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Crebert MJ, Kasunic D, Karunaratne SR, Alexander KG, Scholtz AC, Boyle RA, Steffens D. Patient-Reported Outcomes and Range of Motion Following Knee Arthroplasty Using a Megaprosthesis in Non-Oncological Patients: A Systematic Review. J Arthroplasty 2024; 39:2633-2644.e4. [PMID: 38754706 DOI: 10.1016/j.arth.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND This review aimed to determine outcomes following megaprostheses in non-oncological indications for knee arthroplasty, including range of motion (ROM) and patient-reported outcome measures of function, pain, and quality of life (QoL). METHODS A search of MEDLINE, Embase, and Cochrane via Ovid and PubMed between January 2003 and June 2023 was conducted. Studies reporting function, pain, ROM, and/or QoL in non-oncological patients who have received knee megaprostheses were included. Studies with sample sizes (n ≤ 5) were excluded. The risk of bias was assessed using the Downs and Black Quality Checklist for Health Care Intervention Studies. Central tendency measures (mean or median) were reported at each time point, and dispersion measures were extracted and reported whenever data were available. RESULTS A total of 30 studies (involving 1,294 megaprostheses) were included. Of which, 14 of 30 studies reviewed patients who had mixed indications; 14 of 30 looked at fracture only; 1 of 30 focused on distal femur nonunion; and 1 of 30 focused on patients who had periprosthetic infections. The average patient follow-up time was 40.1 months (range, 1.0 to 93.5). Most studies presented a high risk of bias (27 of 30), while a few (3 of 30) presented a low risk of bias. Improvements from preoperative baseline were observed in 85.7% of studies that reported baseline and follow-up data for function (12 of 14), 100.0% pain (4 of 4), 90.9% ROM (10 of 11), and 66.6% QoL (2 of 3). CONCLUSIONS Favorable function, pain, ROM, and QoL outcomes following knee megaprostheses in non-oncological patients were observed. Heterogeneity in outcome measures and follow-up periods prevented the pooling of data. Future comparative studies are warranted to enhance the body of evidence relating to knee megaprostheses in non-oncological patients.
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Affiliation(s)
- Mitchell J Crebert
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Daniel Kasunic
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Sascha R Karunaratne
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Kate G Alexander
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Amelia C Scholtz
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Richard A Boyle
- Orthopaedic Surgery Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital and Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
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Cianni L, Taccari F, Bocchi MB, Micheli G, Sangiorgi F, Ziranu A, Fantoni M, Maccauro G, Vitiello R. Characteristics and Epidemiology of Megaprostheses Infections: A Systematic Review. Healthcare (Basel) 2024; 12:1283. [PMID: 38998818 PMCID: PMC11241048 DOI: 10.3390/healthcare12131283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/18/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Megaprostheses were first employed in oncological orthopedic surgery, but more recently, additional applications have arisen. These implants are not without any risks and device failure is quite frequent. The most feared complication is undoubtedly the implants' infection; however, the exact incidence is still unknown. This systematic review aims to estimate in the current literature the overall incidence of megaprosthesis infections and to investigate possible risk/protective factors. METHODS We conducted a systematic search for studies published from July 1971 to December 2023 using specific keywords. To be included, studies needed to report either the megaprosthesis anatomical site, and/or whether the megaprosthesis was coated, and/or the surgical indication as oncological or non-oncological reasons. RESULTS The initial literature search resulted in 1281 studies. We evaluated 10,456 patients and the overall infection rate was 12%. In cancer patients, the infection rate was 22%, while in non-oncological patients, this was 16% (trauma 12%, mechanical failure 17%, prosthetic joint infections 26%). The overall infection rates comparing coated and uncoated implants were 10% and 12.5%, respectively. CONCLUSIONS The number of megaprosthesis implants is increasing considerably. In traumatological patients, the infection rate is lower compared to all the other subgroups, while the infection rate remains higher in the cancer patient group. As these devices become more common, focused studies exploring epidemiological data, clinical outcomes, and long-term complications are needed to address the uncertainties in prevention and management.
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Affiliation(s)
- Luigi Cianni
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Taccari
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Beatrice Bocchi
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulia Micheli
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Flavio Sangiorgi
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonio Ziranu
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Ospedale Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Unità Operativa Complessa di Malattie infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giulio Maccauro
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Dipartimento di Scienze dell'invecchiamento, Ortopediche e Reumatologiche, Unità Operativa Complessa di Ortopedia e Traumatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Dipartimento di Sicurezza e Bioetica-Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Caredda M, Cianni L, De Fazio A, Ziranu A, Vitiello R, Maccauro G. Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series. J Orthop Surg Res 2024; 19:53. [PMID: 38212796 PMCID: PMC10782750 DOI: 10.1186/s13018-023-04465-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock. METHODS A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields. RESULTS Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures. CONCLUSIONS The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.
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Affiliation(s)
- Matteo Caredda
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Luigi Cianni
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy.
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy.
| | - Andrea De Fazio
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Antonio Ziranu
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Raffaele Vitiello
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
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Poelmann J, Kloen P. Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:425-433. [PMID: 35061100 PMCID: PMC9930358 DOI: 10.1007/s00590-022-03203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion. METHODS Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome. RESULTS In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty. CONCLUSION This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.
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Affiliation(s)
- Josje Poelmann
- Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ, The Netherlands.
| | - Peter Kloen
- grid.509540.d0000 0004 6880 3010Department of Orthopedic Surgery, Amsterdam University Medical Center, Meiberdreef 9, Amsterdam, 1105AZ The Netherlands
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Ayati Firoozabadi M, Rezaee H, Ziaee O, Bagheri N, Mortazavi SMJ. Treatment of Simultaneous Femoral Supracondylar Nonunion and Tibial Plateau Malunion along with Stiff Knee in a Young Patient: A Case Report. THE ARCHIVES OF BONE AND JOINT SURGERY 2023; 11:783-786. [PMID: 38146522 PMCID: PMC10748815 DOI: 10.22038/abjs.2023.74326.3440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/27/2023] [Indexed: 12/27/2023]
Abstract
A 41-year-old man underwent Total Knee Arthroplasty with NexGen Legacy Constrained Condylar Knee (LCCK) system to treat his nonunion of distal femur, stiff knee, and malunion of tibia plateau. The treatment involved femoral and tibial stems and PS polyethylene. As a result, his knee range of motion improved, and he no longer experienced pain. After two years, he resumed work without any signs of loosening or stiffness.
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Affiliation(s)
| | - Hesan Rezaee
- Joint reconstruction research center, Tehran University of medical science, Tehran, Iran
| | - Omid Ziaee
- Joint reconstruction research center, Tehran University of medical science, Tehran, Iran
| | - Nima Bagheri
- Joint reconstruction research center, Tehran University of medical science, Tehran, Iran
| | - SM Javad Mortazavi
- Joint reconstruction research center, Tehran University of medical science, Tehran, Iran
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Corap Y, Brix M, Emmeluth C, Lindberg-Larsen M. Patient safety in distal femoral resection knee arthroplasty for non-tumor indications: a single-center consecutive cohort study of 45 patients. BMC Musculoskelet Disord 2022; 23:199. [PMID: 35241040 PMCID: PMC8892708 DOI: 10.1186/s12891-022-05100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Distal femoral resection knee arthroplasty may be a viable option for several indications other than bone tumors. Resection knee arthroplasty appears to be becoming more common, but patients requiring this type of surgery are often elderly and with high comorbidity. The aim of this study was to report in-hospital complications, readmissions, reoperations, and mortality after distal femoral resection knee arthroplasty for non-tumor indications. METHODS We retrospectively identified a consecutive cohort of 45 knees (45 patients) treated with distal femoral resection knee arthroplasty in a single institution between 2012 and 2021. Indications for surgery were failure of osteosynthesis (8), primary fracture treatment (2), periprosthetic fracture (22), and revision arthroplasty with severe bone loss (13). A major reoperation was defined as a major component exchange procedure or amputation. Mean follow-up was 3.9 years. RESULTS The mean age was 71.3 years (SD 12.3), and 64.4% were female; 8.9% were ASA I, 40% ASA II, and 51% ASA III. Median length of stay was 7 days (range 3-19) with no major in-hospital complications, but 55.6% (n = 25) required blood transfusion. The 90-day readmission rate was 17.8% (n = 8), of which 50% was prosthesis-related. Four patients (8.9%) underwent major reoperation due to infection (n = 2), mechanical failure (n = 1), or periprosthetic fracture (n = 1). The mortality rate was 0% ≤ 90 days and 2.2% ≤1 year. CONCLUSIONS Distal femoral resection knee arthroplasty in this fragile patient population appears to be a viable and safe option considering that it is a limp salvage procedure most cases.
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Affiliation(s)
- Yasemin Corap
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Michael Brix
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Emmeluth
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Martin Lindberg-Larsen
- Orthopaedic research unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Vitiello R, Ziranu A, Oliva MS, Meluzio MC, Cauteruccio M, Maccauro G, Liuzza F, Saccomanno MF. The value of megaprostheses in non-oncological fractures in elderly patients: A short-term results. Injury 2022; 53:1241-1246. [PMID: 34602244 DOI: 10.1016/j.injury.2021.09.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The management of both hip and distal femur fractures as well as periprosthetic fractures can be challenging for orthopaedic surgeons. The use of megaprosthetic implants could provide substantial advantages in elderly population affected by complex fractures. The aim of the study was to evaluate the effectiveness of megaprosthetic implants for treating hip and distal femur fractures as well as periprosthetic fractures in elderly. MATERIAL AND METHODS From January 1st 2015 to December 31st 2019, patients treated for proximal or distal femoral fractures with severe bone loss or failure of previous surgery were retrospectively reviewed. Patients were divided into two group based on diagnosis: proximal femur fractures (group A) and distal femur fractures (group B). Subsequently, patients underwent hip (group A) or knee (group B) megaprosthesis. Self-assessed questionnaires were administered to all patients pre and postoperatively. Primary outcome was the Activity Daily Living. Secondary outcomes were: Instrumental Activity Daily Living, Short Form-12, Oxford knee or hip score, complications. Charlson score, Harris classification for hip or Anderson Orthopaedic Research Institute score and complication were recorded. All patients underwent a radiological follow up to rule out implant loosening and mobilization. Pre and postoperative functional score comparisons in each group were undertaken. Significance was set p ≤ 0.05. RESULTS Twelve patients were finally included in the study. There were 6 male and 6 females, the mean age was 72,9 years old (± 7,4); the mean BMI was 29,8 points (± 4.5). The mean follow-up was 2.9 years (± 1.4). No differences could be found between pre and postoperative evaluation in each group. No aseptic loosening, dislocation, mobilization or radiolucency were recorded during the follow-up. In group A, two surgical site infections (2/6 patients) and one pneumonia (1/6 patients) were recorded. In group B, two surgical site infections occurred (2/6 patients). All patients were treated by antimicrobial oral therapy with complete regression. CONCLUSION The use of hip and knee megaprosthetic implants in traumatology is a safe and viable option in elderly patients.
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Affiliation(s)
- Raffaele Vitiello
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Antonio Ziranu
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Maria Serena Oliva
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia.
| | - Maria Concetta Meluzio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Michele Cauteruccio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Giulio Maccauro
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Francesco Liuzza
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
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Brodke DJ, Devana SK, Upfill-Brown A, Lee C. Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures. Injury 2022; 53:661-668. [PMID: 34887075 PMCID: PMC10400013 DOI: 10.1016/j.injury.2021.11.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations. METHODS A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon. RESULTS From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model. CONCLUSION Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.
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Affiliation(s)
- Dane J Brodke
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Sai K Devana
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095, USA.
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Rajasekaran RB, Siddiqi MA, Whitwell D. Jig-assisted modified Harrington reconstruction for metastatic bone destruction of the acetabulum. INTERNATIONAL ORTHOPAEDICS 2022; 46:433-441. [PMID: 34993556 DOI: 10.1007/s00264-022-05304-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/02/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION We developed a technique using an indigenously designed jig to assist pin placement in producing a stable and long-lasting construct to augment the acetabulum combined with a cemented hip replacement in cases of metastatic destruction of the acetabulum. We describe our novel modified Harrington technique and retrospectively assess our cohort's clinical outcomes and complications. METHODS Between 2006 and 2019, 27 patients with a median age of 69 (49-81) years and a median ASA grade of III (II-IV) were managed using our modified 'Harrington' technique. We assessed outcomes on the following criteria: mechanical complications, post-surgery mobility, and functional outcome using Musculoskeletal Tumour Society Score (MSTS). RESULTS At the last follow-up, ten patients were alive with disease [median follow-up of 26 months (12-74)], and 17 patients died of their oncological disease [median follow-up of 15 months (9-22)]. There were no perioperative deaths or intra-operative complications in our series. In total, ten complications were noted in nine patients (33%). Mobility-wise, 13 patients (48%) mobilised unaided, ten patients (37%) required a stick or crutch, two patients (7%) required a frame and two patients (7%) were wheel chair-dependent. The median MSTS score of all patients during their latest follow-up was 18 (8-26). CONCLUSION Our jig-aided modified Harrington reconstruction technique assists in safe placement of antegrade pins in acetabulum during surgery and offers a long-lasting solution to these high-risk patients. The use of large diameter pins, appropriate patient selection, and cage used during construction in the acetabulum demonstrated relief of pain, improved mobility, and favorable functional outcomes with minimal complication rates.
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Affiliation(s)
- Raja Bhaskara Rajasekaran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Muhammad Ather Siddiqi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Duncan Whitwell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
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Thippeswamy PB, Nedunchelian M, Rajasekaran RB, Riley D, Khatkar H, Rajasekaran S. Updates in postoperative imaging modalities following musculoskeletal surgery. J Clin Orthop Trauma 2021; 22:101616. [PMID: 34660193 PMCID: PMC8502706 DOI: 10.1016/j.jcot.2021.101616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 11/18/2022] Open
Abstract
Postoperative imaging following orthopaedic surgeries is essential in assessing complications post-surgery and also helps plan further treatment. Combining a high degree of clinical insight with appropriate imaging can guide the treating clinician to the correct diagnosis. Imaging is quite challenging because of surgery-related soft tissue changes, especially in the early postoperative period and the presence of metal implants resulting in image scatter and metal artifacts. Newer modalities and advances in imaging have helped overcome shortcomings and assess better, especially in procedures that involve implants. Collaborative decision-making involving radiologists and clinicians has shown to be beneficial and is the way forward. This narrative review discusses the utility of imaging in evaluating postoperative complications following musculoskeletal surgeries with specific relation to trauma, arthroplasty, and tumour by discussing commonly encountered clinical scenarios.
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Affiliation(s)
- Pushpa Bhari Thippeswamy
- Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Meena Nedunchelian
- Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Raja Bhaskara Rajasekaran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
- Corresponding author. 17, Horwood Close, Headington, Oxford, OX3 7RF, UK.
| | - Dylan Riley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Harman Khatkar
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics & Spine Surgery, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
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The use of modular total knee prostheses in femoral defects in traumatic and revision patients: a prospective case series. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rajasekaran RB, Palanisami DR, Natesan R, Jayaramaraju D, Rajasekaran S. Reply to "Megaprosthesis in distal femur nonunions in elderly patients-experience from twenty-four cases: a letter to editor". INTERNATIONAL ORTHOPAEDICS 2020; 44:2191-2192. [PMID: 32377782 DOI: 10.1007/s00264-020-04586-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/27/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Raja Bhaskara Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India.
| | - Dhanasekara Raja Palanisami
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Rajkumar Natesan
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Dheenadhayalan Jayaramaraju
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam road, Coimbatore, India
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Gavaskar AS, Mauffrey C, Babhulkar S. Indian orthopaedics: the past, present, and future. INTERNATIONAL ORTHOPAEDICS 2020; 44:605-608. [PMID: 31974642 DOI: 10.1007/s00264-020-04487-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/15/2020] [Indexed: 11/24/2022]
Abstract
The editorial summarizes the Indian orthopaedic history in brief and provides an overview of the articles to be published in the Indian traumatology edition.
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Affiliation(s)
- Ashok S Gavaskar
- Rela Institute of Orthopedics, Dr. Rela Institute and Medical Centre, 7, CLC Works Road, Chromepet, Chennai, 600044, India.
| | - C Mauffrey
- Department of Orthopedics, Denver Health, Denver, CO, USA
| | - S Babhulkar
- Sushrut Institute of Medical Sciences, Nagpur, India
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Johnson JD, Wyles CC, Perry KI, Yuan BJ, Rose PS, Houdek MT. Outcomes of knee arthroplasty for primary treatment of pathologic peri-articular fractures of the distal femur and proximal tibia. INTERNATIONAL ORTHOPAEDICS 2019; 44:187-193. [PMID: 31485681 DOI: 10.1007/s00264-019-04408-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Treatment goals for pathologic fractures about the knee include pain relief and unrestricted weight bearing. In cases of condylar destruction, these fractures may not be amenable to internal fixation, and arthroplasty may be considered. The purpose of this study was to analyze the outcomes of knee arthroplasty for primary treatment of impending or pathologic fractures of the distal femur or proximal tibia. METHODS Fifteen (8 males and 7 females) patients, mean age 62 ± nine years, undergoing arthroplasty for management of a pathologic peri-articular distal femur (n = 11) or proximal tibia (n = 4) fracture between 2001 and 2017 were reviewed. Implants included tumour endoprostheses (n = 11) and rotating hinged total knees (n = 4). Pathology included metastatic disease (n = 14) and lymphoma (n = 1). Eight (53%) patients presented with a fracture while the remainder had large impending lesions. RESULTS Mean follow-up was 19 months. At final follow-up, 11 patients had died with overall five year survival of 33%. Two (13%) patients required re-operation; including wound irrigation and debridement (n = 1) and above knee amputation for local recurrence (n = 1). An additional two (13%) patients developed post-operative VTE. MSTS, KSS, and KSS-F scores improved from a mean 12 ± 16%, 30 ± 11, and 14 ± 24 pre-operatively to 69 ± 26%, 75 ± 16, and 67 ± 25 at final follow-up, respectively (P < 0.001). Thirteen (87%) patients had severe pain prior to surgery with no patients (0%, P < 0.001) reporting severe pain at last follow-up. CONCLUSION Knee arthroplasty provided improved function and full weight-bearing making it an effective treatment for pathologic periarticular fractures of the distal femur and proximal tibia.
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Affiliation(s)
- Joshua D Johnson
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Cody C Wyles
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
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Vaishya R, Vaish A. Megaprosthesis in distal femur non-unions in elderly patients-experience from twenty-four cases: a letter to editor. INTERNATIONAL ORTHOPAEDICS 2019; 44:811-812. [PMID: 31471624 DOI: 10.1007/s00264-019-04406-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India
| | - Abhishek Vaish
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India.
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