[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.

Return to sport after shoulder arthroplasty: a systematic review

The main goal of this study was to determine the rate of return to sport (RTS) after shoulder arthroplasty.

A systematic review of the literature was performed using the PRISMA guidelines. All clinical studies written in English, French or German, with a level of evidence of 1 to 4, and evaluating return to sport after shoulder arthroplasty, were included.

A total of 23 studies were included with 2199 patients who underwent hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RSA). Mean age was 68 years (range 18 to 92.6), sex ratio (male:female) was 1:1.5. The surgery was performed on the non-dominant/dominant shoulder in 1:1.8 cases. The mean follow-up was 4.2 years. The rate of RTS was 75.5% with a mean time of 7 months. It was 77.4% for TSA, 75% for RSA and 71.2% for HA (P = non-significant).

RTS after shoulder arthroplasty is high, regardless the type of arthroplasty, with a trend for a higher rate after TSA. Patients who were able to maintain a sport activity preoperatively had a greater chance of RTS after arthroplasty. Failure to RTS seems to be mostly linked to the severity of the underlying condition and length of preoperative disability.

Cite this article: EFORT Open Rev 2021;6:771-778. DOI: 10.1302/2058-5241.6.200147

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.

A most hazardous year

Cite this article: EFORT Open Rev 2021;6:1-2. DOI: 10.1302/2058-5241.6.211000

EFORT Open Reviews: Turbulence

Cite this article: EFORT Open Rev 2020;5:568-569. DOI: 10.1302/2058-5241.5.200200

Congress Theme: Harmonisation and Diversity

Cite this article: EFORT Open Rev 2020;5:742-742. DOI: 10.1302/2058-5241.5.200202.

Shoulder biomechanics in normal and selected pathological conditions

The stability of the glenohumeral joint depends on soft tissue stabilizers, bone morphology and dynamic stabilizers such as the rotator cuff and long head of the biceps tendon. Shoulder stabilization techniques include anatomic procedures such as repair of the labrum or restoration of bone loss, but also non-anatomic options such as remplissage or tendon transfers.

Rotator cuff repair should restore the cuff anatomy, reattach the rotator cable and respect the coracoacromial arch whenever possible. Tendon transfer, superior capsular reconstruction or balloon implantation have been proposed for irreparable lesions.

Shoulder rehabilitation should focus on restoring balanced glenohumeral and scapular force couples in order to avoid an upward migration of the humeral head and secondary cuff impingement. The primary goal of cuff repair is to be as anatomic as possible and to create a biomechanically favourable environment for tendon healing.

Cite this article: EFORT Open Rev 2020;5:508-518. DOI: 10.1302/2058-5241.5.200006

'Frozen shoulder' is ill-defined. How can it be described better?

Frozen shoulder, a common and debilitating shoulder complaint, has been the subject of uncertainty within the scientific literature and clinical practice.

We performed an electronic PubMed search on all (1559) articles mentioning ‘frozen shoulder’ or ‘adhesive capsulitis’ to understand and qualify the range of naming, classification and natural history of the disease. We identified and reviewed six key thought leadership papers published in the past 10 years and all (24) systematic reviews published on frozen shoulder or adhesive capsulitis in the past five years.

This revealed that, while key thought leaders such as the ISAKOS Upper Extremity Council are unequivocal that ‘adhesive capsulitis’ is an inappropriate term, the long-term and short-term trends showed the literature (63% of systematic reviews assessed) preferred ‘adhesive capsulitis’.

The literature was divided as to whether or not to classify the complaint as primary only (9 of 24) or primary and secondary (9 of 24); six did not touch on classification.

Furthermore, despite a systematic review in 2016 showing no evidence to support a three-phase self-limiting progression of frozen shoulder, 11 of 12 (92%) systematic reviews that mentioned phasing described a three-phase progression. Eight (33%) described it as ‘self-limiting’, three (13%) described it as self-limiting in ‘nearly all’ or ‘most’ cases, and six (25%) stated that it was not self-limiting; seven (29%) did not touch on disease resolution.

We call for a data and patient-oriented approach to the classification and description of the natural history of the disease, and recommend authors and clinicians (1) use the term ‘frozen shoulder’ over ‘adhesive capsulitis’, (2) use an updated definition of the disease which recognizes the often severe pain suffered, and (3) avoid the confusing and potentially harmful repetition of the natural history of the disease as a three-phase, self-limiting condition.

Cite this article: EFORT Open Rev 2020;5:273-279.DOI: 10.1302/2058-5241.5.190032

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.

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.

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

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Shoulder apprehension: A multifactorial approach

Shoulder apprehension is related to changes in functional cerebral networks induced by dislocations, peripheral neuromuscular lesions and persistent mechanical glenohumeral instability consisting of micro-motion.All the damage to the osseous and soft-tissue stabilizers of the shoulder, as well as neurologic impairment persisting even after stabilization, must be properly identified in order to offer the best possible treatment to the patient.There is growing evidence supporting the use of a global multimodal approach, involving, on the one hand, shoulder 'reafferentation', including proprioception, mirror therapy and even cognitive behavioural approaches, and, on the other hand, surgical stabilization techniques and traditional physical therapy in order to minimize persistent micro-motion, which may help brain healing. This combined management could improve return to sport and avoid dislocation arthropathy in the long term. Cite this article: EFORT Open Rev 2018;3:550-557. DOI: 10.1302/2058-5241.3.180007.

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.

Non-compliance with IDSA guidelines for patients presenting with methicillin-susceptible Staphylococcus aureus prosthetic joint infection is a risk factor for treatment failure

OBJECTIVE

The long-term impact of treatment strategies proposed by the IDSA guidelines for patients presenting with methicillin-susceptible S. aureus (MSSA) prosthetic joint infection (PJI) is not well-known.

PATIENTS AND METHODS

Retrospective (2000-2010) cohort study including patients presenting with MSSA hip or knee PJI. A univariate Cox analysis was performed to determine if the non-compliance with IDSA surgical guidelines was a risk factor for treatment failure.

RESULTS

Eighty-nine patients with a mean follow-up of 2.8 years were included. Non-compliance with IDSA surgical guidelines was associated with treatment failure (hazard ratio 2.157; 95% CI [1.022-4.7]). The American Society of Anesthesiologists score, inadequate antimicrobial therapy, and a rifampicin-based regimen did not significantly influence patient outcome.

CONCLUSION

Based on the IDSA guidelines, if a patient presenting with MSSA PJI is not eligible for implant retention, complete implant removal is needed to limit treatment failure.

Revision rate after screw or plate arthrodesis of the glenohumeral joint

INTRODUCTION

Glenohumeral arthrodesis is a rare salvage procedure for selected patients with different shoulder pathologies. Among a variety of surgical techniques, compression screws or plate fixation are most widely used. Minimally invasive screw fixation has become more popular, although it has been shown to be biomechanically inferior to plate arthrodesis.

HYPOTHESIS

Screw arthrodesis would lead to a higher revision rate than plate arthrodesis.

MATERIAL AND METHODS

Twenty-seven plate and 7 screw arthrodesis of the glenohumeral joint in 19 male and 15 female patients of a mean age of 50years (range, 16-85years) were reviewed in a retrospective multicenter study with at a follow-up of 43months (range, 11-152months) to compare their clinical and radiographic outcome with special focus on revision rate.

RESULTS

Constant score did not change, but its subscore for pain significantly improved from 4.5 points (range, 0-15 points) to 11 points (range, 6-15 points). The subjective shoulder value increased significantly from 19% (range, 0-70%) to 41% (range, 10-80%) and 81% of the patients were satisfied. In 14 patients (41%), the arthrodesis had to be revised either for non-union (11) or malunion (3) at a mean of 12months (range, 0-47months). The 2 groups did not differ in terms of demographic data, nor of preoperative and postoperative clinical data. There were more revisions after screw than plate fixation. If revision was performed for non-union, this difference was significant.

DISCUSSION/CONCLUSION

In selected patients, glenohumeral arthrodesis can significantly reduce pain and achieve at best a reasonable function and subjective satisfaction rate. Revision rates favor plate over isolated screw fixation.

LEVEL OF EVIDENCE

IV retrospective series.

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.

One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial

OBJECTIVE

To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis.

PATIENTS AND METHODS

From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1- vs 2-stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days.

RESULTS

Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1-stage in 79 patients and 2-stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1-stage arm and 14 of 85 (16%) in the 2-stage arm (Pearson χ² test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1- vs 2-stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses' workload (605 vs 1055 points), and total costs (Sw₣6881 vs Sw₣11,178; all P<.01).

CONCLUSION

For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2-stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1-stage approach.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01406652.

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.

Brain activity in the right-frontal pole and lateral occipital cortex predicts successful post-operatory outcome after surgery for anterior glenoumeral instability

Shoulder apprehension is more complex than a pure mechanical problem of the shoulder, creating a scar at the brain level that prevents the performance of specific movements. Surgery corrects for shoulder instability at the physical level, but a re-dislocation within the first year is rather common. Predicting which patient will be likely to have re-dislocation is therefore crucial. We hypothesized that the assessment of neural activity at baseline and follow-up is the key factor to predict the post-operatory outcome. 13 patients with shoulder apprehension (30.03 ± 7.64 years) underwent clinical and fMRI examination before and one year after surgery for shoulder dislocation contrasting apprehension cue videos and control videos. Data analyses included task-related general linear model (GLM) and correlations imaging results with clinical scores. Clinical examination showed decreased pain and increased shoulder functions for post-op vs. pre-op. Coherently, GLM results show decreased activation of the left pre-motor cortex for post-surgery vs. pre-surgery. Right-frontal pole and right-occipital cortex activity predicts good recovery of shoulder function measured by STT. Our findings demonstrate that beside physical changes, changes at the brain level also occur one year after surgery. In particular, decreased activity in pre-motor and orbito-frontal cortex is key factor for a successful post-operatory outcome.

Classification of full-thickness rotator cuff lesions: a review

Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability.

Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, ‘Fosbury flop tears’, and musculotendinous lesions.

Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further.

Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. EFORT Open Rev 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.

Rivaroxaban for Thromboprophylaxis After Nonelective Orthopedic Trauma Surgery in Switzerland

This study investigated the effectiveness and the outcomes of rivaroxaban vs the standard of care for venous thromboembolic prophylaxis in patients undergoing fracture-related surgery. A total of 413 patients undergoing fracture-related surgery from 9 Swiss orthopedic and trauma centers were enrolled. The authors selected the type of venous thromboembolic prophylaxis according to standardized medical practice at the participating centers before the inclusion of patients: 208 patients received rivaroxaban and 205 received the standard of care. Data on symptomatic thromboembolic and bleeding events, surgery-related complications, death, adverse events, time to mobilization, and hospital discharge were collected. Symptomatic thromboembolic events were reported in 1 patient (0.5%) and 2 patients (1.0%) and treatment-emergent major bleeding events were reported in 1 patient (0.5%) and 2 patients (1.0%) receiving rivaroxaban and the standard of care, respectively. The durations of hospital stay and venous thromboembolic prophylaxis were similar in the 2 groups. In both groups, adverse events related to venous thromboembolic prophylaxis were reported in 12 patients. The proportion of patients with minor and major fracture surgery was 74.3% and 25.7%, respectively. In patients undergoing minor fracture surgery receiving rivaroxaban (n=167) and the standard of care (n=140), no symptomatic thromboembolic events and no major bleeding events were reported. Outcomes of this study indicate that rivaroxaban might be an appropriate oral alternative for venous thromboembolic prophylaxis in routine medical care after fracture-related major and minor surgery. Reported results were comparable to those from other large-scale, noninterventional and randomized controlled studies. [Orthopedics. 2017; 40(2):109-116.].

Structural white matter and functional connectivity alterations in patients with shoulder apprehension

Previous functional magnetic resonance imaging (fMRI) findings indicate that shoulder apprehension is more complex than a pure mechanical problem of the shoulder, showing a direct modification in functional brain networks associated with motor inhibition and emotional regulation. The current study extends these findings by investigating further structural alterations in patients with shoulder apprehension compared to controls. 14 aged patients with shoulder apprehension (27.3 ± 2.0 years) and 10 matched healthy controls (29.6 ± 1.3 years) underwent clinical and fMRI examination including fMRI and diffusion tensor imaging (DTI). Tract-based spatial statistics procedure was used to analyze white matter (WM) alterations. Functional images were analyzed investigating resting state network connectivity. DTI results were correlated with different shoulder clinical scores and functional connectivity networks. Fractional anisotropy (FA), representing white matter integrity, is increased in the left internal capsule and partially in the thalamus in patients compared to controls. Moreover, FA correlates negatively with simple shoulder test (SST) scores (p < .05) and positively with a functional connectivity network qualitatively replicating previous results (p < .01). This study extends previous findings, showing that in addition to functional changes, structural white matter changes are also present in patients with shoulder apprehension.

Comparison of dual-mobility cup and unipolar cup for prevention of dislocation after revision total hip arthroplasty

Background and purpose - Revision total hip arthroplasty (THA) is associated with higher dislocation rates than primary THA. We compared the risk of dislocation within 6 months and all-cause re-revision during the whole study period using either the dual-mobility cup or the unipolar cup. Methods - We used a prospective hospital registry-based cohort including all total and cup-only revision THAs performed between 2003 and 2013. The cups used were either dual-mobility or unipolar; the choice was made according to the preference of the surgeon. 316 revision THAs were included. The mean age of the cohort was 69 (25-98) years and 160 THAs (51%) were performed in women. The dual-mobility group (group 1) included 150 THAs (48%) and the mean length of follow-up was 31 (0-128) months. The unipolar group (group 2) included 166 THAs (53%) and the mean length of follow-up was 52 (0-136) months. Results - The incidence of dislocation within 6 months was significantly lower with the dual-mobility cup than with the unipolar cup (2.7% vs. 7.8%). The unadjusted risk ratio (RR) was 0.34 (95% CI: 0.11-1.02) and the adjusted RR was 0.28 (95% CI: 0.09-0.87). The number of patients needed to treat with a dual-mobility cup in order to prevent 1 case of dislocation was 19. The unadjusted incidence rate ratio for all-cause re-revision in the dual-mobility group compared to the unipolar group was 0.6 (95% CI: 0.3-1.4). Interpretation - Use of a dual-mobility rather than a unipolar cup in revision THA reduced the risk of dislocation within 6 months.

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.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Variables associated with remission in spinal surgical site infections

BACKGROUND

There is few medical literature regarding factors associated with remission after surgical and medical treatment of postoperative spine infections.

METHODS

Single-centre case-control study 2007-2014. Cluster-controlled Cox regression model with emphasis on surgical and antibiotic-related parameters.

RESULTS

Overall, we found 66 episodes in 48 patients (49 episodes with metalwork) who had a median follow-up of 2.6 years (range, 0.5 to 6.8 years). The patients had a median of two surgical debridements. The median duration of antibiotic therapy was 8 weeks, of which 2 weeks parenteral. Clinical recurrence after treatment was noted in 13 episodes (20%), after a median interval of 2 months. In 53 cases (80%), the episodes were considered as in remission. By multivariate analyses, no variable was associated with remission. Especially, the following factors were not significantly related to remission: number of surgical interventions [hazard ratio (HR) 0.9; 95% confidence interval (CI), 0.8-1.1]; infection due to Staphylococcus aureus (HR 0.9; 0.8-1.1), local antibiotic therapy (HR 1.2; 0.6-2.4), and, duration of total (HR 1.0; 0.99-1.01) (or just parenteral) (HR 1.0; 0.99-1.01) antibiotic use.

CONCLUSIONS

In patients with post-operative spine infections, remission is achieved in 80%. The number of surgical debridement or duration of antibiotic therapy shows no association with recurrence, suggesting that individual risk factors might be more important than the duration of antibiotic administration.

Neural Correlates of Clinical Scores in Patients with Anterior Shoulder Apprehension

INTRODUCTION

Anterior shoulder apprehension is a commonly reported complaint in anterior shoulder instability, which may lead to patient morbidity and impede shoulder function. It is the result of a cognitively complex mechanism, which includes anxiety, salience, fear, and anticipation.

PURPOSE

The aim of this prospective case-control study was to correlate five clinically established scores using functional magnetic resonance imaging to assess brain activation patterns in patients with apprehension related to anterior shoulder instability.

METHODS

This study includes 28 consecutive male right-handed patients (mean ± SEM, 26.8 ± 1.2 yr) with positive shoulder apprehension test and 10 healthy matched control participants without apprehension or a history of instability. Task-related and functional connectivity functional magnetic resonance imaging activation patterns occurring during apprehension video cue stimulation were correlated with five clinical tests and scores: Visual Analog Scale (VAS), Rowe score for instability, Simple Shoulder Test, Subjective Shoulder Value (SSV), and Western Ontario Shoulder Instability (WOSI).

RESULTS

Rowe, pain VAS, and WOSI scores correlated with prefrontal cortex, dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, somatosensory area, and parieto-occipital and temporal areas (default mode network). Rowe score additionally correlated with frontal pole, anterior midcingulate cortex, and visual areas. Moreover, SSV correlated with task-related brain activity in the bilateral precentral gyrus, bilateral postcentral gyrus, and bilateral superior parietal lobe.

CONCLUSIONS

Overall, Rowe score provides the strongest link between shoulder apprehension and brain level alterations as it correlates with the highest number of independent components involving areas responsible for both motor and cognitive functions, whereas pain VAS and WOSI occupy an intermediately strong link recruiting less brain networks. Finally, Simple Shoulder Test and SSV have the weakest link at the brain level.

Eight-year sustainability of a successful intervention to prevent urinary tract infection: A mixed-methods study

BACKGROUND

Data on long-term effects of interventions in infection control are scarce. We aimed to evaluate the 8-year sustainability of a successful intervention to reduce urinary tract infections (UTIs) through restriction of urinary catheter (UC) use in an orthopedic surgical population.

METHODS

Prospective UTI surveillance from November 2009-January 2010 was conducted to compare the results against the 2-year sustainability assessment performed in 2004. Semistructured staff interviews focused on UC indication, training, insertion techniques, and recall of the former intervention.

RESULTS

A total of 336 consecutive patients were included (median age, 63 years; range, 16-95 years; 55% women). A UC was placed in 17.6% of patients (operating room [OR], 10.1%; postanesthesia care unit [PACU], 3.6%; surgical wards [SW], 3.9%) compared with 20.0% in 2004 (OR, 15.7%; PACU, 1.0%; SW, 3.7%). The incidence rate of UTI was 2.4 per 1,000 patient-days in 2010 versus 2.6 per 1,000 patient-days in 2004; adjusted incidence rate ratio 0.76; 95% confidence interval, 0.21-2.76; P = .67. The qualitative inquiry demonstrated poor recall of the intervention and knowledge of guidelines except in the OR, where we identified a champion leader.

DISCUSSION

The intervention effect was sustained with regard to overall UTI rate and UC placement in the OR, but less in the PACU and SW.

CONCLUSIONS

Continuous leadership of a single opinion leader in a pivotal position can contribute critically to sustainability.

Gesture-Controlled Image Management for Operating Room: A Randomized Crossover Study to Compare Interaction Using Gestures, Mouse, and Third Person Relaying

OBJECTIVE

In this work, we aim at comparing formally three different interaction modes for image manipulation that are usable in a surgery setting: 1) A gesture-controlled approach using Kinect ®; 2) oral instructions to a third part dedicated to manipulate the images; and 3) direct manipulation using a mouse.

MATERIALS AND METHODS

Each participant used the radiology image viewer Weasis with the three interaction modes. In a crossover randomized controlled trial participants were attributed block wise to six experimental groups. For each group, the order for testing the three modes was randomly assigned. Nine standardized scenarios were used.

RESULTS

30 physicians and senior medical students participated in the experiment. Efficiency, measured as time used to pass the scenario, was best when using the mouse (M = 109.10s, SD = 25.96), followed by gesture-controlled (M = 214.97s, SD = 46.29) and oral instructions (M = 246.33s, SD = 76.50). Satisfaction, measured by a questionnaire, was rated highest in the condition mouse (M = 6.63, SD = 0.56), followed by gesture-controlled (M = 5.77, SD = 0.93) and oral instructions (M = 4.40, SD = 1.71). Differences in efficiency and satisfaction rating were significant. No significant difference in effectiveness, measured with error rates, was found.

DISCUSSION

The study shows with formal evaluation that the use of gestures is advantageous over instructions to a third person. In particular, the use of gestures is more efficient than verbalizing instructions. The given gestures could be learned easily and reliability of the tested gesture-control system is good.

CONCLUSION

Under the premise that mouse cannot be used directly during surgery, gesture-controlled approaches demonstrate to be superior to oral instructions for image manipulation.

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.

Reducing a Shoulder Dislocation Without Sweating. The Davos Technique and its Results. Evaluation of a Nontraumatic, Safe, and Simple Technique for Reducing Anterior Shoulder Dislocations

BACKGROUND

Anterior shoulder dislocation is a well-known injury for people working in emergency departments (EDs). Throughout the years, the focus has been shifted onto more gentle reduction techniques with less risk of iatrogenic injury, fracture displacement, and less pain for the patient. We present the results of one such technique, the Davos reduction maneuver, also known as the Boss-Holzach-Matter technique, as well as its advantages, disadvantages, and a few practical tips.

DISCUSSION

We evaluated, retrospectively, 100 patients presenting with an anteroinferior shoulder dislocation, who were treated in the ED of the university hospital of Geneva, Switzerland, in a time period of 18 months. In every case, the Davos technique was used for shoulder reduction. The detailed technique is described. Successful reduction was achieved in 86 patients. There were no neurological complications. Greater tuberosity fracture malreduction was noted in one case. Eighteen patients received no analgesia. Our results were comparable or superior to other reduction techniques.

CONCLUSION

We concluded that the Davos technique is an easy, nontraumatic, very well-tolerated, and most of all, safe way to reduce a shoulder. It is complication free and easy to apply, giving reproducible and comparable or superior results to other reduction techniques. At the same time, it is well tolerated by a compliant patient, which makes it an ideal first-time reduction technique for anterior shoulder dislocations.

[Clinical gait analysis: user guide]

Clinical gait analysis has become an indispensable medical examination for the management of patients with complex gait disorders. As its name suggests, the purpose of this examination is to assess patients whilst they are walking in a laboratory setting. Measurements include: 3 dimensional joint motion, forces applied to joints, and electromyographic muscle activity. This quantitative data allows identification of walking deviations and to deduce the likely causes of these deviations thanks to the clinical data available for each patient.

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.

Effect of Vancomycin Therapy for Osteomyelitis on Colonization by Methicillin-ResistantStaphylococcus aureus: Lack of Emergence of Glycopeptide Resistance

Background:

In treating orthopedic infections, the long-term impact of vancomycin therapy on colonization by methicillin-resistantStaphylococcus aureus(MRSA) and the emergence of vancomycin-intermediate S.aureusis unknown.

Design:

Prospective surveillance of the effect of long-term vancomycin therapy on colonization by MRSA and the emergence of vancomycin-intermediateS. aureus.

Methods:

Thirty-four patients with MRSA osteomyelitis that was microbiologically documented were longitudinally observed for the emergence of vancomycin-intermediate S.aureusat 3 body sites (wound, anterior nares, and groin) during the initial period of vancomycin therapy and at the 2-month follow-up. Twenty patients received the standard dose (20 mg/kg/d) for 34 ± 6 days and 14 patients received a high dose (40 mg/kg/d) of vancomycin for 37 ± 9 days.

Results:

During vancomycin treatment, global MRSA carriage (all body sites) fell from 100% to 25% in the group of patients receiving the standard dose of vancomycin, and from 100% to 40% in the group receiving the high dose. During the 2-month follow-up period after vancomycin therapy, global MRSA carriage increased from 25% to 55% in the group receiving the standard dose and decreased from 43% to 36% in the group receiving the high dose.

Conclusion:

Therapy with a high dose of vancomycin contributes to the sustained eradication of MRSA carriage without promoting the emergence of glycopeptide resistance.

[Shoulder arthroplasty: the situation in 2014]

Evolution of shoulder arthroplasty has led to mainly three types of implants: hemiarthroplasty, total shoulder arthroplasty and reverse shoulder arthroplasty. There is yet no clear consensus about indications for the different existing types of prothesis. The aim of this article is therefore to bring together and clarify the indications found in the current literature. Hemiarthroplasty, historically the first widely used implant, has lost much ground to total shoulder arthroplasty, and keeps its place only for specific situations. Total shoulder arthroplasty is mainly used for centered glenohumeral osteoarthritis, whereas reverse shoulder arthroplasty is indicated for most situations in which the rotator cuff or tuberoties are deficient.

[Incidence of major lower limb amputation in Geneva: twenty-one years of observation]

Between 1990 and 2010 the incidence of major lowerlimb amputations (by definition any level of amputation above the foot) in the canton of Geneva was 10.02 per 100,000 inhabitants/ year. The analysis of various population groups revealed that the presence of diabetes increased the relative risk of amputation by a factor of 20, and age 65 years or older by a factor of 9. During this 21 years period we observed a gradual decline in the incidence of amputation and an increased age at the time of amputation, despite the increasing prevalence of diabetes and an aging population. This was a reflection on the efforts of primary and secon- dary prevention, initiated in the 1980s in which Geneva was a pioneer.

Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review

The measure of radiographic pelvic and spinal parameters for sagittal balance analysis has gained importance in reconstructive surgery of the spine and particularly in degenerative spinal diseases (DSD). Fusion in the lumbar spine may result in loss of lumbar lordosis (LL), with possible compensatory mechanisms: decreased sacral slope (SS), increased pelvic tilt (PT) and decreased thoracic kyphosis (TK). An increase in PT after surgery is correlated with postoperative back pain. A decreased SS and/or abnormal sagittal vertical axis (SVA) after fusion have a higher risk of adjacent segment degeneration. High pelvic incidence (PI) increases the risk of sagittal imbalance after spine fusion and is a predictive factor for degenerative spondylolisthesis. Restoration of a normal PT after surgery is correlated with good clinical outcome. Therefore, there is a need for comparative prospective studies that include pre- and postoperative spinopelvic parameters and compare complication rate, degree of disability, pain and quality of life.

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.