) and range of motion (ROM). Post-operative complications were also compared. Results 9 studies involving 210 patients were included (98 REPs and 112 RECs). There was no statistically significant difference (p = 0.51) demonstrated between in the mean MEPS of the REP group (mean 88.6) and REC group (mean 88.5). Similarly, there was no statistically significant difference demonstrated between the REP and REC groups in terms of ROM. The risk of re-operation was high in both the REP (18.4%) and REC (17.9%) group. The overall complication rate of all patients included in the study was high (65%). Conclusions Comparable results with good outcomes in terms of functional scores and ROM can be achieved with both REP and REC when treating TTIE, although the re-operation rate for both remains relatively high. Given there is no apparent clear advantage between the two treatment groups, we would suggest that REC should be performed when a satisfactory fixation can be achieved as the longevity of REP in young patients with a TTIE is currently uncertain.
  PubDate: 2019-04-01
Pathoanatomy of Maisonneuve fracture based on radiologic and CT
examination
- Abstract: Introduction Although Maisonneuve fracture (MF) is a well-known type of ankle fracture–dislocation, there is still a lack of information about the epidemiology and the extent of all associated injuries. The aim of study is to describe MF pathoanatomy on the basis of radiographs, CT scans and intraoperative findings. Materials and methods The study comprised 54 adult patients. MF was defined as an ankle fracture–dislocation with a fracture of the fibula in its proximal quarter. Ankle radiographs and lower leg radiographs were obtained in all patients. Computed tomography (CT) examination was performed in 43 patients, of these in 34 patients in combination with 3D CT reconstructions. A total of 51 patients were treated operatively, and in 38 of these an open procedure was performed. Results The fibular fracture—fibular head was involved in four cases, and the subcapital region of the proximal quarter of the fibula was affected in 50 cases. Fractures of the posterior malleolus were identified in 43 of 54 patients (80%). Injury to the deltoid ligament was recorded in 27 cases (50%), a fracture of the medial malleolus in 20 cases (37%) and medial structures were intact in 7 cases (13%). Position fibula in fibular notch—in 9 cases the position changed only minimally, in 11 cases the space between the tibia and the fibula was larger than 2 mm, in 20 cases widening of the tibiofibular space was associated with external rotation of the fibula, in 2 cases fibula was trapped behind the posterior tibial tubercle and in 1 case it was associated with a complete tibiofibular diastasis. Conclusion MF is a variable injury, always associated with rupture of the anterior and interosseous tibiofibular ligaments. CT examination should be employed widely in MF, and MRI should be considered under special circumstances.
  PubDate: 2019-04-01
Development of the double level osteotomy in severe varus osteoarthritis
showed good outcome by preventing oblique joint line
- Abstract: Introduction The purpose of the study was to describe the development of the surgical technique of double level osteotomy in patients with severe varus malalignment and to investigate the clinical and radiological outcome. It was hypothesized that good clinical results without a higher complication rate can be achieved by double level osteotomy to normalize joint angles and avoid joint line obliquity even in cases of progressed osteoarthritis. Materials and methods Between 2011 and 2014, 33 patients (37 knees) undergoing double level osteotomies (open wedge HTO and closed wedge DFO) were included; of these, 24 patients (28 knees) were available in mean of 18 ± 10 months for the follow-up examination. Indication was symptomatic varus malalignment and medial compartment osteoarthritis. Postoperatively, these patients were assigned to 20 kg partial weight-bearing using two crutches for 6 weeks followed by full weight-bearing. No braces or casts were used. Full weight-bearing long leg anteroposterior radiographs were obtained preoperatively, after 6 weeks and at the time of final follow-up. Mechanical tibiofemoral angle (mTFA), mechanical lateral distal femoral angle (mLDFA) and medial proximal tibia angle (MPTA) were measured. Clinical outcome was evaluated using Lequesne-, Lysholm-, Oxford-, and IKDC-score at the time of follow-up. Results The preoperative mTFA of − 11 ± 3° increased to 0 ± 2° at final follow-up. The difference between mTFA-planning and final follow-up was − 2 ± 3° (p < 0.0006). At final follow-up, MPTA and mLDFA were 89.2 ± 2° and 87 ± 2°, respectively. The Lysholm, Oxford, Lequesne, and IKDC scores were 88 ± 13, 44 ± 3, 2 ± 2, and 77 ± 12, respectively. Conclusions This study showed that double level osteotomy for the patients with severe varus malalignment and medial compartment osteoarthritis normalises the alignment, joint-angles, avoids joint line obliquity, and leads to good clinical results, despite progressive osteoarthritis. Level of evidence Case series, Level IV.
  PubDate: 2019-04-01
Biomechanical comparison of the proximal interphalangeal joint arthrodesis
using a compression wire
- Abstract: Introduction/aim Arthrodesis of the proximal interphalangeal joint of the finger is a common procedure for the treatment of osteoarthritis. The aim of this biomechanical study was to compare the primary stability of one, respectively, two compression wires to intraosseous wiring and tension band wiring for the arthrodesis. Materials and methods The stability of the arthrodesis was tested by applying flexion (n = 11) and extension (n = 10) force with 10° bending. Arthrodesis was achieved by one, respectively, two crossed compression wires and intraosseous wiring. In a control group (n = 11) tension band wiring was tested to 10° flexion and extension as well. Results Mean values for flexion bending for intraosseous wiring were 10.94 N, for one compression wire 12.82 N, for tension band wiring 17.95 N, and for two crossed compression wires 20.42 N. Mean values for extension bending were 9.71 N for intraosseous wiring, 13.63 N for one compression wire, 21.43 N for tension band wiring and 22.56 N for two crossed compression wires. Conclusion The primary stability of the compression wires was statistically significant superior to intraosseous wiring. In comparison to tension band wiring which showed an intermediate stability. The application of a compression wire could be considered for further clinical testing in the arthrodesis of interphalangeal joints.
  PubDate: 2019-04-01
Minimally invasive internal fixator for unstable pelvic ring injuries with
a pedicle screw–rod system: a retrospective study of 23 patients after
13.5 months
- Abstract: Purpose Pelvic ring fractures are challenging injuries and require effective treatment due to the frequently compromised patient condition. The aim of this study was to evaluate the outcome of unstable pelvic ring injuries treated with a minimally invasive pedicle screw–rod system. Methods Retrospective analysis was performed for patients with an unstable pelvic ring injury that were treated with a minimally invasive anterior internal pelvic fixator (INFIX) with or without a posterior pedicle screw–rod fixator (6/2012–4/2015). The quality of reduction was evaluated by the Tornetta and Matta criteria and the clinical outcome was evaluated by the Majeed scores. Further evaluation included the operation time, intraoperative blood loss, and complication rate. Results A total of 23 patients (12 males and 11 females) with a mean age of 37.6 years (range 10–65 years) and a follow-up of 13.5 months (6–27 months) were evaluated. The Tile classification showed 13 type B (B1 = 6, B2 = 4, and B3 = 3) and 10 type C (C1 = 7 and C2 = 3) fractures. Mean operation time and intraoperative blood loss were 24.8 min (20–30 min) and 20.4 ml (16–29 ml) for an anterior INFIX (n = 13), and 60 min (45–70 min) and 150 ml (115–168 ml) when combined with a posterior pedicle screw–rod fixator (n = 10). Quality of reduction was excellent in 13, good in 6, and fair in 4 patients, with no signs of heterotopic ossification. Clinical results after 6 months were excellent in 14 patients, good in 6, fair in 2, and poor in 1. Unilateral thigh paresthesia was seen in 2 patients which resolved after implant removal. Conclusions The INFIX appears to be a safe and minimally invasive surgical technique which can effectively be combined with posterior pedicle screw–rod fixation. It also can be applied for the definitive treatment of vertically and/or rotationally unstable pelvic ring injuries, especially in severely compromised patients with a high mortality risk.
  PubDate: 2019-04-01
Four questions to identify patients with ASA III or higher
- Abstract: Background Increased age, obesity, and American Society of Anesthesiologists (ASA) Physical Status class III and IV have been reported as predictors for mortality and perioperative complications. High-volume institutions rely on central referral services as first contact point for patients. The current study reports on a simple four-step questionnaire to identify patients with ASA-physical status class III and IV to improve referral processes and optimize perioperative work ups. Materials and methods Seven hundred and seventy-five patients who called the physician referral service (PRS) at the author’s institution and subsequently underwent surgery were enrolled in this study. The answers to the initial PRS questionnaire were analyzed. The study cohort consisted of 414 women (53.4%) and 361 men (46.6%) with an average age of 61.4 years (range 44–90 years) at the time of surgery. Results Binary logistic regression revealed hypertension, diabetes mellitus (using medication), using blood thinner (other than Aspirin) and a number of 4–9 prescribed medication, respectively, as predictors for ASA III and IV. Receiver-operating characteristic (ROC) curve analysis identified a sensitivity of 82.4%, a specificity of 82.9%, and an accuracy of 82.8%, when two of these four questions are answered “yes”. The area under the curve for this analysis was 0.876 [95% confidence interval (CI) 0.845–0.908]. Positive and negative likelihood ratios were 4.8 (95% CI 4.0–5.8) and 0.2 (95% CI 0.1–0.3), respectively. Conclusions This study revealed a simple four-step questionnaire to identify patients with ASA III or IV before a medical appointment. This helps to balance referrals between multiple providers in high-volume medical groups.
  PubDate: 2019-04-01
Augmentation of plate osteosynthesis for proximal humeral fractures: a
systematic review of current biomechanical and clinical studies
- Abstract: Introduction Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies. Materials and methods The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively. Results Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II–IV and study quality was 26–70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients’ clinical outcome. None of the studies showed relevant augmentation-associated complication rates. Conclusions Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs’ stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.
  PubDate: 2019-03-22
Multiple intravenous tranexamic acid doses in total knee arthroplasty
without tourniquet: a randomized controlled study
- Abstract: Background Tranexamic acid (TXA) is widely used in the orthopedic field and particularly in total knee arthroplasty (TKA). Its efficacy and safety in reducing the blood loss in TKA have been well-documented in the current literature. Little data regarding TKA without tourniquet and TXA exist. Our aim is to compare three different dosages of intravenous (IV) TXA in TKA without tourniquet. Materials and methods A total of 180 patients undergoing TKA for knee osteoarthritis were stratified in three equal groups. All surgeries were performed under spinal anesthesia, without tourniquet. Group A (60 patients) received 15 mg/kg of IV TXA given on induction, Group B (60 patients) received an additional dose of IV TXA (15 mg/kg) 3 h after incision and Group C (60 patients) received an additional (third) dose 3 h later (15 mg/kg). The measured outcomes were the change in hemoglobin (Hb) from pre-operatively to post-operatively, the amount of blood transfusion given (units), the functional and quality of life (QoL) and pain assessment based on their corresponding scoring system. Results Calculated blood loss, Hb decrease and transfusion rate were significantly lower in Group C (p value < 0.05). Additionally, patients that had been included in the three-dosage group benefited much more in terms of faster rehabilitation, better QoL, decreased post-operative pain, with no increase in complications. Conclusion According to our results, three doses of IV TXA have effectively and safely reduced blood loss and the need of allogeneic blood transfusion in patients undergoing TKA without tourniquet, with additional patients-related benefits. Level of evidence II.
  PubDate: 2019-03-22