Direct Anterior Approach in Total Hip Arthroplasty: A Single Center Experience

Purpose

The direct anterior approach (DAA) for conducting total hip arthroplasty (THA) is gaining popularity worldwide. However, careful selection of patients and surgeon experience are important. Although promising outcomes have been reported in international studies, research on DAA in Southern and Southeast Asia has been limited.

Materials and Methods

This prospective study included 157 patients who underwent THA using the DAA between January 2019 and June 2022. The patients were divided into three groups for the comparison. Data on preoperative, intraoperative, and postoperative variables were acquired. Improvement of the surgeon's performance to use of a DAA approach was examined using the CUSUM (cumulative summation method).

Results

The mean age of the patients was 43.9 years. Differences in intraoperative variables and complications were observed among the three groups, and improved outcomes were reported in later cases. Functional outcomes showed significant improvement, and no differences were observed between groups. The results of learning curve analysis indicated a shift towards consistent success after the 82nd case, reaching an acceptable rate of failure by the 118th case.

Conclusion

The findings of this study suggest that DAA can offer benefits but there is a learning curve. Complications were initially high but began decreasing after approximately 80 cases. Careful selection of patients is critical, particularly in the effort to minimize being presented with a challenging case. This study provides insights that may be helpful to surgeons when considering DAA; however, further study is warranted.

N-Alkylation of amines with primary/secondary alcohols using a novel cobalt(II) inverse triazolyl-pyridine complex

Herein, we report a highly effective homogeneous methodology for the N-alkylation of amines with primary and secondary alcohols using a Co(II)-complex of an inverse triazolyl-pyridine ligand. The developed methodology tolerates various functional groups to produce the desired N-alkylated products in up to 98% yield. A number of control experiments establish that the developed methodology follows a hydrogen auto-transfer (HAT) pathway.

K2S2O8 promoted metal-free direct C-alkylation of acetophenones with alcohols

Herein, we report a metal-free synthetic methodology for the C-alkylation of acetophenones following a hydrogen borrowing-like pathway using the commercially available inorganic oxidant K2S2O8 in conjunction with KOtBu. This study articulates the potential of K2S2O8 in fast initiation of the oxidation of benzyl alcohols to develop an atom-economical, easy, and more efficient methodology for the C-alkylation of various acetophenones and synthesis of a variety of substituted quinolines. Experimental data from control experiments, literature and characterization of intermediates through spectroscopic techniques support the proposed plausible mechanism.

Philadelphia chromosome- positive myelodysplastic syndrome with single lineage dysplasia

Myelodysplastic syndrome (MDS) is a group of acquired clonal disorders characterized by dysplastic and ineffective hematopoiesis in the bone marrow. Various specific karyotypic and molecular abnormalities associated with MDS further guide the prognosis. Although translocation t(9;22)(q34;q11) (Philadelphia positive [Ph+]) and corresponding BCR-ABL fusion transcript are classically defined to differentiate CML from non-CML myeloproliferative disorders, it is also associated with adult acute lymphoblastic leukemia (Ph+ ALL), acute myeloid Leukemia (Ph+ AML), myelodysplastic syndrome (Ph+ MDS). The occurrence of Ph+ MDS is very uncommon, and a review of literature has shown by far 40 cases so far in which the majority are seen on progression to Leukemia. Few had de novo presence of such chromosomal abnormality. Due to its rarity, this entity has not yet found its space in the current WHO classification. Also, the role of tyrosine kinase inhibitors in such a scenario is still debatable. We found two such cases of de novo Ph+ MDS diagnosed at institute of medical sciences, Banaras Hindu university and a brief literature review.

Alternating Layers of Morselized Allograft and Injectable Ceramic Bone Graft Substitute in Acetabular Reconstruction: A Novel 'Sandwich' Technique

Background

Impaction of morselized allograft is an appealing procedure for addressing the bone defects. However, concerns remain about its suitability for massive defects. We used a novel "sandwich" technique by impacting the morselized allograft in layers with an intervening layer of injectable bone graft substitute for restoring bone defects during acetabular reconstruction in total hip arthroplasties.

Methods

From August 2015 to June 2017, 17 revisions, 4 rerevisions, and 3 complex primary total hip arthroplasties were operated by this novel technique. Postoperatively, serial X-rays were evaluated at regular intervals. Clinical and functional outcomes were assessed by the Harris hip score. To examine if introducing an injectable bone substitute into allograft stock increased its load-bearing capability, simulated mechanical testing using Synbone samples was conducted in the laboratory.

Results

The mean Harris hip score significantly improved from 54.6 preoperatively to 86.8 at the latest follow-up. Graft incorporation was seen in all the cases. There was no evidence of component migration or loosening as compared to the X-rays at 3 weeks and 3 months in all the cases. With revision of component as end point, the survivorship was 100% at 82 months. The mechanical testing reported a higher capability of allograft samples when compared to those without bone substitutes.

Conclusions

Our data confirms that the use of the "sandwich" technique is a reliable option for major acetabular reconstruction. Early weight bearing is a significant value addition, and short-term results confirm good clinical and functional outcome. Longer follow-up is necessary to assess the status of the construct in the long term.

Unusual Coordination of a bis(1,2,3-Triazolyl-Pyridine) Ligand in a Pd(II) Complex: Application in Suzuki-Miyaura Coupling Reaction

A modified “click” reaction between 2-azidopyridine and di(prop-2-yn-1-yl) phthalate [dpp] (2) produces a novel bis(1,2,3-triazolyl-pyridine) ligand on an ortho-phthalic acid platform [bptmp] (3). The [bptmp] ligand is prepared to produce...

Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation

Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.

99mTc-Ethambutol Scan with SPECT/CT in Knee Joint Tuberculosis

Modalities for in vivo imaging of Mycobacterium tuberculosis are limited and inadequately studied. One such modality is 99mTc-ethambutol scintigraphy which has shown promising results for diagnosis of tuberculosis (TB). Ethambutol, one of the primary antitubercular drugs, is bacteriostatic which acts on the mycolic acid cell wall synthesis of the M. tuberculosis. However, literature on its utility is scarce. The few studies that exist have reported its sensitivity and specificity between 90%- 95% and 71%-85%. We present here a case demonstrating the role of 99mTc-ethambutol scan in knee joint TB.

Uneven global and racial representation in major orthopaedic clinical trials: Trends over a decade

BACKGROUND

The presence of geographic and demographic disparities in randomized controlled trials (RCTs) may affect the external validity of trials. While some studies have addressed racial or ethnic disparities, they have been limited to a certain region, and there is limited information about the global representation in orthopaedic research.

METHODS

RCTs published in major medical and orthopaedic journals from 2010 to 2019 were identified. After screening 6961 articles, 1769 trials enrolling 323,506 patients were included. The details of individual trials such as the country of origin, the proportion of women, and the proportion of different racial groups were recorded. Factors associated with reporting and representation of specific demographic groups, and annual changes were assessed.

RESULTS

Majority of the trials were from were from United States (US) (N = 380, 21.5%). US (30.7%, N = 99,356), United Kingdom (15.7%, N = 50,691) and Canada (8.3%, N = 26,890) accounted for majority of the enrolled patients. 59.1% of the patients were women. Among US trials reporting race, 81.2% were White, and 9.9% were African American. There was no significant variation in the global distribution (p = 0.056), percentage of women (p = 0.811), or percentage of Whites (p = 0.389) over the years.

CONCLUSION

The top three countries contributed to about 55% of the enrolled patients, whereas they contributed to only 6% of the world population. Overall, women appeared to be adequately represented in the trials, while racial minorities were underrepresented. There has not been any considerable improvement in the representation of developing regions or minorities over the last decade.

Acinetobacter baumannii: An overview of emerging multidrug-resistant pathogen

The emergence of infections caused by Acinetobacter baumannii, a multidrug-resistant bacterium, has been a concern worldwide. This bacterium is an important hospitalacquired pathogen that causes several diseases including ventilator-associated pneumonia, bloodstream infections, and meningitis. This study aimed to determine antibioticresistant mechanisms in the pathogenesis of A. baumannii and the alternative treatment strategies against it. The combined actions of outer membrane protein A, formation of a biofilm on biotic and abiotic surfaces, phospholipases C and D, metal homeostatic system, lipopolysaccharides, and verotoxins are relevant for virulence and pathogenesis. A. baumannii resists the broad-spectrum antibiotics by its mechanisms of resistance, such as β-lactamases, efflux pump, aminoglycoside modifying enzymes, permeability changes, and alternation of targets. In an attempt to overcome the resistance mechanisms, plant-derived compounds and a combination of the antibiotics and the plant phytocompounds have been focused. Nanoparticles synthesised with the plant extract have been studied extensively. Furthermore, we projected modern methods, including multi-omics analysis, to study insight into mechanisms of actions of antibiotics. The information suggested that the potential antibiotic mechanisms of A. baumannii could lead to an alternative treatment against A. baumannii infections.

Clinical outcome in total hip arthroplasty for septic sequelae in childhood

Aims

Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

Methods

A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented.

Results

There was significant improvement in HHS, Modified Merle d’Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years.

Conclusion

We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314–320.

Functionalized Imidazolium Salt: An Efficient Catalyst for Buchwald-Hartwig type C–N Cross-Coupling of (Hetero)aryl Chlorides/Bromides with Amines Under Solvent-, Inert gas-, and Base-free Ambience

The intermingle of novel imidazolium salt (HL1 -Br) and Cu(OAc)2 marked down as a highly efficient catalytic system for Buchwald-Hartwig type C-N Coupling of a variety of amines with (hetero)...

A New Type of Periprosthetic Fracture: Is It the Time to Update the Unified Classification System?

INTRODUCTION

Increased number of primary and revision arthroplasties performed globally has led to a surge in the numbers of periprosthetic fractures. The Unified Classification System (UCS) advocated a rational approach towards the classification of periprosthetic fractures. We present here an update to the UCS with addition of new fracture pattern encountered in orthopedic practice.

METHODS

A retrospective study was conducted to review the service arthroplasty register for the cases with unique fracture pattern where the periprosthetic fracture around total hip arthroplasty was also associated with fracture of the prosthetic component. The details were retrieved from the medical record and the patients were called for a review. The radiological assessment was done with X-rays and clinical assessment with Harris Hip Scores at the latest follow-up.

RESULTS

Between 2012 and 2019, 11 patients (7 males and 4 females) were operated for peri-prosthetic fracture with a unique pattern where the fracture of femur was associated with fracture of the femoral stem as well. The mean age of the patient at the time of fracture was 56.8 years (range 42-71 years). All patients were managed with revision hip surgery. One patient died due to malignancy after 7 years of revision surgery. All the surviving patients are doing well with a mean Harris Hip Score of 86.8 at the latest follow-up of 2-9 years (mean 5.0 years).

CONCLUSION

With emergence of this new fracture pattern, it is recognition as a separate entity would help in better understanding and augmentation of the existing classification system of periprosthetic fractures.

An algorithmic approach to total hip arthroplasty in patient with post-polio paralysis and fixed pelvic obliquity

Aims

Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening.

Methods

In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment.

Results

The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6^o (SD 7.9^o) to 1.8^o (SD 2.4^o; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months.

Conclusion

Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity.

Cite this article: Bone Jt Open 2021;2(9):696–704.

Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies

PURPOSE OF REVIEW

Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality.

RECENT FINDINGS

The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence.

LEVEL OF EVIDENCE (CEBM)

2a.

Estimation of Expenditure and Challenges Related to Rehabilitation After Knee Arthroplasty: A Hospital-Based Cross-Sectional Study

BACKGROUND

Expenditure for rehabilitation following knee arthroplasty for osteoarthritis- and rehabilitation-related challenges following discharge to home after surgery is not available in the Indian context.

OBJECTIVES

To estimate cost of rehabilitation and document challenges in following rehabilitation advices, from a patient perspective.

METHODS

We conducted a hospital-based cross-sectional study of patients visiting the orthopedic department at a tertiary care public-funded hospital in New Delhi and included those who recently (less than 4 months) underwent primary knee arthroplasty for osteoarthritis. A trained physiotherapist not involved in clinical care collected information on expenditures incurred after discharge from hospital, patient's ability to recall the advices given by the physician and challenges they experienced using a semi-structured questionnaire. We report median costs by category of direct and indirect cost and used linear regression to explore determinants of cost.

RESULTS

We interviewed 82 consecutive patients (mean age 60.8 years and 68% females) with median time since surgery of 28 days. More than half (52%) sought some support for physiotherapy. The median cost of rehabilitation was INR 18,395 (Interquartile-range 11,325-27,775). Direct medical cost contributed to 74% of total cost (32% fee for services, 21% medications and lab investigations, 21% assistive devices). Twenty percent higher costs were incurred among those undergoing bilateral knee surgery after adjusting for age, sex, income, and type of physiotherapy support sought. Challenges were related to recall of advices, not understanding the recovery process and pain management.

CONCLUSION

About half patients undergoing knee arthroplasty seek support for rehabilitation after discharge to home contributing to a major portion of expenses incurred during rehabilitation. Cost-effective support mechanism for home-based rehabilitation is required for improving patient rehabilitation experiences.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00405-6.

Total hip arthroplasty in tubercular arthritis of the hip - Surgical challenges and choice of implants

Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic consequences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various applications in different presenting scenarios with a guide to surgical tips and tricks for managing this challenging condition.

Electrodeposited Thin-Film Micro-Thermoelectric Coolers with Extreme Heat Flux Handling and Microsecond Time Response

Thin-film thermoelectric coolers are emerging as a viable option for the on-chip temperature management of electronic and photonic integrated circuits. In this work, we demonstrate the record heat flux handling capability of electrodeposited Bi₂Te₃ films of 720(±60) W cm^-2 at room temperature, achieved by careful control of the contact interfaces to reduce contact resistance. The characteristic parameters of a single leg thin-film devices were measured in situ, giving a Seebeck coefficient of S = -121(±6) μV K^-1, thermal conductivity of κ = 0.85(±0.08) W m^-1 K^-1, electrical conductivity of σ = 5.2(±0.32) × 10⁴ S m^-1, and electrical contact resistivity of ∼10^-11 Ω m². These thermoelectric parameters lead to a material ZT = 0.26(±0.04), which, for our device structure, allowed a net cooling of ΔT_max = 4.4(±0.12) K. A response time of τ = 20 μs was measured experimentally. This work shows that with the correct treatment of contact interfaces, electrodeposited thin-film thermoelectrics can compete with more complicated and expensive technologies such as metal organic chemical vapor deposition (MOCVD) multilayers.

Knowledge, attitude, and practices of health-care providers toward antibiotic prescribing, antibiotic resistance, and multidrug-resistant tuberculosis

Introduction:

Antibiotic resistance (ABR) is a growing public health problem and is a subject of international concern. It poses a serious threat to health and health-care systems in both developed and developing countries. The problem is more confounding with tuberculosis (TB), and drug resistance in TB has threatened the progress made in TB care and control worldwide. The aim of this study was to understand the knowledge, attitude, and practices of health-care providers (HCPs) toward antibiotics, antibiotic prescribing, ABR, and multidrug-resistant TB (MDR-TB).

Materials and Methods:

A total of 125 participants were included in this cross-sectional, questionnaire-based survey conducted in tertiary care teaching hospitals of the Delhi-NCR region. A five-point Likert scale, whose responses ranged from “strongly agree” to “do not know,” was used to record the responses from participants.

Results:

Among the 125 HCPs who participated in the survey, the response rate was 100%. Around 94.4% of the respondents agreed that ABR is an important and a serious public health issue. More than 80% of the respondents strongly agreed that over-the-counter sale and/or dispensing antibiotics without prescription should be controlled. About 86.4% of the participants agreed that MDR-TB is a growing problem and 59.2% strongly agreed that indiscriminate use of anti-TB drugs could be a major causative factor. Almost 85.6% of the participants agreed that a proper diagnosis should be ensured before treating the TB cases.

Conclusions:

HCPs had a good knowledge of antibiotics and the association of its misuse or overuse with increasing ABR. Educational and persuasive measures are certainly needed, but the use of restrictive and organizational measures appears mandatory if the misuse of antibiotics is to be decreased in the near future. A stringent assessment of the impact of implemented measures seems essential to better guide antibiotic stewardship in our country.