Reliability of the Harris Hip limping sub-score in patients undergoing total hip arthroplasty

PURPOSE

In patients undergoing total hip arthroplasty, limping is a significant symptom, often assessed with the limping sub-score of the Harris Hip Score. However, the reliability of this sub-score has not been specifically investigated. The purpose of this study is to investigate the intra- and inter-rater reliability of this sub-score.

METHODS

Thirty patients undergoing THA were recruited and performed a gait analysis before surgery and three months after surgery. In addition, 30 asymptomatic participants were included. In total, 90 visits were analysed in this study. The HHS limping sub-score was assessed for each visit using a video (front and back view side-by-side) of a ten metre walk at a self-selected speed. Two orthopaedic surgeons evaluated the limping of each video in two different grading sessions with a one week delay. To avoid recall bias, the patient's number identity was randomized and different for each grading session and each rater. The weighted Cohen's Kappa coefficient was used to quantify the intra- and inter-reliability. The reliability of three components was studied: the presence of limping, its severity, and the compensation type.

RESULTS

For all components, the agreement for intra-rater reliability ranged from moderate to strong and from none to moderate for the inter-rater reliability.

CONCLUSION

These results do not encourage the use of HHS-limping sub-score for data involving different raters in both clinical and research contexts. It calls for improved consensus on limping definitions or the creation of objective measures.

Patients' experience on pain outcomes after hip arthroplasty: insights from an information tool based on registry data

BACKGROUND

Arthroplasty registries are rarely used to inform encounters between clinician and patient. This study is part of a larger one which aimed to develop an information tool allowing both to benefit from previous patients' experience after total hip arthroplasty (THA). This study focuses on generating the information tool specifically for pain outcomes.

METHODS

Data from the Geneva Arthroplasty Registry (GAR) about patients receiving a primary elective THA between 1996 and 2019 was used. Selected outcomes were identified from patient and surgeon surveys: pain walking, climbing stairs, night pain, pain interference, and pain medication. Clusters of patients with homogeneous outcomes at 1, 5, and 10 years postoperatively were generated based on selected predictors evaluated preoperatively using conditional inference trees (CITs).

RESULTS

Data from 6,836 THAs were analysed and 14 CITs generated with 17 predictors found significant (p < 0.05). Baseline WOMAC pain score, SF-12 self-rated health (SRH), number of comorbidities, SF-12 mental component score, and body mass index (BMI) were the most common predictors. Outcome levels varied markedly by clusters whilst predictors changed at different time points for the same outcome. For example, 79% of patients with good to excellent SRH and less than moderate preoperative night pain reported absence of night pain at 1 year after THA; in contrast, for those with fair/poor SHR this figure was 50%. Also, clusters of patients with homogeneous levels of night pain at 1 year were generated based on SRH, Charnley, WOMAC night and pain scores, whilst those at 10 years were based on BMI alone.

CONCLUSIONS

The information tool generated under this study can provide prospective patients and clinicians with valuable and understandable information about the experiences of "patients like them" regarding their pain outcomes.

Radiographic signs and hip pain 5 years after THA with a cemented stem predict future revision for aseptic loosening: a prospective cohort study

BACKGROUND AND PURPOSE

We aimed to evaluate the long-term predictive value of radiographic abnormality and/or hip pain assessed 5 years following primary total hip arthroplasty (THA) and the occurrence of revision for aseptic loosening between 5 and 25 years postoperatively.

PATIENTS AND METHODS

We included all primary THAs performed between 1996 and 2011 (same uncemented cup, polyethylene-ceramic bearing, 28 mm head, cemented stem) and prospectively enrolled in the institutional registry, for whom baseline and follow-up radiographs were available. At 5 years radiographically we assessed femoral osteolysis and/or stem migration. Pain was evaluated with the Harris Hip pain subscore. Kaplan-Meier survival and Cox regression analyses were performed.

RESULTS

1,317 primary THAs were included. 25 THAs (2%) were revised for aseptic stem loosening. Any abnormal radiographic sign at 5 years was present in 191 THAs (14%). Occasional hip pain was reported by 20% and slight to severe pain by 12% of patients at 5 years. In patients < 60 years, 10 of the 12 later revised for aseptic stem loosening had abnormal radiographs at 5 years vs. 5 of the 13 later revised in those ≥ 60 years. Hazard ratios (HR) were 34 (95% confidence interval [CI] 7-155) in younger vs. 4 (CI 1-11) in the older group. HR for association of hip pain at 5 years with future revision was 3 (CI 1-5).

CONCLUSION

The presence of abnormal radiographic signs 5 years after THA was strongly associated with later revision for aseptic stem loosening, especially in patients < 60 years. The association between pain at 5 years and future revision was much weaker.

Clinical investigations to evaluate high-risk orthopaedic devices: a systematic review of the peer-reviewed medical literature

Purpose

The objective of this systematic review was to give an overview of clinical investigations regarding hip and knee arthroplasty implants published in peer-reviewed scientific medical journals before entry into force of the EU Medical Device Regulation in May 2021.

Methods

We systematically reviewed the medical literature for a random selection of hip and knee implants to identify all peer-reviewed clinical investigations published within 10 years before and up to 20 years after regulatory approval. We report study characteristics, methodologies, outcomes, measures to prevent bias, and timing of clinical investigations of 30 current implants. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

We identified 2912 publications and finally included 151 papers published between 1995 and 2021 (63 on hip stems, 34 on hip cups, and 54 on knee systems). We identified no clinical studies published before Conformité Européene (CE)-marking for any selected device, and no studies even up to 20 years after CE-marking in one-quarter of devices. There were very few randomized controlled trials, and registry-based studies generally had larger sample sizes and better methodology.

Conclusion

The peer-reviewed literature alone is insufficient as a source of clinical investigations of these high-risk devices intended for life-long use. A more systematic, efficient, and faster way to evaluate safety and performance is necessary. Using a phased introduction approach, nesting comparative studies of observational and experimental design in existing registries, increasing the use of benefit measures, and accelerating surrogate outcomes research will help to minimize risks and maximize benefits.

Quality and Utility of European Cardiovascular and Orthopaedic Registries for the Regulatory Evaluation of Medical Device Safety and Performance Across the Implant Lifecycle: A Systematic Review

BACKGROUND

The European Union Medical Device Regulation (MDR) requires manufacturers to undertake post-market clinical follow-up (PMCF) to assess the safety and performance of their devices following approval and Conformité Européenne (CE) marking. The quality and reliability of device registries for this Regulation have not been reported. As part of the Coordinating Research and Evidence for Medical Devices (CORE-MD) project, we identified and reviewed European cardiovascular and orthopaedic registries to assess their structures, methods, and suitability as data sources for regulatory purposes.

METHODS

Regional, national and multi-country European cardiovascular (coronary stents and valve repair/replacement) and orthopaedic (hip/knee prostheses) registries were identified using a systematic literature search. Annual reports, peer-reviewed publications, and websites were reviewed to extract publicly available information for 33 items related to structure and methodology in six domains and also for reported outcomes.

RESULTS

Of the 20 cardiovascular and 26 orthopaedic registries fulfilling eligibility criteria, a median of 33% (IQR: 14%-71%) items for cardiovascular and 60% (IQR: 28%-100%) items for orthopaedic registries were reported, with large variation across domains. For instance, no cardiovascular and 16 (62%) orthopaedic registries reported patient/ procedure-level completeness. No cardiovascular and 5 (19%) orthopaedic registries reported outlier performances of devices, but each with a different outlier definition. There was large heterogeneity in reporting on items, outcomes, definitions of outcomes, and follow-up durations.

CONCLUSION

European cardiovascular and orthopaedic device registries could improve their potential as data sources for regulatory purposes by reaching consensus on standardised reporting of structural and methodological characteristics to judge the quality of the evidence as well as outcomes.

Introduction of innovations in joint arthroplasty: Recommendations from the 'EFORT implant and patient safety initiative'

With the implementation of the new MDR 2017/745 by the European Parliament, more robust clinical and pre-clinical data will be required due to a more stringent approval process. The EFORT Implant and Patient Safety Initiative WG1 'Introduction of Innovation', combined knowledge of orthopaedic surgeons, research institutes, orthopaedic device manufacturers, patient representatives and regulatory authorities to develop a comprehensive set of recommendations for the introduction of innovations in joint arthroplasty within the boundaries of MDR 2017/745. Recommendations have been developed to address key questions about pre-clinical and clinical requirements for the introduction of new implants and implant-related instrumentation with the participation of a steering group, invited by the EFORT Board in dialogue with representatives from European National Societies and Speciality Societies. Different degrees of novelty and innovation were described and agreed on in relation to when surgeons can start, using implants and implant-related instrumentation routinely. Before any clinical phase of a new implant, following the pre-market clinical investigation or the equivalent device PMCF pathway, it is a common understanding that all appropriate pre-clinical testing (regulatory mandatory and evident state of the art) - which has to be considered for a specific device - has been successfully completed. Once manufacturers receive the CE mark for a medical device, it can be used in patients routinely when a clinical investigation has been conducted to demonstrate the conformity of devices according to MDR Article 62 or full equivalence for the technical, biological and clinical characteristics has been demonstrated (MDR, Annex XIV, Part A, 3.) and a PMCF study has been initiated.

Identification of implant outliers in joint replacement registries

Recent concerns surrounding joint replacements that have a higher than expected rate of revision have led to stricter controls by regulatory authorities with regards to the introduction of new devices into the marketplace. Implant post-market surveillance remains important, and joint replacement registries are ideally placed to perform this role. This review examined if and how joint replacement registries identified outlier prostheses, outlined problems and suggested solutions to improve post-market surveillance. A search was performed of all joint replacement registries that had electronic or published reports detailing the outcomes of joint replacement. These reports were examined for registry identification of outlier prostheses. Five registries publicly identified outlier prostheses in their reports and the methods by which this was performed, and three others had internal reports. Identification of outlier prostheses is one area that may improve overall joint replacement outcomes; however, further research is needed to determine the optimum methods for identification, including the threshold, the comparator and the numbers required for notification of devices. Co-operation of registries at a global level may lead to earlier identification of devices and thereby further improve the results of joint replacement.

[Dilated cardiomyopathy: a toxic cause?]

Dilated cardiomyopathy is defined by the presence of left ventricular dilatation and contractile dysfunction in the absence of abnormal loading conditions and severe coronary artery disease. Once dilated cardiomyopathy is discovered, a careful and detailed history with laboratory tests may reveal a potential toxic cause. In this article, we present the case of a patient with suspected toxic dilated cardiomyopathy, and then discuss the common causes and treatment of toxic dilated cardiomyopathy.

[Dislocation after total hip arthroplasty : how to avoid it ?]

Dislocation after hip replacement is a complication that can have dramatic consequences for the patient. The purpose of this article is to review the different parameters influencing stability and how to reduce this risk. The approach, the diameter of the femoral head, and the use of dual-mobility acetabular cups have led to a drastic reduction in the rate of dislocation, particularly in patients at risk, in cases of imbalance of the spino-pelvic complex, or in cases of revision surgery. The inclusion of patients in dedicated clinical pathways and participation in preoperative education sessions also contribute to the reduction of dislocation risk.

Feasibility and sustainability of working in different types of jobs after total hip arthroplasty: analysis of longitudinal data from two cohorts

OBJECTIVES

To investigate the rates of return to work and workability among working-age people following total hip arthroplasty (THA).

METHODS

Participants from the Geneva Arthroplasty Registry and the Clinical Outcomes for Arthroplasty Study aged 18-64 years when they had primary THA and with at least 5 years' follow-up were mailed a questionnaire 2017-2019. Information was collected about preoperative and post-THA employment along with exposure to physically demanding activities at work or in leisure. Patterns of change of job were explored. Survival analyses using Cox proportional hazard models were created to explore risk factors for having to stop work because of difficulties with the replaced hip.

RESULTS

In total, 825 returned a questionnaire (response 58%), 392 (48%) men, mean age 58 years, median follow-up 7.5 years post-THA. The majority (93%) of those who worked preoperatively returned to work, mostly in the same sector but higher rates of non-return (36%-41%) were seen among process, plant and machine operatives and workers in elementary occupations. 7% reported subsequently leaving work because of their replaced hip and the risk of this was strongly associated with: standing >4 hours/day (HR 3.81, 95% CI 1.62 to 8.96); kneeling/squatting (HR 3.32, 95% CI 1.46 to 7.55) and/or carrying/lifting ≥10 kg (HR 5.43, 95% CI 2.29 to 12.88).

CONCLUSIONS

It may be more difficult to return to some (particularly physically demanding) jobs post-THA than others. Rehabilitation may need to be targeted to these types of workers or it may be that redeployment or job change counselling are required.

The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up

Background

Ankle fractures are a common injury and the main cause of post-traumatic ankle arthritis. The prevalence of obesity is increasing worldwide, and this population is known to have poorer short and midterm outcomes after ankle fractures. Our objective is to assess long-term patient-reported outcomes in patients with operatively treated ankle fractures, and the effect of BMI on these results using the new and validated patient-reported outcome questionnaire, the Manchester Oxford foot and ankle questionnaire (MOXFQ).

Methods

We performed a retrospective review of all ankle fractures treated operatively in a ten-year period from 2002–2012. The MOXFQ and SF-12 were sent to all patients and were obtained, on average, 11.1 years after surgery (range 5.3–16.2 years).

Results

Two thousand fifty-five ankle fractures were reviewed, of which 478 (34%) patients completed the questionnaires. The mean age was 48.1 ± 15.5 years, 52% were men and the mean BMI was 26.1 ± 4.5 kg/m2. Of the 478, 47% were of normal weight, 36% were overweight, and 17% were obese. Overall, 2.1% were type A, 69.9% B, and 24.9% type C fractures. There were no significant differences in the type of fracture between the BMI groups. Comparing obese and non-obese patients, there were large differences in MOXFQ pain (33 ± 29 vs. 18.7 ± 22.1, effect size 0.55), and function scores (27.3 ± 29 vs. 12.5 ± 21.1, effect size 0.58). No differences in complications and reoperations rates were observed. The BMI value at surgery correlated more strongly with the MOXFQ pain score than the BMI at follow-up (Spearman’s Rho 0.283 vs. 0.185, respectively).

Conclusion

These findings reveal that obese patients have significant worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture. Moreover, pain and function linearly declined with increasing BMI. Our findings appear to indicate that increased BMI at surgery is an important contributor to adverse outcome in the operative management of rotational ankle fractures.

Level of evidence

III.

[Lessons learned from 25 years of an institutional hip and knee arthroplasty registry]

Since 1996, the Geneva Arthroplasty Registry at the University Hospitals of Geneva (HUG) has been collecting, archiving and disseminating relevant high-quality information on primary total hip and knee arthroplasties and revision procedures performed at the Division of Orthopaedics and Traumatology. Patients are followed throughout their lifetime with the prosthesis. The registry has been essential to better understand and subsequently improve the care of patients with hip and knee replacements. It will continue to fulfil its mission and to work towards an even more effective transfer of the knowledge obtained to all stakeholders and as well as towards its implementation.

History of previous surgery is associated with higher risk of revision after primary total knee arthroplasty: a cohort study from the Geneva Arthroplasty Registry

Background and purpose - Prior to primary total knee arthroplasty (pTKA), 6-34% of patients have undergone surgical procedure(s) of their knee. We investigated whether history of previous surgeries influences the risk of revision of pTKA, the risk according to the type of previous surgery, and how previous surgery influences specific causes of revision and the time of revision.Patients and methods - This is a prospective cohort study from the Geneva Arthroplasty Registry. All pTKA between 2000 and 2016 were included and followed until December 31, 2019. Outcomes were risk of revision, evaluated using Kaplan-Meier survival and Cox and competing risks regression, the specific causes, and time of revision.Results - Of 3,945 pTKA included (mean age 71 years, 68% women), 21% had a history of previous surgery, with 8.3% revisions vs. 4.3%, at 3-20 years' follow-up (mean 8.6). 5- and 10-year cumulative failure by previous surgery (yes vs. no) were 6.6% (95% CI 5.1-8.5) vs. 3.3% (CI 2.7-4.0), and 8.4% (CI 6.6-10.6) vs. 4.5% (CI 3.8-5.4). Baseline differences explained only part of the higher risk (adjusted HR 1.5, CI 1.1-2.1). The risk of failure was higher for all causes of revision considered. Patients in the previous surgery group had a higher risk of an early revision.Interpretation - A history of previous surgery adversely affected the outcome with a 1.5 times higher cumulative risk of all-cause revision over the course of up to 20 years after index surgery. The increased risk was seen for all causes of revision and was highest in the first years.

Three-Year Rates of Reoperation and Revision Following Mobile Versus Fixed-Bearing Total Ankle Arthroplasty: A Cohort of 302 Patients with 2 Implants of Similar Design

BACKGROUND

Currently, the implants utilized in total ankle arthroplasty (TAA) are divided between mobile-bearing 3-component and fixed-bearing 2-component designs. The literature evaluating the influence of this mobility difference on implant survival is sparse. The purpose of the present study was therefore to compare the short-term survival of 2 implants of similar design from the same manufacturer, surgically implanted by the same surgeons, in fixed-bearing or mobile-bearing versions.

METHODS

All patients were enrolled who underwent TAA with either the mobile-bearing Salto (Tornier and Integra) or the fixed-bearing Salto Talaris (Integra) in 3 centers by 2 surgeons between January 2004 and March 2018. All patients who underwent TAA from January 2004 to April 2013 received the Salto implant, and all patients who underwent TAA after November 2012 received the Salto Talaris implant. The primary outcome was time, within 3 years, to first all-cause reoperation, revision of any metal component, and revision of any component, including the polyethylene insert. Secondary outcomes included the frequency, cause, and type of reoperation.

RESULTS

A total of 302 consecutive patients were included, of whom 171 received the mobile-bearing and 131 received the fixed-bearing implant. The adjusted hazard ratio for all-cause reoperation was 1.42 (95% confidence interval [CI], 0.67 to 3.00; p = 0.36); for component revision, 3.31 (95% CI, 0.93 to 11.79; p = 0.06); and for metal component revision, 2.78 (95% CI, 0.58 to 13.33; p = 0.20). A total of 31 reoperations were performed in the mobile-bearing group compared with 14 in the fixed-bearing group (p = 0.07). More extensive reoperation procedures were performed in the mobile-bearing group.

CONCLUSIONS

With the largest comparison of 2 implants of similar design from the same manufacturer, the present study supports the use of a fixed-bearing design in terms of short-term failure. We found a 3-times higher rate of revision among mobile-bearing implants compared with fixed-bearing implants at 3 years after TAA. Reoperations, including first and subsequent procedures, tended to be less common and the causes and types of reoperations less extensive among fixed-bearing implants.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gait Analysis 1 Year after Primary TKA: No Difference between Gap Balancing and Measured Resection Technique

Mechanical alignment in total knee arthroplasty (TKA) can be achieved using dependent bone cuts. The hypothesis is that patients have a better balanced TKA, as a result. The aim of this study was to determine if this technique is superior to an independent bone cut technique in terms of gait parameters, patient-reported outcome measures (PROMs), and satisfaction assessed before surgery and at 1-year follow-up. A total of 58 patients were evaluated before and 1 year following TKA, using the Press Fit Condylar (PFC) Sigma posterior stabilizer (PS) design; 39 (70 ± 8 years; 27 women) with independent bone cuts and 19 (71 ± 7 years; 12 women) with dependent bone cuts using the Specialist TRAM. Gait was evaluated with a three-dimensional motion analysis system for spatiotemporal and kinematics parameters. Pain and functional levels were assessed using the Western Ontario and McMaster Universities arthritis index (WOMAC); general health was assessed by the short form (SF)-12. Global satisfaction, as well as patient satisfaction, related to pain and functional levels were assessed using a five-point Likert's scale. No significant difference was found between both groups in terms of age, body mass index, pain, and functional levels at baseline. At 1-year follow-up, despite an overall improvement in gait, WOMAC, SF-12 physical score and pain, none of the patients showed gait parameters comparable to a healthy control group. No surgical technique effect was observed on gait, clinical outcomes, and satisfaction level. While observing an overall improvement at 1-year follow-up, we did not find any significant difference between the two surgical techniques in terms of gait parameters, patients' outcomes, and satisfaction.

International variation in distribution of ASA class in patients undergoing total hip arthroplasty and its influence on mortality: data from an international consortium of arthroplasty registries

Background and purpose - A challenge comparing outcomes from total hip arthroplasty between countries is variation in preoperative characteristics, particularly comorbidity. Therefore, we investigated between-country variation in comorbidity in patients based on ASA class distribution, and determined any variation of ASA class to mortality risk between countries.Patients and methods - All arthroplasty registries collecting ASA class and mortality data in patients with elective primary THAs performed 2012-2016 were identified. Survival analyses of the influence of ASA class on 1-year mortality were performed by individual registries, followed by meta-analysis of aggregated data.Results - 6 national registries and 1 US healthcare organization registry with 418,916 THAs were included. There was substantial variation in the proportion of ASA class III/IV, ranging from 14% in the Netherlands to 39% in Finland. Overall, 1-year mortality was 0.93% (95% CI 0.87-1.01) and increased from 0.2% in ASA class I to 8.9% in class IV. The association between ASA class and mortality measured by hazard ratios (HR) was strong in all registries even after adjustment for age and sex, which reduced them by half in all registries. Combined adjusted HRs were 2.0, 6.1, and 22 for ASA class II-IV vs. I, respectively. Associations were moderately heterogeneous across registries.Interpretation - We observed large variation in ASA class distribution between registries, possibly explained by differences in background morbidity and/or international variation in access to surgery. The similar, strong mortality trends by ASA class between countries enhance the relevance of its use as an indicator of comorbidity in international registry studies.

Operatively treated ankle fractures in Switzerland, 2002-2012: epidemiology and associations between baseline characteristics and fracture types

BACKGROUND

Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types.

METHODS

We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012.

RESULTS

Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age.

CONCLUSION

Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

The case for an academic discipline of medical device science

Medical devices are a very important but largely under-recognized and fragmented component of healthcare.The limited regulation of the past and the lack of systematic rigorous evaluation of devices leading to numerous high-profile failures will now be replaced by stricter legal requirements and more transparent evaluation processes.This constitutes an unprecedented opportunity, but it also uncovers urgent needs in landscaping, methodology development, and independent comprehensive assessment of device risks and benefits for individual patients and society, especially in the context of increasingly complex devices.We argue that an academic discipline of 'medical device science' is well placed to lead and coordinate the efforts necessary to achieve much needed improvement in the medical device sector.Orthopaedics and traumatology could contribute and benefit considerably as one of the medical specialties with the highest use of medical devices. Cite this article: EFORT Open Rev 2021;6:160-163. DOI: 10.1302/2058-5241.6.200094.

Short stem total hip arthroplasty with the direct anterior approach demonstrates suboptimal fixation

PURPOSE

Short stems use has increased substantially despite variable results reported in the literature. The purpose of this study was to report the rate of complications using a short stem implanted through the direct anterior approach (DAA), and to evaluate mid-term clinical and radiological results focusing on femoral stem fixation.

METHODS

Between April 2009 and November 2014, 698 elective total hip arthroplasties (THAs) were performed using a fully hydroxyapatite-coated short stem (AMIStem-H®). The mean age was 65.7 years (SD 12.6). Patients were invited for clinical and radiological evaluation, and to complete patient-reported outcomes questionnaires at two and five years after surgery. The mean follow-up was 6.2 years (range 2-9.73 years).

RESULTS

During the study period, 59 (8.5%) patients died and 24 (3.4%) were lost to follow-up. There were six (0.9%) dislocations and 12 (1.7%) fractures, seven occurred intra-operatively. Twenty-nine (4.2%) THAs required revision surgery. Eleven THAs were revised for aseptic loosening of the stem at a mean 4.9 years (1.2-7.3 years). Five years after surgery, radiographs of 324 THAs (324/425 eligible = 76.2%) were available. Stem subsidence ≥ 2 mm was present in 42 cases (12.9%), proximal radiolucencies in 101 hips (31.5%), cortical thickening in 52 (16.0%), and a pedestal in 219 (67.6%). An Engh score between - 10 and 0 was associated with lower HHS pain subscore (p = 0.005), a higher risk of stem revision for aseptic loosening (18.8% vs. 2.7%; p = 0.008), and was more frequent in younger patients with ASA score 1.

CONCLUSION

Patients presenting radiological alterations at five years had an increased risk of revision for aseptic stem loosening and also inferior clinical results. Our study warrants further continued scrutiny of mid- and long-term survivorship of the AMIStem-H®, with radiological results at five years indicating suboptimal fixation of the stem in younger and active patients.

Development and psychometric performance of the French language version of the Manchester-Oxford Foot Questionnaire (MOXFQ)

BACKGROUND

The Manchester-Oxford Foot Questionnaire (MOXFQ) is a 16-item patient-reported outcome measure (PROM) validated for use in patients with foot and ankle pathologies. It contains three sub-scores for pain, walking/standing and social interaction dimensions. The aim of this study was to develop a French language version of the MOXFQ and to assess its psychometric properties in patients affected by foot and ankle pathologies.

METHODS

According to guidelines, forward and backward independent translations were performed. The final French version was pre-tested in 45 patients. The French MOXFQ and the Short-form 36 Health Survey (SF-36) were filled in by 149 patients. A retest was performed in 39 patients. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed by factor analysis, and through correlations of MOXFQ scales with SF-36 scales.

RESULTS

Internal consistency coefficients were high with Cronbach's alpha ranging from 0.79 and 0.94. Test-retest ICCs were between 0.74 and 0.93. No floor or ceiling effects were observed. The correlations between French MOXFQ and French SF-36 subscales were moderate ranging from -0.33 to -0.71.

CONCLUSIONS

The French translation of the MOXFQ revealed good psychometric properties. Our French version proved to be a reliable instrument which can be used for evaluation of patients with foot and ankle disorders.

LEVEL OF EVIDENCE

II.

Walking Speed and Maximal Knee Flexion During Gait After Total Knee Arthroplasty: Minimal Clinically Important Improvement Is Not Determinable; Patient Acceptable Symptom State Is Potentially Useful

BACKGROUND

Total knee arthroplasty (TKA) is the operation of choice in patients with end-stage knee osteoarthritis (OA). Up to 1 in 5 patients still encounter functional limitations after TKA, partly explaining patient dissatisfaction. Which gait ability to target after TKA remains unclear. To determine whether Minimal Clinical Important Improvement (MCII) or Patient Acceptable Symptom State (PASS) values could be derived from gait parameters recorded in patients with TKA. And, if so, to define those values.

METHODS

In this ancillary study, we retrospectively analyzed gait parameters of patients scheduled for a unilateral TKA between 2011 and 2013. We investigated MCII and PASS values for walking speed and maximal knee flexion using anchor-based methods: 5 anchoring questions based on perceived body function and patients' satisfaction.

RESULTS

Over the study period, 79 patients performed a clinical gait analysis the week before and 1 year after surgery, and were included in the present study. All clinical and gait parameters improved 1 year after TKA. Nevertheless, changes in gait outcomes were not associated with perceived body function or patients' satisfaction, precluding any MCII estimation in gait parameters. PASS values, however, could be determined as 1.2 m/s for walking speed and 50° for maximal knee flexion.

CONCLUSION

In this study, we found that MCII and PASS values are not necessarily determinable for gait parameters after TKA in patients with end-stage OA. Using anchor questions based on perceived body function and patient's satisfaction, MCII could not be defined while PASS values were potentially useful.

LEVEL OF EVIDENCE

Level III.

Associations between gait analysis parameters and patient satisfaction one year following primary total knee arthroplasty

BACKGROUND

The purpose of this prospective study was to understand the relation between gait outcomes and patient satisfaction one year after total knee arthroplasty (TKA).

METHODS

Seventy-nine patients were evaluated before and one year after TKA using clinical gait analysis. Specific gait outcomes were analyzed: gait speed, stance phase, range of motion (ROM) knee flexion and maximal knee flexion. The parameters of interest selected for the statistical analysis were: gait speed and maximal knee flexion during gait. The Western Ontario and MacMaster Osteoarthritis Index (WOMAC) and patient satisfaction were also assessed. The satisfaction was evaluated using a questionnaire and was splited in five categories: very unsatisfied, unsatisfied, neutral, satisfied or very satisfied. To assess associations between patient satisfaction and maximal knee flexion during gait and gait speed, an unadjusted ordinal logistic regression analysis was used. The analysis was then adjusted for covariates: age and Body Mass Index (BMI) before surgery and WOMAC pain one year after surgery.

RESULTS

All gait outcomes after TKA had significantly improved. The ordinal logistic regression analysis found significant associations between patient satisfaction and maximal knee flexion after TKA (unadjusted and adjusted) but not for gait speed.

CONCLUSION

These findings show that all patients improved their gait outcomes one year after TKA but only a higher maximal knee flexion during gait may influence the level of patient satisfaction.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study

Background

The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome.

Methods

270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05.

Results

Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm.

Conclusions

One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

ASA class is associated with early revision and reoperation after total hip arthroplasty: an analysis of the Geneva and Swedish Hip Arthroplasty Registries

Background and purpose - Data from several joint replacement registries suggest that the rate of early revision surgery after primary total hip arthroplasty (THA) is increasing. The ASA class, now widely recorded in arthroplasty registries, may predict early revision. We investigated the influence of ASA class on the risk of revision and other reoperation within 3 months and within 5 years of primary THA. Patients and methods - We used data from the Geneva and Swedish Hip Arthroplasty Registries, on primary elective THAs performed in 1996-2016 and 2008-2016, respectively. 5,319 and 122,241 THAs were included, respectively. Outcomes were all-cause revision and other reoperations evaluated using Kaplan-Meier survival and Cox regression analyses. Results - Within 3 months after surgery, higher ASA class was associated with greater risk of revision and other reoperation. 3-month cumulative incidences of revision by ASA class I, II, and III-IV respectively, were 0.6%, 0.7%, and 2.3% in Geneva and 0.5%, 0.8%, and 1.6% in Sweden. 3-month cumulative incidences of other reoperation were 0.4%, 0.7%, and 0.9% in Geneva and 0.2%, 0.4%, and 0.7% in Sweden. Adjusted hazard ratios (ASA III-IV vs. I) for revision within 3 months were 2.7 (95% CI 1.2-5.9) in Geneva and 3.3 (CI 2.6-4.0) in Sweden. Interpretation - Assessment of ASA class of patients prior to THA will facilitate risk stratification. Targeted risk-reduction strategies may be appropriate during the very early postoperative period for patients identified as at higher risk. Systematically recording ASA class in arthroplasty registries will permit risk adjustment and facilitate comparison of revision rates internationally.

Improvement in mental health following total hip arthroplasty: the role of pain and function

Background

Mental health has been shown to improve after total hip arthroplasty (THA). Little is known about the role of pain and function in this context. We assessed whether change in mental health was associated with improvement in pain and function 1 year post-surgery.

Methods

This prospective study included patients enrolled in a THA registry from 2010 to 2014. We examined the mental component score (MCS) before and 1 year post-surgery, and 1-year change, in association with Western Ontario McMaster Universities (WOMAC) pain and function scores. All scores were normalized, ranging from 0 to 100 (larger score indicating better outcome). Analyses were adjusted for potential confounders.

Results

Our study included 610 participants, of which 53% were women. Descriptive statistics are as follows: the average (SD) for age (years) was 68.5 (11.8), and for BMI was 26.9 (4.9). In addition, the MCS average (SD) at baseline was 44.7 (11.2), and at 1-year after THA was 47.5 (10.5). The average change from baseline to 1-year post-THA in MCS was 2.8 (95% CI: 1.9, 3.6), for an effect size of 0.26. As for the WOMAC pain score, the average change from baseline to 1-year post-THA was 44.2 (95%CI: 42.4, 46.0), for an effect size of 2.5. The equivalent change in WOMAC function was 38.1 (95% CI: 36.2, 40.0), for an effect size of 2.0. Results from multivariable analysis controlling for covariates showed that an improvement of 10 points in the 1-year change in pain score resulted in a 0.78 point (95%: CI 0.40, 1.26) increase in the 1-year change in MCS, whereas a 10-point improvement in the 1-year change in function was associated with a 0.94 point (95% CI: 0.56, 1.32) increase.

Conclusions

Mental health significantly improved from baseline to 1-year post-THA. Greater improvement in pain and function was associated with greater improvement in mental health 1 year post-THA.

Symptoms of osteoarthritis influence mental and physical health differently before and after joint replacement surgery: A prospective study

Background

Patient-reported outcomes are increasingly used in evaluations of joint replacement surgery, but it is unclear if symptoms of osteoarthritis (i.e., pain and dysfunction) influence health perceptions similarly before and after surgery.

Methods

In this prospective study based on a hospital-based arthroplasty registry, patients with primary total hip or knee arthroplasty (THA, N = 990, and TKA, N = 907) completed the WOMAC Pain and Function scales, and the SF12 Physical and Mental Component Scores (PCS and MCS), before surgery and one year later. Associations between WOMAC and SF12 scales were examined using mixed linear regression models.

Results

All patient-reported outcomes improved following total joint arthroplasty, but the associations between symptom scales and global health perceptions were altered. Mental health scores at a given level of pain or function were lower after surgery than before, by about 4–5 points, a clinically meaningful and statistically significant difference. In contrast, the associations between WOMAC scales and the PCS remained stable. These findings were observed in both cohorts of patients.

Conclusions

After total joint arthroplasty, mental health scores were lower than would have been expected given the symptomatic improvement. This suggests that relationships between patient-reported outcomes are context-dependent, and that care should be exerted when interpreting changes in patient-reported outcomes over time.

Registry stakeholders

Clinical registries are health information systems, which have the mission to collect multidimensional real-world data over the long term, and to generate relevant information and actionable knowledge to address current serious healthcare problems.

This article provides an overview of clinical registries and their relevant stakeholders, focussing on registry structure and functioning, each stakeholder’s specific interests, and on their involvement in the registry’s information input and output.

Stakeholders of clinical registries include the patients, healthcare providers (professionals and facilities), financiers (government, insurance companies), public health and regulatory agencies, industry, the research community and the media.

The article discusses (1) challenges in stakeholder interaction and how to strengthen the central role of the patient, (2) the importance of adding cost reporting to enable informed value choices, and (3) the need for proof of clinical and public health utility of registries.

In its best form, a registry is a mission-driven, independent stakeholder–registry team collaboration that enables rapid, transparent and open-access knowledge generation and dissemination.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180077

MoM total hip replacements in Europe: a NORE report

The purpose of this paper is to determine the prevalence of metal-on-metal (MoM) total hip replacement (THR) in European registries, to assess the incidence of revision surgery and to describe the national follow-up guidelines for patients with MoM THR including resurfacings.

Eleven registries of the Network of Orthopaedic Registries of Europe (NORE) participated totalling 54 434 resurfacings and 58 498 large stemmed MoM THRs.

The resurfacings and stemmed large head MoM had higher pooled revision rates at five years than the standard total hip arthroplasties (THA): 6.0%, 95% confidence interval (CI) 5.3 to 6.8 for resurfacings; 6.9%, 95% CI 4.4 to 9.4 for stemmed large head MoM; and 3.0%, 95% CI 2.5 to 3.6 for conventional THA.

The resurfacings and stemmed large head MoM had higher pooled revision rates at ten years than the standard THAs: 12.1%, 95% CI 11.0 to 13.3 for resurfacings; 15.5%, 95% CI 9.0 to 22 for stemmed large head MoM; and 5.1%, 95% CI 3.8 to 6.4 for conventional THA.

Although every national registry reports slightly different protocols for follow-up, these mostly consist of annual assessments of cobalt and chromium levels in blood and MRI (MARS) imaging.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180078

Orthopaedic registries with patient-reported outcome measures

Total joint arthroplasty is performed to decreased pain, restore function and productivity and improve quality of life.

One-year implant survivorship following surgery is nearly 100%; however, self-reported satisfaction is 80% after total knee arthroplasty and 90% after total hip arthroplasty.

Patient-reported outcomes (PROs) are produced by patients reporting on their own health status directly without interpretation from a surgeon or other medical professional; a PRO measure (PROM) is a tool, often a questionnaire, that measures different aspects of patient-related outcomes.

Generic PROs are related to a patient’s general health and quality of life, whereas a specific PRO is focused on a particular disease, symptom or anatomical region.

While revision surgery is the traditional endpoint of registries, it is blunt and likely insufficient as a measure of success; PROMs address this shortcoming by expanding beyond survival and measuring outcomes that are relevant to patients – relief of pain, restoration of function and improvement in quality of life.

PROMs are increasing in use in many national and regional orthopaedic arthroplasty registries.

PROMs data can provide important information on value-based care, support quality assurance and improvement initiatives, help refine surgical indications and may improve shared decision-making and surgical timing.

There are several practical considerations that need to be considered when implementing PROMs collection, as the undertaking itself may be expensive, a burden to the patient, as well as being time and labour intensive.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180080

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND

Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status.

METHODS

A prospective hospital registry-based cohort study was performed including all primary knee and hip TJAs performed between March 1996 and December 2013. Smoking status preoperatively was classified into never, former, and current smoker. Incidence rates and hazard ratios (HRs) for prosthetic joint infection according to smoking status were assessed within the first year and beyond.

RESULTS

We included 8559 primary TJAs (mean age 69.5 years), and median follow-up was 67 months. There were 5722 never, 1315 former, and 1522 current smokers. Incidence rates of infection within the first year for never, former, and current smokers were, respectively, 4.7, 10.1, and 10.9 cases/1000 person-years, comparing ever vs never smokers, crude and adjusted HRs were 2.35 (95% confidence interval [CI] 1.39-3.98) and 1.8 (95% CI 1.04-3.2). Beyond the first year, crude and adjusted HRs were 1.37 (95% CI 0.78-2.39) and 1.12 (95% CI 0.61-2.04).

CONCLUSION

Smoking increased the infection risk about 1.8 times after primary hip or knee TJA in both current and former smokers. Beyond the first year, the infection risk was similar to never smokers.

Research methodology for orthopaedic surgeons, with a focus on outcome

Since improving the patient's condition is the ultimate goal of clinical care and research, this review of research methodology focuses on outcomes in the musculoskeletal field.This paper provides an overview of conceptual models, different types of outcomes and commonly assessed outcomes in orthopaedics as well as epidemiological and statistical aspects of outcomes determination, measurement and interpretation.Clinicians should determine the outcome(s) most important to patients and/or public health in collaboration with the patients, epidemiologists/statisticians and other stakeholders.Key points in outcome choice are to evaluate both the benefit and harm of a health intervention, and to consider short- and longer-term outcomes including patient-reported outcomes.Outcome estimation should aim at identifying a clinically important difference (not the same as a statistically significant difference), at presenting measures of effects with confidence intervals and at taking the necessary steps to minimize bias. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170064.

Third-generation pure alumina and alumina matrix composites in total hip arthroplasty: What is the evidence?

Wear, corrosion and periprosthetic osteolysis are important causes of failure in joint arthroplasty, especially in young patients.

Ceramic bearings, developed 40 years ago, are an increasingly popular choice in hip arthroplasty. New manufacturing procedures have increased the strength and reliability of ceramic materials and reduced the risk of complications.

In recent decades, ceramics made of pure alumina have continuously improved, resulting in a surgical-grade material that fulfills clinical requirements.

Despite the track record of safety and long-term results, third-generation pure alumina ceramics are being replaced in clinical practice by alumina matrix composites, which are composed of alumina and zirconium.

In this review, the characteristics of both materials are discussed, and the long-term results with third-generation alumina-on-alumina bearings and the associated complications are compared with those of other available ceramics.

Cite this article: EFORT Open Rev 2018;3:7-14. DOI: 10.1302/2058-5241.3.170034

[Do degenerative meniscal tears need surgery ?]

Degenerative meniscal tears (DMT) are common, often asymptomatic, and are associated with early-stage knee osteoarthritis in patients over 35 years of age. Conservative treatment, including exercise, physiotherapy and pain medication, should be offered as a first management approach for patients with symptomatic DMT. The indication for partial arthroscopic meniscectomy should be considered carefully, and based on specific criteria. Recently, several randomized controlled studies comparing partial medial meniscectomy to conservative treatment or to a sham procedure have questioned the effectiveness of surgical treatment of these lesions.The purpose of this article is to provide an update on the diagnosis and treatment of DMT.

[Does total knee arthroplasty meet patient's expectations ?]

Total knee arthroplasty has grown considerably over the past decade, due to the aging of the population, the increase in the prevalence of obesity, and an increasing demand. The 10-year revision rate is less than 5%. Functional outcomes, assessed by range of motion measures and functional scores, were significantly improved with the advent of more reliable and less invasive surgical techniques, better management of postoperative pain, and early high-intensity rehabilitation protocols. However, 20% of patients say they are dissatisfied with their knee replacement, either because of the persistence of pain, or because their function does not match their preoperative expectations. Improved preoperative communication between patient and surgeon is essential to match patients' expectations to realistic treatment outcomes.

International variation in shoulder arthroplasty

Background and purpose - The number of shoulder registries increases. We assessed international trends in use of shoulder arthroplasty, and described the current state of procedure selection and outcome presentation as documented in national and regional joint registries. Methods - Published reports from 9 population-based shoulder arthroplasty registries (country/region: Norway, Sweden, New Zealand, Denmark, California, Australia, Emilia-Romagna, Germany, and United Kingdom) were analyzed. Data were extracted on age, sex, disease indication, type of surgical procedure, surgical volume, and outcomes. Results - Shoulder arthroplasty incidence rate in 2012 was 20 procedures/10⁵ population with a 6-fold variation between the highest (Germany) and lowest (United Kingdom) country. The annual incidence rate increased 2.8-fold in the past decade. Within the indications osteoarthritis, fracture, and cuff-tear arthropathy variations in procedure choice between registries were large. Outcomes evaluation focused on revision in all registries, but different measures and strata were used. Only Australia provided revision rates for prosthesis brands stratified by both indication and procedure. Finally, in 2 registries with available data surgeons performed on average 10-11 procedures yearly. Interpretation - Annual incidence rates of shoulder arthroplasty have almost tripled over the past decade. There is wide variation in procedure selection for the major indications, a low average surgeon volume, a substantial number of brands with small annual volume, and large variation in outcome presentation. The internationally increasing registry activity is an excellent basis for improving the so far weak evidence in shoulder arthroplasty.

The role of national registries in improving patient safety for hip and knee replacements

Background

The serious adverse events associated with metal on metal hip replacements have highlighted the importance of improving methods for monitoring surgical implants.

The new European Union (EU) device regulation will enforce post-marketing surveillance based on registries among other surveillance tools. Europe has a common regulatory environment, a common market for medical devices, and extensive experience with joint replacement registries. In this context, we elaborate how joint replacement registries, while building on existing structure and data, can better ensure safety and balance risks and benefits.

Main text

Actions to improve registry-based implant surveillance include: enriching baseline and diversifying outcomes data collection; improving methodology to limit bias; speeding-up failure detection by active real-time monitoring; implementing risk-benefit analysis; coordinating collaboration between registries; and translating knowledge gained from the data into clinical decision-making and public health policy.

Conclusions

The changes proposed here will improve patient safety, enforce the application of the new legal EU requirements, augment evidence, improve clinical decision-making, facilitate value-based health-care delivery, and provide up-to-date guidance for public health.

Influence of Body Mass Index on Sagittal Knee Range of Motion and Gait Speed Recovery 1-Year After Total Knee Arthroplasty

BACKGROUND

The purpose of this prospective study was to investigate the influence of body mass index (BMI) on gait parameters preoperatively and 1 year after total knee arthroplasty (TKA).

METHODS

Seventy-nine patients were evaluated before and 1 year after TKA using clinical gait analysis. The gait velocity, the knee range of motion (ROM) during gait, their gains (difference between baseline and 1 year after TKA), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), quality of life, and patient satisfaction were assessed. Nonobese (BMI <30 kg/m²) and obese patients (BMI ≥30 kg/m²) were compared. Healthy controls were also assessed. Univariate and multivariate linear regression analyses were used to assess the association between gait speed and ROM gains. Adjustment was performed for gender, age, and WOMAC pain improvement.

RESULTS

At baseline, gait velocity and knee ROM were significantly lower in obese compared with those in the nonobese patients (0.99 ± 0.27 m/s vs 1.11 ± 0.18 m/s; effect size, 0.53; P = .021; and ROM, 41.33° ± 9.6° vs 46.05° ± 8.39°; effect size, 0.52; P = .022). Univariate and multivariate linear regressions did not show any significant relation between gait speed gain or knee ROM gain and BMI. At baseline, obese patients were more symptomatic than nonobese (WOMAC pain: 36.1 ± 14.0 vs 50.4 ± 16.9; effect size, 0.9; P < .001), and their improvement was significantly higher (WOMAC pain gain, 44.5 vs 32.3; effect size, 0.59; P = .011).

CONCLUSION

These findings show that all patients improved biomechanically and clinically, regardless of their BMI.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial plateau fractures: a retrospective cohort study

Background

The aim of the study was to evaluate the relation between demographic, injury-related, clinical and radiological factors of patients with tibial plateau fractures and the development of acute compartment syndrome.

Methods

All consecutive adult patients with intra-articular tibial plateau fractures admitted in our urban academic medical centre between January 2005 and December 2009 were included in this retrospective cohort study. The main outcome measurement was the development of acute compartment syndrome.

Results

The charts of 265 patients (mean age 48.6 years) sustaining 269 intra-articular tibial plateau fractures were retrospectively reviewed. Acute compartment syndrome occurred in 28 fractures (10.4%). Four patients presented bilateral tibial plateau fractures; of them, 2 had unilateral, but none had bilateral acute compartment syndrome. Non-contiguous tibia fracture or knee dislocation and higher AO/OTA classification (type 41-C) were statistically significantly associated with the development of acute compartment syndrome in multivariable regression analysis, while younger age (<45 years), male sex, higher Schatzker grade (IV-V-VI), higher tibial widening ratio (≥1.05) and higher femoral displacement ratio (≥0.08) were significantly associated in the analysis adjusted for age and sex.

Conclusions

Two parameters related to the occurrence of ACS in tibial plateau fractures were highlighted in this study: the presence of a non-contiguous tibia fracture or knee dislocation, and higher AO/OTA classification. They may be especially useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients), and should rise the suspicion level of the treating surgeon. In these cases, regular clinical examinations and/or intra-compartmental pressure measurements should be performed before and after surgery, even if acute compartment syndrome seemed unlikely during initial assessment. However, larger studies are mandatory to confirm and refine both factors in predicting the occurrence of acute compartment syndrome.

Presence of IL-17 in synovial fluid identifies a potential inflammatory osteoarthritic phenotype

Purpose

Osteoarthritis (OA) is a common and heterogeneous arthritic disorder. Patients suffer pain and their joints are characterized by articular cartilage loss and osteophyte formation. Risk factors for OA include age and obesity with inflammation identified as a key mediator of disease pathogenesis. Interleukin-17A (IL-17) is a pro-inflammatory cytokine that has been implicated in inflammatory diseases such as rheumatoid arthritis. IL-17 can upregulate expression of inflammatory cytokines and adipocytokines. The aim of this study was to evaluate IL-17 levels in the synovial fluid of patients with end-stage knee and hip OA in relation to inflammation- and pain-related cytokines and adipocytokines in synovial fluid and serum, and clinical and radiographic disease parameters.

Methods

This is a cross-sectional study of 152 patients undergoing total hip and knee arthroplasty for OA. IL-17, IL-6, leptin, adiponectin, visfatin, resistin, C-C Motif Chemokine Ligand 2 (CCL2), C-C Motif Chemokine Ligand 7 (CCL7) and nerve growth factor (NGF) protein levels were measured in synovial fluid and serum using enzyme-linked immunosorbent assay (ELISA). Baseline characteristics included age, sex, body mass index, co-morbidities, pain and function, and radiographic analyses (OA features, K&L grade, minimal joint space width).

Results

14 patients (9.2%) had detectable IL-17 in synovial fluid. These patients had significantly higher median concentrations of IL-6, leptin, resistin, CCL7 and NGF. Osteophytes, sclerosis and minimum joint space width were significantly reduced in patients with detectable IL-17 in synovial fluid. No differences were found in pain, function and comorbidities. IL-17 concentrations in synovial fluid and serum were moderately correlated (r = 0.482).

Conclusion

The presence of IL-17 in the synovial fluid therefore identifies a substantial subset of primary end-stage OA patients with distinct biological and clinical features. Stratification of patients on the basis of IL-17 may identify those responsive to therapeutic targeting.

Important patient characteristics differ prior to total knee arthroplasty and total hip arthroplasty between Switzerland and the United States

Background

Outcomes after total knee (TKA) and hip (THA) arthroplasty are often generalized internationally. Patient-dependent factors and preoperative symptom levels may differ across countries. We compared preoperative patient and clinical characteristics from two large cohorts, one in Switzerland, the other in the US.

Methods

Patient characteristics were collected prospectively on all elective primary TKAs and THAs performed at a large Swiss hospital and in a US national sample. Data included age, sex, education level, BMI, diagnosis, medical co-morbidities, PROMs (WOMAC pain/function), global health (SF-12).

Results

Six thousand six hundred eighty primary TKAs (US) and 823 TKAs (Swiss) were evaluated. US vs. Switzerland TKA patients were younger (mean age 67 vs. 72 years.), more obese (BMI ≥30 55% vs. 43%), had higher levels of education, more cardiac disease. Swiss patients had lower preoperative WOMAC pain scores (41 vs. 52) but pre-operative physical disability were comparable. 4,647 primary THAs (US) and 1,023 THAs (Swiss) were evaluated. US vs. Switzerland patients were younger (65 vs. 68 years.), more obese (BMI ≥30: 38% vs. 24%), had higher levels of education, more diabetes. Swiss patients had lower preoperative WOMAC pain scores (40 vs. 48 points). Physical disability was reported comparable, but Swiss patients indicated lower mental health scores.

Conclusion

We found substantial differences between US and Swiss cohorts in pre-operative patient characteristics and pain levels, which has potentially important implications for cross-cultural comparison of TKA/THA outcomes. Reports from national registries lack detailed patient information while these data suggest the need for adequate risk adjustment of patient factors.

Patient-reported outcome measures in arthroplasty registries

The International Society of Arthroplasty Registries (ISAR) Steering Committee established the Patient-Reported Outcome Measures (PROMs) Working Group to convene, evaluate, and advise on best practices in the selection, administration, and interpretation of PROMs and to support the adoption and use of PROMs for hip and knee arthroplasty in registries worldwide. The 2 main types of PROMs include generic (general health) PROMs, which provide a measure of general health for any health state, and specific PROMs, which focus on specific symptoms, diseases, organs, body regions, or body functions. The establishment of a PROM instrument requires the fulfillment of methodological standards and rigorous testing to ensure that it is valid, reliable, responsive, and acceptable to the intended population. A survey of the 41 ISAR member registries showed that 8 registries administered a PROMs program that covered all elective hip or knee arthroplasty patients and 6 registries collected PROMs for sample populations; 1 other registry had planned but had not started collection of PROMs. The most common generic instruments used were the EuroQol 5 dimension health outcome survey (EQ-5D) and the Short Form 12 health survey (SF-12) or the similar Veterans RAND 12-item health survey (VR-12). The most common specific PROMs were the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Oxford Hip Score (OHS), the Oxford Knee Score (OKS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and the University of California at Los Angeles Activity Score (UCLA).

Patient-reported outcome measures in arthroplasty registries Report of the Patient-Reported Outcome Measures Working Group of the International Society of Arthroplasty Registries Part II. Recommendations for selection, administration, and analysis

- The International Society of Arthroplasty Registries (ISAR) Patient-Reported Outcome Measures (PROMs) Working Group have evaluated and recommended best practices in the selection, administration, and interpretation of PROMs for hip and knee arthroplasty registries. The 2 generic PROMs in common use are the Short Form health surveys (SF-36 or SF-12) and EuroQol 5-dimension (EQ-5D). The Working Group recommends that registries should choose specific PROMs that have been appropriately developed with good measurement properties for arthroplasty patients. The Working Group recommend the use of a 1-item pain question ("During the past 4 weeks, how would you describe the pain you usually have in your [right/left] [hip/knee]?"; response: none, very mild, mild, moderate, or severe) and a single-item satisfaction outcome ("How satisfied are you with your [right/left] [hip/knee] replacement?"; response: very unsatisfied, dissatisfied, neutral, satisfied, or very satisfied). Survey logistics include patient instructions, paper- and electronic-based data collection, reminders for follow-up, centralized as opposed to hospital-based follow-up, sample size, patient- or joint-specific evaluation, collection intervals, frequency of response, missing values, and factors in establishing a PROMs registry program. The Working Group recommends including age, sex, diagnosis at joint, general health status preoperatively, and joint pain and function score in case-mix adjustment models. Interpretation and statistical analysis should consider the absolute level of pain, function, and general health status as well as improvement, missing data, approaches to analysis and case-mix adjustment, minimal clinically important difference, and minimal detectable change. The Working Group recommends data collection immediately before and 1 year after surgery, a threshold of 60% for acceptable frequency of response, documentation of non-responders, and documentation of incomplete or missing data.

Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of Tarsometatarsal Joint Complex Injuries

BACKGROUND

Injuries to the tarsometatarsal (TMT) joint complex, or Lisfranc injuries, have been reported to result in osteoarthritis (OA) following surgical treatment. Good outcomes with respect to short and medium-term results have been reported. However, long-term results, specifically regarding clinical outcomes and the development of symptomatic OA, are limited. The objectives of this study were to assess clinical outcomes, the occurrence of symptomatic OA, and risk factors for OA at 2 to 24 years after a Lisfranc injury treated surgically with open reduction and internal fixation (ORIF) or with primary arthrodesis.

METHODS

This was a retrospective study involving 61 patients treated surgically at our institution between 1988 and 2009 for an injury to the TMT joint complex. Patients underwent either ORIF with transarticular screws or primary arthrodesis when joint comminution at the TMT level was such that ORIF was not possible. Functional outcomes were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) score, the Foot Function Index (FFI), and a visual analog scale (VAS) for pain. Global health was evaluated with the Short Form (SF)-12 Health Survey physical component summary (PCS).

RESULTS

Sixty-one of the 128 patients were available for clinical evaluation, including the use of questionnaires, and radiographic assessment at a mean of 10.9 years postoperatively (range, 2.4 to 23.9 years). Mean scores were as follows: AOFAS score, 79.0; FFI, 16.9, and VAS for pain, 2.5. Radiographic evidence of OA was noted in 44 (72.1%) of the patients, and symptomatic OA, in 54.1%, the latter having worse outcomes. Risk factors for OA were nonanatomic reduction, fracture classification of Myerson type C, and a history of smoking.

CONCLUSIONS

Two to 24 years following surgical treatment to restore and maintain joint anatomy for Lisfranc injuries, we found satisfactory clinical outcome scores and a large number of patients who had returned to their previous level of functioning and employment, with little need for secondary procedures. However, there was a substantial occurrence of posttraumatic OA, as evident on radiographs, albeit the occurrence of symptomatic OA was lower.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Body mass and weight thresholds for increased prosthetic joint infection rates after primary total joint arthroplasty

BACKGROUND AND PURPOSE

Obesity increases the risk of deep infection after total joint arthroplasty (TJA). Our objective was to determine whether there may be body mass index (BMI) and weight thresholds indicating a higher prosthetic joint infection rate.

PATIENTS AND METHODS

We included all 9,061 primary hip and knee arthroplasties (mean age 70 years, 61% women) performed between March 1996 and December 2013 where the patient had received intravenous cefuroxime (1.5 g) perioperatively. The main exposures of interest were BMI (5 categories: < 24.9, 25-29.9, 30-34.9, 35-39.9, and ≥ 40) and weight (5 categories: < 60, 60-79, 80-99, 100-119, and ≥ 120 kg). Numbers of TJAs according to BMI categories (lowest to highest) were as follows: 2,956, 3,350, 1,908, 633, and 214, respectively. The main outcome was prosthetic joint infection. The mean follow-up time was 6.5 years (0.5-18 years).

RESULTS

111 prosthetic joint infections were observed: 68 postoperative, 16 hematogenous, and 27 of undetermined cause. Incidence rates were similar in the first 3 BMI categories (< 35), but they were twice as high with BMI 35-39.9 (adjusted HR = 2.1, 95% CI: 1.1-4.3) and 4 times higher with BMI ≥ 40 (adjusted HR = 4.2, 95% CI: 1.8-9.7). Weight ≥ 100 kg was identified as threshold for a significant increase in infection from the early postoperative period onward (adjusted HR = 2.1, 95% CI: 1.3-3.6).

INTERPRETATION

BMI ≥ 35 or weight ≥ 100 kg may serve as a cutoff for higher perioperative dosage of antibiotics.

Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms

OBJECTIVE

To assess reliability and construct validity of the Kellgren-Lawrence (K&L) scale in posttraumatic ankle osteoarthritis (OA); additionally evaluate the validity of including tibiotalar tilting in the scale.

METHOD

One-hundred and fifty ankle radiographs (75 patients, unilateral malleolar fractures) evaluated at average of 18 years after surgery. American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot (HF) score and pain (visual analog scale) were recorded. Grading of OA according to K&L criteria and identification of OA features was performed on standardized radiographs by four physicians. Minimal joint space width, sclerosis, and talar tilt angle were quantified by digital measurements. A modified K&L scale including talar tilting is presented. Validity of original and modified scale was evaluated and expressed as ability to (1) Identify those with clinical symptoms of ankle OA; and (2) Distinguish between different degrees of fracture severity.

RESULTS

Inter- and intra-observer reliability of OA assessment according to K&L were good (ICC 0.61 and 0.75). Original and modified K&L grades significantly increased with decreasing AOFAS ankle-HF scores and greater pain. A talar-tilt angle > 2° compared with ≤ 2° in grade 3 was associated with significantly higher pain levels (VAS pain 4.2 vs 1.4, respectively; mean difference 2.8, 95% CI 0.5-5.1). More severe fracture patterns at time of surgery were more often in patients with the highest K&L grades.

CONCLUSIONS

The K&L scale is a valid and reliable radiographic grading system for assessment of ankle OA. Inclusion of the talar tilt angle might allow for better differentiation with respect to clinical outcomes.

A comparative assessment of small-head metal-on-metal and ceramic-on-polyethylene total hip replacement

Large-head metal-on-metal (MoM) total hip replacements (THR) have given rise to concern. Comparative studies of small-head MoM THRs over a longer follow-up period are lacking. Our objective was to compare the incidence of complications such as infection, dislocation, revision, adverse local tissue reactions, mortality and radiological and clinical outcomes in small-head (28 mm) MoM and ceramic-on-polyethylene (CoP) THRs up to 12 years post-operatively. A prospective cohort study included 3341 THRs in 2714 patients. The mean age was 69.1 years (range 24 to 98) and 1848 (55.3%) were performed in women, with a mean follow-up of 115 months (18 to 201). There were 883 MoM and 2458 CoP bearings. Crude incidence rates (cases/1000 person-years) were: infection 1.3 vs 0.8; dislocation 3.3 vs 3.1 and all-cause revision 4.3 vs 2.2, respectively. There was a significantly higher revision rate after ten years (adjusted hazard ratio 9.4; 95% CI 2.6 to 33.6) in the MoM group, and ten of 26 patients presented with an adverse local tissue reaction at revision. No differences in mortality, osteolysis or clinical outcome were seen. In conclusion, we found similar results for small-head MoM and CoP bearings up to ten years post-operatively, but after ten years MoM THRs had a higher risk of all-cause revision. Furthermore, the presence of an adverse response to metal debris seen in the small-head MOM group at revision is a cause for concern.