Preliminary results of a new test for rapid diagnosis of septic arthritis with use of leukocyte esterase and glucose reagent strips
Mohamed Omar, Max Ettinger, Moritz Reichling, Maximilian Petri, Ralf Lichtinghagen, Daniel Guenther, Eduardo M Suero, Michael Jagodzinski, Christian Krettek
Journal of Bone and Joint Surgery. American Volume 2014 December 17, 96 (24): 2032-7
BACKGROUND: Most currently used tools to diagnose septic arthritis are either not readily available or fail to provide real-time results. Reagent strip tests have identified infections in various body fluids. We hypothesized that combined leukocyte esterase and glucose strip tests can aid in diagnosing septic arthritis in native synovial fluid because (1) leukocyte esterase concentrations would be elevated at the infection site because of secretion by recruited neutrophils, and (2) glucose concentrations would be reduced because of bacterial metabolism.
METHODS: We prospectively investigated synovial fluid from consecutive patients with an atraumatic joint effusion who underwent arthrocentesis in our emergency department during a one-year period. Leukocyte esterase and glucose strip tests were performed on the synovial fluid. Synovial fluid leukocyte count, crystal analysis, Gram staining, culture, and glucose concentration results were also assessed.
RESULTS: Nineteen fluids were classified as septic and 127 as aseptic. Considering septic arthritis to be present when the leukocyte esterase reading was positive (++ or +++) and the glucose reading was negative (-) yielded a sensitivity of 89.5% (95% confidence interval [CI], 66.9% to 98.7%), specificity of 99.2% (95% CI, 95.7% to 99.9%), positive predictive value of 94.4% (95% CI, 72.7% to 99.9%), negative predictive value of 98.4% (95% CI, 94.5% to 99.8%), positive likelihood ratio of 114, and negative likelihood ratio of 0.11. The synovial leukocyte counts and polymorphonuclear cell percentages were consistent with the semiquantitative readings on the leukocyte esterase strip tests, and the glucose concentrations were consistent with the glucose strip test results.
CONCLUSIONS: Combined leukocyte esterase and glucose strip tests can be a useful additional tool to help confirm or rule out a diagnosis of septic arthritis.
LEVEL OF EVIDENCE: Diagnostic Level II
30 diciembre 2014
Rodilla/Knee/Knie/Genou:¿Con menos complicaciones de lo imaginado?
The John Insall Award: Morbid Obesity Independently Impacts Complications, Mortality, and Resource Use After TKA
Michele R D'Apuzzo, Wendy M Novicoff, James A Browne
Clinical Orthopaedics and related Research 2015, 473 (1): 57-63
BACKGROUND: The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA.
QUESTIONS/PURPOSES: The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA.
METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m(2)) was determined using International Classification of Diseases, 9(th) Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis.
RESULTS: Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0-1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1-1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0-5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients.
CONCLUSIONS: Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA.
LEVEL OF EVIDENCE: Level II, prognostic study.
Michele R D'Apuzzo, Wendy M Novicoff, James A Browne
Clinical Orthopaedics and related Research 2015, 473 (1): 57-63
BACKGROUND: The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA.
QUESTIONS/PURPOSES: The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA.
METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m(2)) was determined using International Classification of Diseases, 9(th) Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis.
RESULTS: Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0-1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1-1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0-5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients.
CONCLUSIONS: Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA.
LEVEL OF EVIDENCE: Level II, prognostic study.
17 diciembre 2014
Rodilla/Knee: Tendencias de una década
Trends in Total Knee Arthroplasty Implant Utilization
Long-Co L. Nguyen, Mandeep Lehil, Kevin J. Bozic
The Journal of Arthroplasty
Published Online: December 13, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.12.009
Abstract
The incidence of total knee arthroplasty (TKA) has increased alongside our knowledge of knee physiology, kinematics, and technology resulting in an evolution of TKA implants. This study examines the trends in TKA implant utilization in the United States.
Data from 2001 to 2012 was extracted from The Orthopedic Research Network to evaluate trends in level of constraint, fixed vs. mobile bearing, fixation, and type of polyethylene.
In 2012, 88% of primary TKAs used cemented femoral and tibial implants. 38% of primary TKA implants were cruciate retaining, 53% posterior stabilized or condylar stabilized, 3% constrained. 91% was fixed-bearing, 7% mobile-bearing. 52% of tibial inserts were HXLPE.
TKA implant trends demonstrate a preference for cemented femoral and tibial components, fixed-bearing constructs, the use of metal-backed tibial components, and increased usage of HXLPE liners.
Long-Co L. Nguyen, Mandeep Lehil, Kevin J. Bozic
The Journal of Arthroplasty
Published Online: December 13, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.12.009
Abstract
The incidence of total knee arthroplasty (TKA) has increased alongside our knowledge of knee physiology, kinematics, and technology resulting in an evolution of TKA implants. This study examines the trends in TKA implant utilization in the United States.
Data from 2001 to 2012 was extracted from The Orthopedic Research Network to evaluate trends in level of constraint, fixed vs. mobile bearing, fixation, and type of polyethylene.
In 2012, 88% of primary TKAs used cemented femoral and tibial implants. 38% of primary TKA implants were cruciate retaining, 53% posterior stabilized or condylar stabilized, 3% constrained. 91% was fixed-bearing, 7% mobile-bearing. 52% of tibial inserts were HXLPE.
TKA implant trends demonstrate a preference for cemented femoral and tibial components, fixed-bearing constructs, the use of metal-backed tibial components, and increased usage of HXLPE liners.
Rodilla-cadera/Knee-Hip: Postoperatorio más gravoso a mayor ASA
The Association of ASA Class on Total Knee and Total Hip Arthroplasty Readmission Rates in an Academic Hospital
Jordan F. Schaeffer, Daniel J. Scott, Jonathan A. Godin, David E. Attarian, Samuel S. Wellman, Richard C. Mather III
The Journal of Arthroplasty
Published Online: December 16, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.12.01
Abstract
Total hip and knee arthroplasty are two of the most successful procedures in orthopaedics. However, with the increasing demand, estimated future costs for these procedures are enormous. Recent data suggests that post-discharge care may account for up to 35% of total episode payments. Yet, little is known about targets that can help improve quality and reduce cost. This retrospective study shows that an ASA score of ≥3 is associated with a 2.9 times (p = 0.0082) greater risk of re-admission in total joint arthroplasty patients. The current literature corroborates this finding by demonstrating an increase risk of post-operative complications in patients with an ASA of ≥3. Therefore, the ASA score is a potential target for interventions designed to increase quality and lower cost in arthroplasty patients.
Jordan F. Schaeffer, Daniel J. Scott, Jonathan A. Godin, David E. Attarian, Samuel S. Wellman, Richard C. Mather III
The Journal of Arthroplasty
Published Online: December 16, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.12.01
Abstract
Total hip and knee arthroplasty are two of the most successful procedures in orthopaedics. However, with the increasing demand, estimated future costs for these procedures are enormous. Recent data suggests that post-discharge care may account for up to 35% of total episode payments. Yet, little is known about targets that can help improve quality and reduce cost. This retrospective study shows that an ASA score of ≥3 is associated with a 2.9 times (p = 0.0082) greater risk of re-admission in total joint arthroplasty patients. The current literature corroborates this finding by demonstrating an increase risk of post-operative complications in patients with an ASA of ≥3. Therefore, the ASA score is a potential target for interventions designed to increase quality and lower cost in arthroplasty patients.
Rodilla/Knee/Knie/Genou: la prótesis unicondílea lateral parece ir bien
The Current Trends for Lateral Unicondylar Knee Arthroplasty
Keith R. Berend, Nathan J. Turnbull, Robert E. Howell, Adolph V. Lombardi
Orthop Clinics of North America
Published Online: December 03, 2014
DOI: http://dx.doi.org/10.1016/j.ocl.2014.10.001
Unicompartmental osteoarthritis of the knee is a relatively common disease that is seen in 40% of the population. Although disease isolated to the medial compartment of the knee is more common, isolated lateral disease also frequently exists (25% vs 10%). However, surgeons perform medial unicondylar knee replacement at a ratio of 10:1 when compared with lateral unicondylar knee replacement. This may be attributed to lack of familiarity or the increased difficulty of the procedure. Recent literature suggests that with proper patient selection, surgical technique, and implant choice, early survivorship ranges from 95% to 99%.
Keith R. Berend, Nathan J. Turnbull, Robert E. Howell, Adolph V. Lombardi
Orthop Clinics of North America
Published Online: December 03, 2014
DOI: http://dx.doi.org/10.1016/j.ocl.2014.10.001
Unicompartmental osteoarthritis of the knee is a relatively common disease that is seen in 40% of the population. Although disease isolated to the medial compartment of the knee is more common, isolated lateral disease also frequently exists (25% vs 10%). However, surgeons perform medial unicondylar knee replacement at a ratio of 10:1 when compared with lateral unicondylar knee replacement. This may be attributed to lack of familiarity or the increased difficulty of the procedure. Recent literature suggests that with proper patient selection, surgical technique, and implant choice, early survivorship ranges from 95% to 99%.
15 diciembre 2014
Rodilla/Knee/Knie/Genou: Por el bien de todos, cuanto antes mucho mejor
Joint infection after knee arthroscopy: Medicolegal aspects
S. Marmora,T. Farmanb, A. Lortat-Jacobc
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 278—283
Summary
Introduction:
Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon’s liability. This study analyzes the context of such infection occurrences, their management as well as their medicolegal consequences.
Patients and methods:
Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medical liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrol- ysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.
Results:
Clinical signs of septic arthritis appeared after a median interval of 8 days (0—37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1—9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0—20), a total temporary work incapacity of 120 days (40—790), a suffering burden averaging 3 out of 7 (0—4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.
Discussion:
Some risk factors of articular infection are known and well-identified. They can be linked to the patient’s condition (addiction to smoking, surgical history, professional activity) or to medical management (intra-articular corticoid injections, interventions under oral anti- coagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid’s inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic management of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.
Level of evidence: Level IV; economic and decision analysis, retrospective study.
KEYWORDS
Knee;
Septic arthritis; Arthroscopy; Complications; Medicolegal
S. Marmora,T. Farmanb, A. Lortat-Jacobc
Orthopaedics & Traumatology: Surgery & Research (2009) 95, 278—283
Summary
Introduction:
Septic knee arthritis following arthroscopy is a rare but dreaded complication: it might compromise patients’ functional prognosis and engage surgeon’s liability. This study analyzes the context of such infection occurrences, their management as well as their medicolegal consequences.
Patients and methods:
Twenty-two cases of knee septic arthritis following arthroscopy were examined during the medicolegal litigation process and collected for assessment from a medical liability specialised insurer. Half of the patients were manual workers who worked on their knees, and seven knees had a previous surgical history. The procedures performed at arthroscopy included seven ligamentoplasties, nine meniscotomies, three arthroscopic lavages, one arthrol- ysis, one chondroma removal and one plica resection. Seven patients, to some point, received corticosteroids: three preoperative joint injections, three intraoperative injections, and one oral corticotherapy.
Results:
Clinical signs of septic arthritis appeared after a median interval of 8 days (0—37), twice after a hemarthrosis and once after an articular burn. The median delay before treatment initiation was 4.2 days, and in 10 cases this therapeutic delay exceeded 3 days. On average, 3.5 additional procedures (1—9) were required to treat the infection and its residual sequels. Two total knee prostheses were implanted. Only two patients were free of disabling sequellae, and in five patients these sequels affected their livelihood. The medicolegal consequences were a partially permanent disability averaging 5% (0—20), a total temporary work incapacity of 120 days (40—790), a suffering burden averaging 3 out of 7 (0—4,5) points on the scale conventionally used in France. Twelve of these legal claims led to court ordered patient compensation.
Discussion:
Some risk factors of articular infection are known and well-identified. They can be linked to the patient’s condition (addiction to smoking, surgical history, professional activity) or to medical management (intra-articular corticoid injections, interventions under oral anti- coagulants, inadvertently overheated irrigation fluid). When infection is suspected, it is often the needle-aspirated fluid’s inappropriate handling (such as absence of bacteriological testing or defective waiting time for the results), which delays the diagnostic or therapeutic management of this complication. All failures of infection diagnosis or treatment heavily contribute to malpractice claims against the surgeon. Early and appropriate management of postoperative infections helps limiting the risk of functional sequellae for the patient and reduces the risk of malpractice litigation for the practitioner.
Level of evidence: Level IV; economic and decision analysis, retrospective study.
KEYWORDS
Knee;
Septic arthritis; Arthroscopy; Complications; Medicolegal
14 diciembre 2014
Rodilla/Knee/Knie/Genou: Es fácil dañar las ramas del safeno al extraer los tendones
The Course And Distribution Of The Infra Patellar Nerve In Relation To Acl Reconstruction
T. Walshaw , S.V. Karuppiah , I. Stewart
The Knee
Publication date: Available online 26 November 2014
Introduction
A common complication after ACL (anterior cruciate ligament reconstruction) is injury to the infra-patellar branch of the saphenous nerve (IPBSN). Very little about its origin and course of this nerve has been described. The aim of this study was to understand the course of IPBSN in relation to surgery around the knee.
Materials and method
The course of the nerve was dissected and traced in 25 knees from 14 cadaveric knees (10 male; 4 female). An incision was made posterior to the medial condyle of the tibia and continued deeper towards the saphenous nerve which is located under the sartorius muscle. The sapheneous nerve branch was then followed distally supply the anterior leg (IPBSN). The relationship of saphenous nerve and IPBSN to each other and the hamstrings were recorded
Results
Four paths of IPBSN, in relation to the Sartorius muscle, were identified: (1) posterior - inferior posterior border of the muscle, (2) transmuscular - penetrating through the muscle, (3) anterior - anterior border of the muscle, (4) posterior patellar - posterior of the muscle at the level of the patellar bone and (5) combined The posterior pathway of IPSBN was the most common (57%) and had the closest proximity to the tendons of semintendinosus and gracilis muscles. The terminal branches of the IPSBN crossed over the patella tendon in every dissection.
Conclusions
A posterior path IPBSN is more prone to damage during a tendon harvest due to its proximity to the gracilis and semitendinosus muscle tendons.
A common complication after ACL (anterior cruciate ligament reconstruction) is injury to the infra-patellar branch of the saphenous nerve (IPBSN). Very little about its origin and course of this nerve has been described. The aim of this study was to understand the course of IPBSN in relation to surgery around the knee.
Materials and method
The course of the nerve was dissected and traced in 25 knees from 14 cadaveric knees (10 male; 4 female). An incision was made posterior to the medial condyle of the tibia and continued deeper towards the saphenous nerve which is located under the sartorius muscle. The sapheneous nerve branch was then followed distally supply the anterior leg (IPBSN). The relationship of saphenous nerve and IPBSN to each other and the hamstrings were recorded
Results
Four paths of IPBSN, in relation to the Sartorius muscle, were identified: (1) posterior - inferior posterior border of the muscle, (2) transmuscular - penetrating through the muscle, (3) anterior - anterior border of the muscle, (4) posterior patellar - posterior of the muscle at the level of the patellar bone and (5) combined The posterior pathway of IPSBN was the most common (57%) and had the closest proximity to the tendons of semintendinosus and gracilis muscles. The terminal branches of the IPSBN crossed over the patella tendon in every dissection.
Conclusions
A posterior path IPBSN is more prone to damage during a tendon harvest due to its proximity to the gracilis and semitendinosus muscle tendons.
08 diciembre 2014
Cadera/Hip/Hüfte/Hanche: un agujerito para ver el futuro
Can we predict femoral head vitality during surgical hip dislocation?
Alessandro Aprato, Andrea Bonani, Matteo Giachino, Marco Favuto, Francesco Atzori, Alessandro Masse
Journal of Hip Preservation Surgery Volume 1, Issue 2, Pp. 77-81.
Abstract
Purpose
Surgical hip dislocation is commonly performed in orthopaedic surgery for several pathologies that often present risk of avascular necrosis (AVN) of femoral head. Observation of blood spilling out from a drill hole, performed in the head after dislocation, has been proposed as a predictive test for AVN. No data have been published about test reliability. Study’s aim was to evaluate the correlation between ‘bleeding sign’ and AVN in surgical dislocation for elective disease and for acetabular fractures.
Methods
All patients meeting the indication for surgical dislocation were included in this prospective study. Patients with follow-up shorter than 8 months were excluded. Intra-operative assessment of head vascularity was performed in 44 patients through the ‘bleeding sign’: a 2.0-mm drill hole carried out on the head during surgery. A positive bleeding test was considered an immediate appearance of active bleeding. Development of AVN was considered the main outcome. Necrosis group criteria were detection of type II, III or IV X-ray according to Ficat classification.
Results
Forty-four patients with selected acetabular fractures, slipped capital femoral epiphysis and femoral head deformity were enrolled. Mean age was 25 years and mean follow-up was 36 months. Thirty-eight patients presented positive intra-operative bleeding sign and six demonstrated no bleeding. Sensitivity for the ‘bleeding sign’ was 97%, specificity was 83%, positive predictive value was 97%, negative predictive value was 83% and accuracy was 95% (P < 0.001).
Conclusions
Bleeding after head drilling is a reliable test for AVN in patients who undergo a surgical hip dislocation.
Cadera/Hip/Hüfte/Hanche: no siempre es trocanteritis
Intra-articular hip injections for lateral hip pain
Matthew C. Bessette, Joshua R. Olsen, Tobias R. Mann and Brian D. Giordano
Journal of Hip Preservation Surgery Volume 1, Issue 2Pp. 71-76.
Abstract
Occult intra-articular hip pathology is commonly found in patients with greater trochanteric pain syndrome, and may be a possible pain generator in patients with recalcitrant lateral hip pain. We investigated the effect of intra-articular hip injections in patients with recalcitrant lateral hip pain. Between September 2012 and May 2013, patients over the age of 18 with a history lateral hip pain who had received prior treatment with non-steroidal anti-inflammatory medications, physical therapy and peritrochanteric corticostroid injections were enrolled. Treatment consisted of an ultrasound guided intra-articular corticosteroid injection followed by a course of directed physical therapy and a non-steroidal anti-inflammatory medication. Patients performed GaitRite analysis at baseline and 12 weeks following the injection. In addition, the Modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Scores (HOS), Short Form 36 (SF-36) and a visual analogue pain score (VAS) were collected at baseline, 1, 6 and 12 weeks.A total of 16 patients were studied. Patients experienced significant improvements from their baseline mHHS at 1 and 12 weeks (P = 0.03, P = 0.04). The minimal clinically important difference (MCID) was exceeded at multiple timepoints on various clinical outcome surveys. Velocity and stride length were not significantly improved at 12 weeks. Intra-articular hip injections may decrease pain and improve function in patients with recalcitrant lateral hip pain, and occult intra-articular hip pathology should be considered in the etiology of lateral hip pain. Though low enrollment numbers left this study underpowered, MCID comparisons demonstrated potential benefit from this treatment.
07 diciembre 2014
Cadera/Hip/Hüfte/Hanche: osteotomía valguizante cuando no una el cuello femoral
Managing Failed Fixation: Valgus osteotomy for femoral neck nonunion
D.E Deakin, P Guy, P.J O’Brien, P.A Blachut, K.A Lefaivre
Published Online: December 05, 2014
DOI: http://dx.doi.org/10.1016/j.injury.2014.11.022
Abstract
Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.
30 noviembre 2014
Mano/Hand/Main: Mujer con un dedo en gatillo, infiltra primero
Long-term outcomes following a single corticosteroid injection for trigger finger.
Wojahn RD, Foeger NC, Gelberman RH, Calfee RP.
J Bone Joint Surg Am. 2014 Nov 19;96(22):1849-54
Abstract
BACKGROUND:
The outcomes of corticosteroid injection for trigger finger are well documented only with short-term follow-up. The purpose of this investigation was to determine the long-term effectiveness of a single injection and to examine predictors of success up to ten years after injection.
METHODS:
This case series analyzed 366 first-time corticosteroid injections in flexor tendon sheaths from January 2000 to December 2007 with a minimum follow-up duration of five years. Two hundred and forty patients (66%) were female, 161 patients (44%) had multiple trigger fingers, and eighty-eight patients (24%) had diabetes at the time of injection. The primary outcome of treatment failure was defined as subsequent injection or surgical trigger finger release of the affected digit. Medical records were reviewed, and any patients without documented failure or a return office visit in 2012 to 2013 were contacted by telephone regarding symptom recurrence and the need for additional treatment. Kaplan-Meier analyses with log-rank test and Cox regression analysis assessed the effect of baseline patient and disease characteristics on injection success.
RESULTS:
Forty-five percent of patients demonstrated long-term treatment success after a single injection. In the final regression model, the interaction of sex and the number of trigger fingers was the single predictor of treatment success. Exploring this association revealed a ten-year success rate of 56% for female patients presenting for the first time with a trigger finger compared with 35% in male patients presenting for the first time with a trigger finger, 39% in female patients with multiple trigger fingers, and 37% in male patients with multiple trigger fingers. Eighty-four percent of treatment failures occurred within the first two years following injection. Patient age, symptom type, and undifferentiated diabetes status were not predictive of treatment success.
CONCLUSIONS:
Female patients presenting with their first trigger finger have the highest rate of long-term treatment success after a single corticosteroid injection. Patients who continue to experience symptom relief two years after injection are likely to maintain long-term success.
LEVEL OF EVIDENCE:
Therapeutic Level IV
Rodilla/Knee/Knie/Genou: Rx de pie pero con las rodillas dobladas
Sensitivity of Standing Radiographs to Detect Knee Arthritis: A Systematic Review of Level I Studies.
Duncan, Khazzam, Burnham, Spindler, Dunn, Wright.
Arthroscopy. 2014 Oct 10. doi: 10.1016/j.arthro.2014.08.023. [Epub ahead of print]
Abstract
PURPOSE:
The purpose of this study was to perform a systematic review of the available literature to define the level of quality evidence for determining the sensitivity and specificity of different radiographic views in detecting knee osteoarthritis and to determine the impact of different grading systems on the ability to detect knee osteoarthritis.
METHODS:
A systematic review of the literature was conducted to identify studies that evaluated the standing anteroposterior (AP) and 45° posteroanterior (PA) views for tibiofemoral and patellofemoral arthritis and those comparing the use of the Kellgren-Lawrence versus the joint space narrowing (JSN) radiographic grading systems using arthroscopy as the gold standard. A comprehensive search of PubMed, Scopus, CINAHL, the Cochrane Database, Clinicaltrial.gov, and EMBASE was performed using the keywords "osteoarthritis," "knee," "x-ray," "sensitivity," and "arthroscopy."
RESULTS:
Six studies were included in the evaluation. The 45° flexion PA view showed a higher sensitivity than the standing AP view for detecting severe arthritis involving either the medial or lateral tibiofemoral compartment. There was no difference in the specificities for the 2 views. The direct comparison of the Kellgren-Lawrence and the JSN radiographic grading systems found no clinical difference between the 2 systems regarding the sensitivities, although the specificity was greater for the JSN system.
CONCLUSIONS:
The ability to detect knee osteoarthritis continues to be difficult without using advanced imaging. However, as an inexpensive screening tool, the 45° flexion PA view is more sensitive than the standing AP view to detect severe tibiofemoral osteoarthritis. When evaluating the radiograph for severe osteoarthritis using either the Kellgren-Lawrence or JSN grading system, there is no clinical difference in the sensitivity between the 2 methods; however, the JSN may be more specific for ruling in severe osteoarthritis in the medial compartment.
LEVEL OF EVIDENCE:
Level I, systematic review of Level I studies.
Rodilla/Knee/Knie/Genou: con unos pinchazos no duele la ptr
Periarticular Regional Analgesia in Total Knee Arthroplasty
A Review of the Neuroanatomy and Injection Technique
George N. Guild III, Rubin P. Galindo, Joseph Marino, Fred D. Cushner, Giles R. Scuderi
Orthopedic Clinics
Volume 46, Issue 1, Pages 1–8, January 2015
Perioperative pain control after total knee arthroplasty may be insufficient, resulting in insomnia, antalgic ambulation, and difficulty with rehabilitation. Current strategies, including the use of femoral nerve catheters, may control pain but have been associated with falls, motor blockade, and quadriceps inhibition. Periarticular infiltration using the appropriate technique and knowledge of intraarticular knee anatomy may increase pain control and maximize rehabilitation.
A Review of the Neuroanatomy and Injection Technique
George N. Guild III, Rubin P. Galindo, Joseph Marino, Fred D. Cushner, Giles R. Scuderi
Orthopedic Clinics
Volume 46, Issue 1, Pages 1–8, January 2015
Perioperative pain control after total knee arthroplasty may be insufficient, resulting in insomnia, antalgic ambulation, and difficulty with rehabilitation. Current strategies, including the use of femoral nerve catheters, may control pain but have been associated with falls, motor blockade, and quadriceps inhibition. Periarticular infiltration using the appropriate technique and knowledge of intraarticular knee anatomy may increase pain control and maximize rehabilitation.
Rodilla/Knee/Knie/Genou: Una buena rodillera para la artrosis
Strength and Functional improvement using Pneumatic Brace with Extension Assist for End-Stage Knee Osteoarthritis: A Prospective, Randomized trial
Jeffrey J. Cherian, Anil Bhave, Bhaveen H. Kapadia, Roland Starr, Mark J. McElroy, Michael A.
The Journal of Arthroplasty
Published Online: November 28, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.036
Publication stage: In Press Accepted Manuscript
Abstract
Pneumatic unloader bracing with extension assists have been proposed as a non-operative modality that may delay the need for knee surgery by reducing pain and improving function.
This prospective, randomized, single blinded trial evaluated 52 patients who had knee osteoarthritis for changes in: (1) muscle strength; (2) objective functional improvements; (3); subjective functional improvements; (4) pain; (5) quality of life; and (6) conversion to total knee arthroplasty (TKA) compared to standard of care.
Patient outcomes were evaluated at a minimum 3 months. Braced patient’s demonstrated significant improvements in muscle strength, several functional tests, and patient reported outcomes when compared to the matched cohort.
These results are encouraging and suggest that this device may represent a promising alternative to standard treatment methods for knee osteoarthritis.
Jeffrey J. Cherian, Anil Bhave, Bhaveen H. Kapadia, Roland Starr, Mark J. McElroy, Michael A.
The Journal of Arthroplasty
Published Online: November 28, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.036
Publication stage: In Press Accepted Manuscript
Abstract
Pneumatic unloader bracing with extension assists have been proposed as a non-operative modality that may delay the need for knee surgery by reducing pain and improving function.
This prospective, randomized, single blinded trial evaluated 52 patients who had knee osteoarthritis for changes in: (1) muscle strength; (2) objective functional improvements; (3); subjective functional improvements; (4) pain; (5) quality of life; and (6) conversion to total knee arthroplasty (TKA) compared to standard of care.
Patient outcomes were evaluated at a minimum 3 months. Braced patient’s demonstrated significant improvements in muscle strength, several functional tests, and patient reported outcomes when compared to the matched cohort.
These results are encouraging and suggest that this device may represent a promising alternative to standard treatment methods for knee osteoarthritis.
Hombro/Shoulder/Schulter/Épaule: Tromboprofilaxis sólo si hubo tromboembolismo previo
Risk of venous thromboembolism after shoulder arthroplasty in the Medicare population
Judd S. Day, Matthew L. Ramsey, Edmund Lau, Gerald R. Williams
Journal of Shoulder and Elbow Surgery
Volume 24, Issue 1, Pages 98–105, January 2015
Background
Chemoprophylaxis for venous thromboembolism (VTE) is considered standard of care after lower but not after upper extremity arthroplasty. Medicare claims data were analyzed to determine the national incidence of symptomatic VTE after shoulder arthroplasty during the index surgical admission and after discharge.
Methods
Incidence of VTE was compared between shoulder arthroplasty and lower extremity arthroplasty, and patient-specific risk factors for pulmonary embolism were determined for shoulder arthroplasty. Finally, the incidence of surgical site bleeding was determined for each type of procedure.
Results
VTE complications occurred in 1.2% of lower extremity and 0.53% of shoulder arthroplasties. Patient factors that were associated with an increased risk of VTE included a principal diagnosis of fracture, history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, alcohol abuse, and obesity. Adjusted rates of VTE were generally higher for lower extremity compared with shoulder arthroplasties. Prevalence of readmission for VTE was higher for shoulder hemiarthroplasty than for total shoulder arthroplasty. Wound hematoma rates were similar between shoulder and lower extremity procedures.
Conclusions
VTE rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty. We believe that the risk of bleeding combined with the lower rates of VTE with existing lower rates of chemoprophylaxis does not warrant the routine use of anticoagulation. Use of mechanical prophylaxis combined with aspirin may be sufficient for shoulder arthroplasty patients who are not at increased risk of VTE. Chemoprophylaxis with agents other than aspirin may be warranted in patients with a demonstrated risk of VTE.
Level of evidence:
Epidemiology Study, Database Analysis with Survey of Experts
Judd S. Day, Matthew L. Ramsey, Edmund Lau, Gerald R. Williams
Journal of Shoulder and Elbow Surgery
Volume 24, Issue 1, Pages 98–105, January 2015
Background
Chemoprophylaxis for venous thromboembolism (VTE) is considered standard of care after lower but not after upper extremity arthroplasty. Medicare claims data were analyzed to determine the national incidence of symptomatic VTE after shoulder arthroplasty during the index surgical admission and after discharge.
Methods
Incidence of VTE was compared between shoulder arthroplasty and lower extremity arthroplasty, and patient-specific risk factors for pulmonary embolism were determined for shoulder arthroplasty. Finally, the incidence of surgical site bleeding was determined for each type of procedure.
Results
VTE complications occurred in 1.2% of lower extremity and 0.53% of shoulder arthroplasties. Patient factors that were associated with an increased risk of VTE included a principal diagnosis of fracture, history of VTE, cardiac arrhythmia, presence of a metastatic tumor, coagulopathy, congestive heart failure, alcohol abuse, and obesity. Adjusted rates of VTE were generally higher for lower extremity compared with shoulder arthroplasties. Prevalence of readmission for VTE was higher for shoulder hemiarthroplasty than for total shoulder arthroplasty. Wound hematoma rates were similar between shoulder and lower extremity procedures.
Conclusions
VTE rates after shoulder arthroplasty were generally lower than those after lower extremity arthroplasty. We believe that the risk of bleeding combined with the lower rates of VTE with existing lower rates of chemoprophylaxis does not warrant the routine use of anticoagulation. Use of mechanical prophylaxis combined with aspirin may be sufficient for shoulder arthroplasty patients who are not at increased risk of VTE. Chemoprophylaxis with agents other than aspirin may be warranted in patients with a demonstrated risk of VTE.
Level of evidence:
Epidemiology Study, Database Analysis with Survey of Experts
27 noviembre 2014
Cadera/Hip/Hüfte/Hanche: Más cabezonas pero más estables
Dislocation Rates Following Primary Total Hip Arthroplasty Have Plateaued in the Medicare Population
Akshay Goel, Edmund Lau, Kevin L. Ong, Daniel J. Berry, Arthur L. Malkani
The Journal of Arthroplasty
Accepted: November 18, 2014;
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.012
Abstract
Dislocation remains one of the most frequent complications following total hip replacement. Numerous risk factors predisposing patients to dislocation have been identified. Larger diameter femoral heads (32 mm or larger) came into common use in the mid 2000’s have been shown to improve hip stability. The purpose of this study was to determine if the use of larger femoral head diameters, in combination with recent practice including enhanced soft tissue choices and various operative exposure choices has led to any further decline in dislocation rates following primary total hip arthroplasty. The study included 51,901 patients undergoing primary THA identified from 5% Medicare Part B (physician/carrier) claims between January 1, 1997 and December 31, 2011. Dislocation rate at 6 months following THA was 2.84% over the study period (1997–2011). From 2005–2011, dislocation rates following primary THA have plateaued in the United States at approximately 2%. This suggests that the full benefits using large femoral head sizes now realized. For further improvement in dislocation rates, a greater emphasis will be required on patient selection, surgical technique and component alignment.
Akshay Goel, Edmund Lau, Kevin L. Ong, Daniel J. Berry, Arthur L. Malkani
The Journal of Arthroplasty
Accepted: November 18, 2014;
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.012
Abstract
Dislocation remains one of the most frequent complications following total hip replacement. Numerous risk factors predisposing patients to dislocation have been identified. Larger diameter femoral heads (32 mm or larger) came into common use in the mid 2000’s have been shown to improve hip stability. The purpose of this study was to determine if the use of larger femoral head diameters, in combination with recent practice including enhanced soft tissue choices and various operative exposure choices has led to any further decline in dislocation rates following primary total hip arthroplasty. The study included 51,901 patients undergoing primary THA identified from 5% Medicare Part B (physician/carrier) claims between January 1, 1997 and December 31, 2011. Dislocation rate at 6 months following THA was 2.84% over the study period (1997–2011). From 2005–2011, dislocation rates following primary THA have plateaued in the United States at approximately 2%. This suggests that the full benefits using large femoral head sizes now realized. For further improvement in dislocation rates, a greater emphasis will be required on patient selection, surgical technique and component alignment.
Cadera/Hip/Hüfte/Hanche: A conducir mucho antes que antes
When is it Safe for Patients to Drive after Right Total Hip Arthroplasty?
Victor H. Hernandez, Alvin Ong, Fabio Orozco, Anne M. Madden, Zachary
The Journal of Arthroplasty
Online: November 25, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.015
Abstract
Old studies recommend 6 weeks post-op before patients can return to driving safely. This is a prospective study assessing brake reaction time (BRT) after THA. 38 patients underwent a pre-op, 2, 4 and 6 weeks post op BRT test. General Linear Repeated Measurement was used. The mean pre-op reaction time was 0.635+/-0.160 sec SD and 2-week was 0.576+/-0.137 sec SD(p = 0.029); 33 patients (87 %) were able to reach their baseline time by 2 weeks. The remaining five patients (13%) reached their baseline at the 4-week post-op. No differences were found with respect to age, gender, and the use of assistive devices. With new techniques in THA, most of patients return to normal times within the 2-week.
Victor H. Hernandez, Alvin Ong, Fabio Orozco, Anne M. Madden, Zachary
The Journal of Arthroplasty
Online: November 25, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.015
Abstract
Old studies recommend 6 weeks post-op before patients can return to driving safely. This is a prospective study assessing brake reaction time (BRT) after THA. 38 patients underwent a pre-op, 2, 4 and 6 weeks post op BRT test. General Linear Repeated Measurement was used. The mean pre-op reaction time was 0.635+/-0.160 sec SD and 2-week was 0.576+/-0.137 sec SD(p = 0.029); 33 patients (87 %) were able to reach their baseline time by 2 weeks. The remaining five patients (13%) reached their baseline at the 4-week post-op. No differences were found with respect to age, gender, and the use of assistive devices. With new techniques in THA, most of patients return to normal times within the 2-week.
Rodilla/Knee/Knie/Genou: Para qué al año si no mejora la atención
Assessing the utility of routine first annual follow-up visits after primary total knee arthroplasty
Cale A. Jacobs, Christian P. Christensen, Tharun Karthikeyan
The Journal of Arthroplasty
Published Online: November 25, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.016
Abstract
The combination of increased TKA utilization and a decreased number of arthroplasty specialists has resulted in a growing need to maximize efficiency without sacrificing the level of care being provided. The purpose of this study was to evaluate the utility of routine first annual follow-up visits for patients that have undergone primary TKA. In order to do so, we determined the current follow-up rate for these visits and the number of revisions that were performed for a complication that was first detected at the routine first annual follow-up visit. Of 339 TKAs performed in 2012, 71 patients failed to attend scheduled first annual visits. Furthermore, none of the revisions performed at our facility since 2003 were the direct result of information gained at a patient’s routine first annual visit. As such, we question the clinical utility of the first annual visit and are evaluating an evidence-based follow-up protocol.
Cale A. Jacobs, Christian P. Christensen, Tharun Karthikeyan
The Journal of Arthroplasty
Published Online: November 25, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.016
Abstract
The combination of increased TKA utilization and a decreased number of arthroplasty specialists has resulted in a growing need to maximize efficiency without sacrificing the level of care being provided. The purpose of this study was to evaluate the utility of routine first annual follow-up visits for patients that have undergone primary TKA. In order to do so, we determined the current follow-up rate for these visits and the number of revisions that were performed for a complication that was first detected at the routine first annual follow-up visit. Of 339 TKAs performed in 2012, 71 patients failed to attend scheduled first annual visits. Furthermore, none of the revisions performed at our facility since 2003 were the direct result of information gained at a patient’s routine first annual visit. As such, we question the clinical utility of the first annual visit and are evaluating an evidence-based follow-up protocol.
16 noviembre 2014
Tobillo/Ankle/Knöchel/Cheville: Salter-Harris II, las más complicadas
Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest.
Leary JT, Handling M, Talerico M, Yong L, Bowe JA.
J Pediatr Orthop. 2009 Jun;29(4):356-61
Abstract
BACKGROUND:
A retrospective review of 124 patients was undertaken to determine the incidence of physeal growth arrest (premature physeal closure [PPC]) after physeal fractures of the distal end of the tibia in children. We also sought to identify clinical predictors of PPC.
METHODS:
We defined PPC as radiographic evidence of physeal closure as compared to the uninjured side in this patient population. We reviewed the charts of 124 pediatric patients with distal tibia physeal fractures. All patients were followed up until symmetric growth was noted (by Harris growth lines) for a minimum of 1 year or until physiologic closure of the growth plates had been documented radiographically. We calculated the overall incidence of PPC and the incidence by fracture type. Cox multivariate regression analysis was also performed for a number of clinical variables.
RESULTS:
The mean follow-up was 57 weeks. Fifteen fractures (12.1%) were complicated by PPC. In our study, 67% of the PPC observed occurred in Salter-Harris II fractures, followed by 13% in Salter-Harris III, 13% in Salter Harris IV, and 7% in triplane fractures. We did not observe any physeal arrest in the Salter-Harris I or Tillaux fractures. Using a Cox multivariate regression analysis, we were able to demonstrate statistically significant correlations between mechanism of injury and PPC and between the amount of initial fracture displacement and the rate of PPC. There was a strong relationship between mechanism of injury and PPC. There were trends seen about residual displacement after reduction and the number of attempted reductions and the rate of PPC, but these correlations were not statistically significant. For each millimeter of initial displacement, there was a relative risk of 1.15 (P < 0.01).
CONCLUSIONS:
Recent articles have shown a much higher rate of PPC after distal tibia physeal fracture than what was observed in our cohort. The amount of initial fracture displacement and the mechanism of injury have a statistically significant predictive value in determining the likelihood of PPC development after distal tibia physeal fracture. Trends were seen regarding residual displacement and the number of fracture reductions but were not statistically significant in predicting the occurrence of a PPC.
LEVEL OF EVIDENCE:
Level III: Retrospective Review.
Leary JT, Handling M, Talerico M, Yong L, Bowe JA.
J Pediatr Orthop. 2009 Jun;29(4):356-61
Abstract
BACKGROUND:
A retrospective review of 124 patients was undertaken to determine the incidence of physeal growth arrest (premature physeal closure [PPC]) after physeal fractures of the distal end of the tibia in children. We also sought to identify clinical predictors of PPC.
METHODS:
We defined PPC as radiographic evidence of physeal closure as compared to the uninjured side in this patient population. We reviewed the charts of 124 pediatric patients with distal tibia physeal fractures. All patients were followed up until symmetric growth was noted (by Harris growth lines) for a minimum of 1 year or until physiologic closure of the growth plates had been documented radiographically. We calculated the overall incidence of PPC and the incidence by fracture type. Cox multivariate regression analysis was also performed for a number of clinical variables.
RESULTS:
The mean follow-up was 57 weeks. Fifteen fractures (12.1%) were complicated by PPC. In our study, 67% of the PPC observed occurred in Salter-Harris II fractures, followed by 13% in Salter-Harris III, 13% in Salter Harris IV, and 7% in triplane fractures. We did not observe any physeal arrest in the Salter-Harris I or Tillaux fractures. Using a Cox multivariate regression analysis, we were able to demonstrate statistically significant correlations between mechanism of injury and PPC and between the amount of initial fracture displacement and the rate of PPC. There was a strong relationship between mechanism of injury and PPC. There were trends seen about residual displacement after reduction and the number of attempted reductions and the rate of PPC, but these correlations were not statistically significant. For each millimeter of initial displacement, there was a relative risk of 1.15 (P < 0.01).
CONCLUSIONS:
Recent articles have shown a much higher rate of PPC after distal tibia physeal fracture than what was observed in our cohort. The amount of initial fracture displacement and the mechanism of injury have a statistically significant predictive value in determining the likelihood of PPC development after distal tibia physeal fracture. Trends were seen regarding residual displacement and the number of fracture reductions but were not statistically significant in predicting the occurrence of a PPC.
LEVEL OF EVIDENCE:
Level III: Retrospective Review.
General: Ultrasonidos para hacerlo mejor
Consensus statement American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine.
Jonathan T Finnoff, Mederic M Hall, Erik Adams, David Berkof, Andrew L Concoff, William Dexter, Jay Smith.
Br J Sports Med doi:10.1136/bjsports-2014-094219
Abstract
Background: The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections.
Objective: Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues.
Design: Systematic review of the literature.
Results: USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C).
Conclusions: The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.
12 noviembre 2014
Rodilla/Knee/Knie/Genou: No importa si eviertes o separas la rótula
A randomized, controlled, prospective study evaluating the effect of patellar eversion on functional outcomes in primary total knee arthroplasty.
Jenkins D, Rodriguez J, Ranawat A, Alexiades M, Deshmukh A, Fukunaga T, Greiz M, Rathod P, McHugh M.
J Bone Joint Surg Am. 2014 May 21;96(10):851-8
Abstract
BACKGROUND: Patellar mobilization technique during total knee arthroplasty has been debated, with some suggesting that lateral retraction, rather than eversion, of the patella may be beneficial. We hypothesized that patients with knees surgically exposed using patellar lateral retraction would have comparable outcomes with patients with knees surgically exposed using patellar eversion.
METHODS: After an a priori power analysis, 120 patients with degenerative arthrosis were prospectively enrolled and were randomized to one of two patellar exposure techniques during the primary total knee arthroplasty: lateral retraction or eversion. The primary outcome measure was one-year, dynamometer-measured quadriceps strength. The secondary outcome measures evaluated during hospital stay included the ability to straight-leg raise, visual analog scale in pain, walking distance, and length of stay. The secondary outcome measures that were evaluated preoperatively and through a one-year follow-up included the Short Form-36 Physical Component Summary and Mental Component Summary scores, range of motion, quadriceps strength, and radiographic rate of patella baja and tilt.
RESULTS: A mixed-model analysis of variance showed no significant differences between the two groups in the one-year outcome measures. At one year postoperatively, quadriceps strength was not different between groups (p = 0.77), and the range of motion significantly improved (p < 0.01) from preoperative values by a mean value (and standard deviation) of 6° ± 17°, with no significant difference (p = 0.60) between groups. The Short Form-36 Physical Component Summary score and Mental Component Summary score significantly improved (p < 0.01) for both study groups from preoperatively to one year postoperatively with no significantly different effects between groups (time × group, p = 0.85 for the Physical Component Summary score and p = 0.71 for the Mental Component Summary score), and the scores were not different at one year after surgery. There were no significant differences between groups in the change in frequency of the radiographic patella baja (p = 0.99) or the radiographic patellar tilt (p = 0.77) from before surgery to one year after surgery.
CONCLUSIONS: Lateral retraction of the patella did not lead to superior postoperative results compared with eversion of the patella during total knee arthroplasty as evaluated using our primary outcome measure of one-year, dynamometer-measured quadriceps strength or our secondary outcome measures.
LEVEL OF-EVIDENCE: Therapeutic Level II
Jenkins D, Rodriguez J, Ranawat A, Alexiades M, Deshmukh A, Fukunaga T, Greiz M, Rathod P, McHugh M.
J Bone Joint Surg Am. 2014 May 21;96(10):851-8
Abstract
BACKGROUND: Patellar mobilization technique during total knee arthroplasty has been debated, with some suggesting that lateral retraction, rather than eversion, of the patella may be beneficial. We hypothesized that patients with knees surgically exposed using patellar lateral retraction would have comparable outcomes with patients with knees surgically exposed using patellar eversion.
METHODS: After an a priori power analysis, 120 patients with degenerative arthrosis were prospectively enrolled and were randomized to one of two patellar exposure techniques during the primary total knee arthroplasty: lateral retraction or eversion. The primary outcome measure was one-year, dynamometer-measured quadriceps strength. The secondary outcome measures evaluated during hospital stay included the ability to straight-leg raise, visual analog scale in pain, walking distance, and length of stay. The secondary outcome measures that were evaluated preoperatively and through a one-year follow-up included the Short Form-36 Physical Component Summary and Mental Component Summary scores, range of motion, quadriceps strength, and radiographic rate of patella baja and tilt.
RESULTS: A mixed-model analysis of variance showed no significant differences between the two groups in the one-year outcome measures. At one year postoperatively, quadriceps strength was not different between groups (p = 0.77), and the range of motion significantly improved (p < 0.01) from preoperative values by a mean value (and standard deviation) of 6° ± 17°, with no significant difference (p = 0.60) between groups. The Short Form-36 Physical Component Summary score and Mental Component Summary score significantly improved (p < 0.01) for both study groups from preoperatively to one year postoperatively with no significantly different effects between groups (time × group, p = 0.85 for the Physical Component Summary score and p = 0.71 for the Mental Component Summary score), and the scores were not different at one year after surgery. There were no significant differences between groups in the change in frequency of the radiographic patella baja (p = 0.99) or the radiographic patellar tilt (p = 0.77) from before surgery to one year after surgery.
CONCLUSIONS: Lateral retraction of the patella did not lead to superior postoperative results compared with eversion of the patella during total knee arthroplasty as evaluated using our primary outcome measure of one-year, dynamometer-measured quadriceps strength or our secondary outcome measures.
LEVEL OF-EVIDENCE: Therapeutic Level II
Rodilla/Knee/Knie/Genou: Se puede reconstruir un tendón rotuliano desaparecido
Management of extreme patella baja using in-situ hamstring tendon autograft
L.S. Moulton, A.P. Davies
The Knee: Volume 21, Issue 5, October 2014, Pages 916–919
Abstract
Successful total knee arthroplasty requires a functioning extensor mechanism. Patella baja following total knee arthroplasty can cause extensor mechanism dysfunction and produce poor outcomes. We present a case of severe patella tendon shortening following revision total knee arthroplasty with almost complete ankylosis of the distal pole of the patella to the proximal tibia. This resulted in effective extensor mechanism dysfunction with pain and severely limited knee flexion. We report a novel method of reconstruction of the patella tendon at the time of revision arthroplasty together with the one-year clinical outcome and review of the literature.
Highlights
We present a difficult case of patella baja following TKR. This was reconstructed using in-situ ipsilateral hamstring autograft. Good radiographic and clinical results were obtained. A review of the literature is presented.
L.S. Moulton, A.P. Davies
The Knee: Volume 21, Issue 5, October 2014, Pages 916–919
Abstract
Successful total knee arthroplasty requires a functioning extensor mechanism. Patella baja following total knee arthroplasty can cause extensor mechanism dysfunction and produce poor outcomes. We present a case of severe patella tendon shortening following revision total knee arthroplasty with almost complete ankylosis of the distal pole of the patella to the proximal tibia. This resulted in effective extensor mechanism dysfunction with pain and severely limited knee flexion. We report a novel method of reconstruction of the patella tendon at the time of revision arthroplasty together with the one-year clinical outcome and review of the literature.
Highlights
We present a difficult case of patella baja following TKR. This was reconstructed using in-situ ipsilateral hamstring autograft. Good radiographic and clinical results were obtained. A review of the literature is presented.
11 noviembre 2014
General: Mucho mejor si estás entrenado
Fundamental Arthroscopic Skill Differentiation With Virtual Reality Simulation.
Rose K, Pedowitz RArthroscopy. 2014 Oct 8. pii: S0749-8063(14)00715-4. doi: 10.1016/j.arthro.2014.08.016. [Epub ahead of print]
Abstract
PURPOSE:
The purpose of this study was to investigate the use and validity of virtual reality modules as part of the educational approach to mastering arthroscopy in a safe environment by assessing the ability to distinguish between experience levels. Additionally, the study aimed to evaluate whether experts have greater ambidexterity than do novices.
METHODS:
Three virtual reality modules (Swemac/Augmented Reality Systems, Linkoping, Sweden) were created to test fundamental arthroscopic skills. Thirty participants-10 experts consisting of faculty, 10 intermediate participants consisting of orthopaedic residents, and 10 novices consisting of medical students-performed each exercise. Steady and Telescope was designed to train centering and image stability. Steady and Probe was designed to train basic triangulation. Track and Moving Target was designed to train coordinated motions of arthroscope and probe. Metrics reflecting speed, accuracy, and efficiency of motion were used to measure construct validity.
RESULTS:
Steady and Probe and Track a Moving Target both exhibited construct validity, with better performance by experts and intermediate participants than by novices (P < .05), whereas Steady and Telescope did not show validity. There was an overall trend toward better ambidexterity as a function of greater surgical experience, with experts consistently more proficient than novices throughout all 3 modules.
CONCLUSIONS:
This study represents a new way to assess basic arthroscopy skills using virtual reality modules developed through task deconstruction. Participants with the most arthroscopic experience performed better and were more consistent than novices on all 3 virtual reality modules. Greater arthroscopic experience correlates with more symmetry of ambidextrous performance. However, further adjustment of the modules may better simulate fundamental arthroscopic skills and discriminate between experience levels.
CLINICAL RELEVANCE:
Arthroscopy training is a critical element of orthopaedic surgery resident training. Developing techniques to safely and effectively train these skills is critical for patient safety and resident education.
10 noviembre 2014
Hombro/Shoulder/Schulter/Épaule: Convertir sin producir más tensión
Conversion of hemi into reverse shoulder arthroplasty: implant design limitations.
Teschner H, Vaske B, Albrecht UV, Meller R, Liodakis E, Wiebking U, Krettek C, Jagodzinski M.
Arch Orthop Trauma Surg. 2014 Nov 4. [Epub ahead of print]
Abstract
PURPOSE:
Cranial migration of shoulder hemiarthroplasties due to rotator cuff insufficiency typically requires conversion into a reverse total shoulder arthroplasty. This study was conducted to analyze differences between the height and offset of six implants designed to enable conversion of a hemiarthroplasty into a reverse system.
METHODS:
Anteroposterior radiographs of 40 shoulders were taken. An image analyzing software was used to simulate the implantation of the hemiprostheses. Then the implant was dissembled, leaving on the stem within the humeral shaft. Finally, the implantation of a reverse system was simulated using the stem in the same position. Values are reported as ∆-height and ∆-offset ± standard deviation. Significance was assumed for P < 0.05.
RESULTS:
The least decrease in height was determined for Implantcast with 11.6 ± 3.3 mm, followed by DePuy (16 ± 5.7 mm) and the greatest for Tornier with 33 ± 5.3 mm. No significant differences were found among Exactech, Mathys and Zimmer. The largest offset-deviation was calculated for DePuy (-21.7 ± 3.7 mm) and the smallest for Implantcast (-3.3 ± 2.8 mm) and Tornier (1.5 ± 5.7 mm).
CONCLUSIONS:
Due to the modular stem, the system of Implantcast can be converted in a reverse system with the least changes in height and offset. For the other manufacturers it does not seem possible to convert a hemiprosthesis to a reversed prosthesis without accepting additional tension of the deltoid muscle. Further experimental studies have to analyze the changes in deltoid abduction moments after conversion of a hemi- into a reversed prosthesis.
Teschner H, Vaske B, Albrecht UV, Meller R, Liodakis E, Wiebking U, Krettek C, Jagodzinski M.
Arch Orthop Trauma Surg. 2014 Nov 4. [Epub ahead of print]
Abstract
PURPOSE:
Cranial migration of shoulder hemiarthroplasties due to rotator cuff insufficiency typically requires conversion into a reverse total shoulder arthroplasty. This study was conducted to analyze differences between the height and offset of six implants designed to enable conversion of a hemiarthroplasty into a reverse system.
METHODS:
Anteroposterior radiographs of 40 shoulders were taken. An image analyzing software was used to simulate the implantation of the hemiprostheses. Then the implant was dissembled, leaving on the stem within the humeral shaft. Finally, the implantation of a reverse system was simulated using the stem in the same position. Values are reported as ∆-height and ∆-offset ± standard deviation. Significance was assumed for P < 0.05.
RESULTS:
The least decrease in height was determined for Implantcast with 11.6 ± 3.3 mm, followed by DePuy (16 ± 5.7 mm) and the greatest for Tornier with 33 ± 5.3 mm. No significant differences were found among Exactech, Mathys and Zimmer. The largest offset-deviation was calculated for DePuy (-21.7 ± 3.7 mm) and the smallest for Implantcast (-3.3 ± 2.8 mm) and Tornier (1.5 ± 5.7 mm).
CONCLUSIONS:
Due to the modular stem, the system of Implantcast can be converted in a reverse system with the least changes in height and offset. For the other manufacturers it does not seem possible to convert a hemiprosthesis to a reversed prosthesis without accepting additional tension of the deltoid muscle. Further experimental studies have to analyze the changes in deltoid abduction moments after conversion of a hemi- into a reversed prosthesis.
Cadera/Hip/Hüfte/Hanche: Crece la resistencia de algunos estafilococos
Increasing Resistance of Coagulase-Negative Staphylococci in Total Hip Arthroplasty Infections: 278 THA-Revisions due to Infection Reported to the Norwegian Arthroplasty Register from 1993 to 2007
Olav Lutro, Håkon Langvatn, Håvard Dale, Johannes Cornelis Schrama, Geir Hallan, Birgitte Espehaug, Haakon Sjursen, Lars B Engesæter
Adv Orthop. 2014;2014:580359. doi: 10.1155/2014/580359. Epub 2014 Oct 9.
We investigated bacterial findings from intraoperative tissue samples taken during revision due to infection after total hip arthroplasty (THA). The aim was to investigate whether the susceptibility patterns changed during the period from 1993 through 2007.
Reported revisions due to infection in the Norwegian Arthroplasty Register (NAR) were identified, and 10 representative hospitals in Norway were visited. All relevant information on patients reported to the NAR for a revision due to infection, including bacteriological findings, was collected from the medical records.
A total of 278 revision surgeries with bacterial growth in more than 2 samples were identified and included. Differences between three 5-year time periods were tested by the chi-square test for linear trend. The most frequent isolates were coagulase-negative staphylococci (CoNS) (41%, 113/278) and Staphylococcus aureus (19%, 53/278). The proportion of CoNS resistant to the methicillin-group increased from 57% (16/28) in the first period, 1993-1997, to 84% (52/62) in the last period, 2003-2007 (P = 0.003). There was also significant increase in resistance for CoNS to cotrimoxazole, quinolones, clindamycin, and macrolides. All S. aureus isolates were sensitive to both the methicillin-group and the aminoglycosides. For the other bacteria identified no changes in susceptibility patterns were found.
Olav Lutro, Håkon Langvatn, Håvard Dale, Johannes Cornelis Schrama, Geir Hallan, Birgitte Espehaug, Haakon Sjursen, Lars B Engesæter
Adv Orthop. 2014;2014:580359. doi: 10.1155/2014/580359. Epub 2014 Oct 9.
We investigated bacterial findings from intraoperative tissue samples taken during revision due to infection after total hip arthroplasty (THA). The aim was to investigate whether the susceptibility patterns changed during the period from 1993 through 2007.
Reported revisions due to infection in the Norwegian Arthroplasty Register (NAR) were identified, and 10 representative hospitals in Norway were visited. All relevant information on patients reported to the NAR for a revision due to infection, including bacteriological findings, was collected from the medical records.
A total of 278 revision surgeries with bacterial growth in more than 2 samples were identified and included. Differences between three 5-year time periods were tested by the chi-square test for linear trend. The most frequent isolates were coagulase-negative staphylococci (CoNS) (41%, 113/278) and Staphylococcus aureus (19%, 53/278). The proportion of CoNS resistant to the methicillin-group increased from 57% (16/28) in the first period, 1993-1997, to 84% (52/62) in the last period, 2003-2007 (P = 0.003). There was also significant increase in resistance for CoNS to cotrimoxazole, quinolones, clindamycin, and macrolides. All S. aureus isolates were sensitive to both the methicillin-group and the aminoglycosides. For the other bacteria identified no changes in susceptibility patterns were found.
08 noviembre 2014
Cadera/Hip/Hüfte/Hanche: tendencias colocando prótesis de cadera
Trends in total hip arthroplasty implant utilization in the United States
Lehil MSBozic KJ
J Arthroplasty 2014 Oct; 29(10):1915-8
Abstract
Total hip arthroplasty (THA) implant usage has evolved as experience has been gained with newer implant designs. The purpose of this study was to characterize trends in THA implant usage between 2001 and 2012. The Orthopedic Research Network, which includes 174 hospitals and ~105,000 THA, was used to evaluate trends in fixation, bearings, acetabular cup and liner, and femoral head usage.
In 2012, 93% of THAs were cementless; 56% of THA bearings were metal-HXLPE; and 35% were ceramic-HXLPE. 99% of acetabular cups were modular. 61% of femoral heads were metal, 39% were ceramic, 51% were 36mm, and 28% were 32mm. V
THA implant usage trends favor cementless fixation, metal-on-polyethylene or ceramic-on-polyethylene bearings, modular acetabular cups, and large diameter femoral heads.
PieTobillo/FootAnkle/FussKnöchel/PiedCheville: Cuidado con los traumatismos
Clinical negligence in foot and ankle surgery: A 17-year review of claims to the NHS Litigation Authority
Ring, J., Talbot, C. L., Clough, T. M.
Bone Joint J 2014;96-B:1510–14.
We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.
A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.
During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.
There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.
Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.
Rodilla/Knee/Knie/Genou: Saber con una rx que la PTR se va a aflojar
Trabecular bone density of the proximal tibia as it relates to failure of a total knee replacement
Ritter, M. A., Davis, K. E., Small, S. R., Merchun, J. G., Farris, A.
Bone Joint J 2014;96-B:1503–9.
The relationship between post-operative bone density and subsequent failure of total knee replacement (TKR) is not known. This retrospective study aimed to determine the relationship between bone density and failure, both overall and according to failure mechanism.
All 54 aseptic failures occurring in 50 patients from 7760 consecutive primary cemented TKRs between 1983 and 2004 were matched with non-failing TKRs, and 47 failures in 44 patients involved tibial failures with the matching characteristics of age (65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis (93.6% OA), date of operation, bilaterality, pre-operative alignment (0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively). In each case, the density of bone beneath the tibial component was assessed at each follow-up interval using standardised, calibrated radiographs. Failing knees were compared with controls both overall and, as a subgroup analysis, by failure mechanism. Knees were compared with controls using univariable linear regression.
Significant and continuous elevation in tibial density was found in knees that eventually failed by medial collapse (p < 0.001) and progressive radiolucency (p < 0.001) compared with controls, particularly in the medial region of the tibia. Knees failing due to ligamentous instability demonstrated an initial decline in density (p = 0.0152) followed by a non-decreasing density over time (p = 0.034 for equivalence). Non-failing knees reported a decline in density similar to that reported previously using dual-energy x-ray absorptiometry (DEXA).
Differences between failing and non-failing knees were observable as early as two months following surgery. This tool may be used to identify patients at risk of failure following TKR, but more validation work is needed.
05 noviembre 2014
Hombro/Shoulder/Shulter/Épaule: Peor si tiene sobrepeso
Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures
Brian C. Werner, Justin W. Griffin, Scott Yang, Stephen F. Brockmeier, F. Winston Gwathmey
Journal of Shoulder and Elbow Surgery
Published Online: October 30, 2014
Background
Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database.
Methods
Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated.
Results
From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications.
Conclusions
Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.
Level of evidence:
Level III, Retrospective Cohort Design from Large Database, Treatment Study
Brian C. Werner, Justin W. Griffin, Scott Yang, Stephen F. Brockmeier, F. Winston Gwathmey
Journal of Shoulder and Elbow Surgery
Published Online: October 30, 2014
Background
Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database.
Methods
Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated.
Results
From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications.
Conclusions
Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.
Level of evidence:
Level III, Retrospective Cohort Design from Large Database, Treatment Study
General: cómo escribir una revisión sin preparación especial
How to write a systematic review
Am J Sports Med. 2014 Nov;42(11):2761-8.
Harris JD, Quatman CE, Manring MM, Siston RA, Flanigan DC.
Abstract
BACKGROUND:
The role of evidence-based medicine in sports medicine and orthopaedic surgery is rapidly growing. Systematic reviews and meta-analyses are also proliferating in the medical literature.
PURPOSE:
To provide the outline necessary for a practitioner to properly understand and/or conduct a systematic review for publication in a sports medicine journal.
STUDY DESIGN:
Review.
METHODS:
The steps of a successful systematic review include the following: identification of an unanswered answerable question; explicit definitions of the investigation's participant(s), intervention(s), comparison(s), and outcome(s); utilization of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and PROSPERO registration; thorough systematic data extraction; and appropriate grading of the evidence and strength of the recommendations.
RESULTS:
An outline to understand and conduct a systematic review is provided, and the difference between meta-analyses and systematic reviews is described. The steps necessary to perform a systematic review are fully explained, including the study purpose, search methodology, data extraction, reporting of results, identification of bias, and reporting of the study's main findings.
CONCLUSION:
Systematic reviews or meta-analyses critically appraise and formally synthesize the best existing evidence to provide a statement of conclusion that answers specific clinical questions. Readers and reviewers, however, must recognize that the quality and strength of recommendations in a review are only as strong as the quality of studies that it analyzes. Thus, great care must be used in the interpretation of bias and extrapolation of the review's findings to translation to clinical practice. Without advanced education on the topic, the reader may follow the steps discussed herein to perform a systematic review.
Am J Sports Med. 2014 Nov;42(11):2761-8.
Harris JD, Quatman CE, Manring MM, Siston RA, Flanigan DC.
Abstract
BACKGROUND:
The role of evidence-based medicine in sports medicine and orthopaedic surgery is rapidly growing. Systematic reviews and meta-analyses are also proliferating in the medical literature.
PURPOSE:
To provide the outline necessary for a practitioner to properly understand and/or conduct a systematic review for publication in a sports medicine journal.
STUDY DESIGN:
Review.
METHODS:
The steps of a successful systematic review include the following: identification of an unanswered answerable question; explicit definitions of the investigation's participant(s), intervention(s), comparison(s), and outcome(s); utilization of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and PROSPERO registration; thorough systematic data extraction; and appropriate grading of the evidence and strength of the recommendations.
RESULTS:
An outline to understand and conduct a systematic review is provided, and the difference between meta-analyses and systematic reviews is described. The steps necessary to perform a systematic review are fully explained, including the study purpose, search methodology, data extraction, reporting of results, identification of bias, and reporting of the study's main findings.
CONCLUSION:
Systematic reviews or meta-analyses critically appraise and formally synthesize the best existing evidence to provide a statement of conclusion that answers specific clinical questions. Readers and reviewers, however, must recognize that the quality and strength of recommendations in a review are only as strong as the quality of studies that it analyzes. Thus, great care must be used in the interpretation of bias and extrapolation of the review's findings to translation to clinical practice. Without advanced education on the topic, the reader may follow the steps discussed herein to perform a systematic review.
04 noviembre 2014
General: condrocitos sensibles al pH
The effect of environmental pH change on bovine articular cartilage metabolism: implications for the use of buffered solution during arthroscopy?
Umut Akgun, Baris Kocaoglu, Selim Ergun, Mustafa Karahan, Metin Turkmen
Knee Surgery, Sports Traumatology, Arthroscopy
PURPOSE: The purpose of this study is to determine the immediate effects of pH change on the metabolism of bovine chondrocytes.
METHODS: Bovine osteochondral explants were pre-cultured and placed in Ringer's lactate solution. Thirty explants were randomly divided into 3 groups. Buffered Ringer's lactate, pH 7.2, was used in Group I; buffered Ringer's lactate, pH 7.4 (normal bovine knee joint pH), was used in Group II; and this group was also set as the control group. Buffered Ringer's lactate, pH 7.6, was used in Group III. All specimens were soaked for 2 h. RNA yield analyses were performed to evaluate the changes in cartilage metabolism at different pH levels.
RESULTS: Mean RNA yields of (hypoxia-induced factor) 1α that were immersed at pH 7.2 and 7.6 were 10.5- and 9.9-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 15.2-fold. Mean RNA yields of aggrecan that were immersed at pH 7.2 and 7.6 were 12.2- and 13.6-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 20-fold. RNA yields of collagen type II at pH 7.2 and 7.6 were 16.1- and 16.6-fold from base, respectively, which were lower compared to explants immersed at pH 7.4 which was found as 22.1-fold.
CONCLUSION: The findings of the presented study suggest that short-term exposures to both acidic and basic pH may have effects on chondrocyte function. Our findings also indicate that exposures to solutions with a pH different from normal by only 0.2 unit could suppress chondrocyte metabolism and RNA synthesis.
CLINICAL RELEVANCE: Using buffered irrigation solutions with a pH closer to the normal joint pH could be more physiologic and causes less ultra-structural damage than regular irrigation solutions.
LEVEL OF EVIDENCE: II.
Umut Akgun, Baris Kocaoglu, Selim Ergun, Mustafa Karahan, Metin Turkmen
Knee Surgery, Sports Traumatology, Arthroscopy
PURPOSE: The purpose of this study is to determine the immediate effects of pH change on the metabolism of bovine chondrocytes.
METHODS: Bovine osteochondral explants were pre-cultured and placed in Ringer's lactate solution. Thirty explants were randomly divided into 3 groups. Buffered Ringer's lactate, pH 7.2, was used in Group I; buffered Ringer's lactate, pH 7.4 (normal bovine knee joint pH), was used in Group II; and this group was also set as the control group. Buffered Ringer's lactate, pH 7.6, was used in Group III. All specimens were soaked for 2 h. RNA yield analyses were performed to evaluate the changes in cartilage metabolism at different pH levels.
RESULTS: Mean RNA yields of (hypoxia-induced factor) 1α that were immersed at pH 7.2 and 7.6 were 10.5- and 9.9-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 15.2-fold. Mean RNA yields of aggrecan that were immersed at pH 7.2 and 7.6 were 12.2- and 13.6-fold from base, respectively, which were lower compared to explants at pH 7.4 which was found as 20-fold. RNA yields of collagen type II at pH 7.2 and 7.6 were 16.1- and 16.6-fold from base, respectively, which were lower compared to explants immersed at pH 7.4 which was found as 22.1-fold.
CONCLUSION: The findings of the presented study suggest that short-term exposures to both acidic and basic pH may have effects on chondrocyte function. Our findings also indicate that exposures to solutions with a pH different from normal by only 0.2 unit could suppress chondrocyte metabolism and RNA synthesis.
CLINICAL RELEVANCE: Using buffered irrigation solutions with a pH closer to the normal joint pH could be more physiologic and causes less ultra-structural damage than regular irrigation solutions.
LEVEL OF EVIDENCE: II.
Trauma: Va bien la fijación con placas de ángulo fijo en la fractura declavicula lateral
Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates
Mark A. Fleming, Robert Dachs, Sithombo Maqungo, Jean-Pierre du Plessis, Basil C. Vrettos, Stephen J.L. Roche
Journal of Shoulder and Elbow Surgery
Published Online: October 29, 2014
Hypothesis
We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery.
Methods
We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport.
Results
Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities.
Conclusion
Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.
Level of evidence:
Level IV, Case Series, Treatment Study
Mark A. Fleming, Robert Dachs, Sithombo Maqungo, Jean-Pierre du Plessis, Basil C. Vrettos, Stephen J.L. Roche
Journal of Shoulder and Elbow Surgery
Published Online: October 29, 2014
Hypothesis
We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery.
Methods
We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport.
Results
Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities.
Conclusion
Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.
Level of evidence:
Level IV, Case Series, Treatment Study
Cadera/Hip/Hüfte/Hanche: hay que centrarse en la persona
Person-centred care compared with standardized care for patients undergoing total hip arthroplasty: a quasi-experimental study
Lars-Eric Olsson, Jón Karlsson, Urban Berg, Johan Kärrholm, Elisabeth Hansson
Journal of Orthopaedic Surgery and Research 2014 October 9, 9 (1): 95
Background
A common approach to decrease length of stay has been to standardize patient care, for example, by implementing clinical care pathways or creating fast-track organizations. In a recent national report, it was found that Sweden's healthcare system often fails to anticipate and respond to patients as individuals with particular needs, values and preferences. We compared a standardized care approach to one of person-centred care for patients undergoing total hip replacement surgery.
Methods
A control group (n =138) was consecutively recruited between 20th September 2010 and 1st March 2011 and an intervention group (n =128) between 12th December 2011 and 12th November 2012, both scheduled for total hip replacement. The primary outcome measures were length of stay and physical function at both discharge and 3 months later.
Results
The mean length of stay in the control group was 7 days (SD 5.0) compared to 5.3 days in the intervention group (SD 2.2). Physical functional performance, as assessed using activities of daily living, was similar at baseline for both groups. At discharge, 84% in the control group had regained activities of daily living level A vs. 72% in the intervention group. At 3 months after surgery, 88% in the control group had regained their independence vs. 92.5% in the person-centred care group.
Conclusions
Focusing attention on patients as people and including them as partners in healthcare decision-making can result in shorter length of stay. The present study shows that the patients should be the focus and they should be involved as partners.
Lars-Eric Olsson, Jón Karlsson, Urban Berg, Johan Kärrholm, Elisabeth Hansson
Journal of Orthopaedic Surgery and Research 2014 October 9, 9 (1): 95
Background
A common approach to decrease length of stay has been to standardize patient care, for example, by implementing clinical care pathways or creating fast-track organizations. In a recent national report, it was found that Sweden's healthcare system often fails to anticipate and respond to patients as individuals with particular needs, values and preferences. We compared a standardized care approach to one of person-centred care for patients undergoing total hip replacement surgery.
Methods
A control group (n =138) was consecutively recruited between 20th September 2010 and 1st March 2011 and an intervention group (n =128) between 12th December 2011 and 12th November 2012, both scheduled for total hip replacement. The primary outcome measures were length of stay and physical function at both discharge and 3 months later.
Results
The mean length of stay in the control group was 7 days (SD 5.0) compared to 5.3 days in the intervention group (SD 2.2). Physical functional performance, as assessed using activities of daily living, was similar at baseline for both groups. At discharge, 84% in the control group had regained activities of daily living level A vs. 72% in the intervention group. At 3 months after surgery, 88% in the control group had regained their independence vs. 92.5% in the person-centred care group.
Conclusions
Focusing attention on patients as people and including them as partners in healthcare decision-making can result in shorter length of stay. The present study shows that the patients should be the focus and they should be involved as partners.
Hombro/Shoulder/Schulter/Épaule: las fracturas de húmero proximal en mayores con el manguito roto
Prevalence of rotator cuff tears in operative proximal humerus fractures
Andrew Choo, Garret Sobol, Mitchell Maltenfort, Charles Getz, Joseph Abboud
Orthopedics 2014 November 1, 37 (11)
Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures.
A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears.
This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear.
A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis.
Andrew Choo, Garret Sobol, Mitchell Maltenfort, Charles Getz, Joseph Abboud
Orthopedics 2014 November 1, 37 (11)
Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures.
A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears.
This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear.
A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis.
Rodilla/Knee/Knie/Genou: algunas prótesis no son tan modélicas
Evidence of trochlear dysplasia in femoral component designs.
Dejour D, Ntagiopoulos PG, Saffarini M.
Knee Surg Sports Traumatol Arthrosc. 2014 Nov;22(11):2599-607.
Abstract
PURPOSE:
The study aimed to compare trochlear profiles of various total knee arthroplasty (TKA) models to anatomic profiles observed in healthy and pathologic knees and to evaluate trochlear designs against radiologic indicators for PF disorders and trochlear dysplasia.
METHODS:
The trochlear profiles of 14 different TKA models were digitized using a coordinate measurement machine at various flexion angles (0°, 15°, 30° and 45°) to deduce the following variables: sulcus angle, trochlear groove orientation, height of lateral facet, and mediolateral groove position. The effect of externally rotating the femoral component on those variables was simulated.
RESULTS:
The sulcus angle was greater than the indicators for trochlear dysplasia of 144° in 11 implants at 45° flexion, and in 13 implants at 30° flexion. The lateral facet height was less than average anatomic values of 5 mm in eight specimens through the entire range of early flexion (0°-30°). The trochlear groove was oriented laterally in 13 specimens (3.3°-11.7°) and was vertical in one specimen (0.3°). Applying an external rotation up to 6° resulted in noticeable lateral translation of the trochlear groove and facets, but negligible posterior translation.
CONCLUSIONS:
The study presented a detailed description of previously overlooked TKA design parameters and revealed that some femoral components exhibit characteristics of trochlear dysplasia. The clinical relevance of this descriptive study is that surgeons should be aware of such design limitations to improve choice of implant for patients with history of PF disorders and to adapt surgical techniques as necessary to optimize PF tracking.
LEVEL OF EVIDENCE:
Case-control study, Level III.
27 octubre 2014
General: Células madre adipocíticas montadas en armazones de PRP
Adipose-derived stem cells incorporated into platelet-rich plasma improved bone regeneration and maturation in vivo
Ariadne Cristiane Cabral Cruz, Thiago Caon, Alvaro Menin, Rodrigo Granato, Fernanda Boabaid, Cláudia Maria Oliveira Simões
Dental Traumatology: 2014 October 21
BACKGROUND/AIM: Some cases of tooth loss related to dental trauma require bone-grafting procedures to improve the aesthetics before prosthetic rehabilitation or to enable the installation of dental implants. Bone regeneration is often a challenge and could be largely improved by mesenchymal stem cells therapy. However, the appropriate scaffold for these cells still a problem. This study evaluated the in vivo effect of human adipose-derived stem cells incorporated into autogenous platelet-rich plasma in bone regeneration and maturation.
MATERIAL AND METHODS: Adipose-derived stem cells were isolated from lipoaspirate tissues and used at passage 4. Immunophenotyping and multilineage differentiation of cells were performed and mesenchymal stem cells characteristics confirmed. Bicortical bone defects (10 mm diameter) were created in the tibia of six beagle dogs to evaluate the effect of adipose-derived stem cells incorporated into platelet-rich plasma scaffolds, platelet-rich plasma alone, autogenous bone grafts, and clot. Samples were removed 6 weeks postsurgeries and analyzed by quantification of primary and secondary bone formation and granulation tissue.
RESULTS: Adipose-derived stem cells incorporated into platelet-rich plasma scaffolds promoted the highest bone formation (primary + secondary bone) (P < 0.001), the highest bone maturation (secondary bone) (P < 0.001), and the lowest amount of granulation tissue (P < 0.001).
CONCLUSIONS: Adipose-derived stem cells incorporated into platelet-rich plasma scaffolds promote more bone formation and maturation, and less granulation tissue in bone defects created in canine tibia. Therefore, platelet-rich plasma can be considered as a candidate scaffold for adipose-derived stem cells to promote bone regeneration.
Ariadne Cristiane Cabral Cruz, Thiago Caon, Alvaro Menin, Rodrigo Granato, Fernanda Boabaid, Cláudia Maria Oliveira Simões
Dental Traumatology: 2014 October 21
BACKGROUND/AIM: Some cases of tooth loss related to dental trauma require bone-grafting procedures to improve the aesthetics before prosthetic rehabilitation or to enable the installation of dental implants. Bone regeneration is often a challenge and could be largely improved by mesenchymal stem cells therapy. However, the appropriate scaffold for these cells still a problem. This study evaluated the in vivo effect of human adipose-derived stem cells incorporated into autogenous platelet-rich plasma in bone regeneration and maturation.
MATERIAL AND METHODS: Adipose-derived stem cells were isolated from lipoaspirate tissues and used at passage 4. Immunophenotyping and multilineage differentiation of cells were performed and mesenchymal stem cells characteristics confirmed. Bicortical bone defects (10 mm diameter) were created in the tibia of six beagle dogs to evaluate the effect of adipose-derived stem cells incorporated into platelet-rich plasma scaffolds, platelet-rich plasma alone, autogenous bone grafts, and clot. Samples were removed 6 weeks postsurgeries and analyzed by quantification of primary and secondary bone formation and granulation tissue.
RESULTS: Adipose-derived stem cells incorporated into platelet-rich plasma scaffolds promoted the highest bone formation (primary + secondary bone) (P < 0.001), the highest bone maturation (secondary bone) (P < 0.001), and the lowest amount of granulation tissue (P < 0.001).
CONCLUSIONS: Adipose-derived stem cells incorporated into platelet-rich plasma scaffolds promote more bone formation and maturation, and less granulation tissue in bone defects created in canine tibia. Therefore, platelet-rich plasma can be considered as a candidate scaffold for adipose-derived stem cells to promote bone regeneration.
Tobillo/Ankle/Knöchel/Cheville: Microfracturas por artroscopia en jóvenes con lesiones pequeñas
Functional and MRI Outcomes After Arthroscopic Microfracture for Treatment of Osteochondral Lesions of the Distal Tibial Plafond
Keir A. Ross, Charles P. Hannon, Timothy W. Deyer, Niall A. Smyth, MaCalus Hogan, Huong T. Do, John G. Kennedy,
J Bone Joint Surg Am, 2014 Oct 15;96(20):1708-1715.
Abstract
Background: Osteochondral lesions of the distal tibial plafond are uncommon compared with talar lesions. The objective of this study was to assess functional and magnetic resonance imaging (MRI) outcomes following microfracture for tibial osteochondral lesions.
Methods: Thirty-one tibial osteochondral lesions in thirty-one ankles underwent arthroscopic microfracture. The Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire were used to obtain patient-reported functional outcome scores preoperatively and postoperatively. MRI scans were assessed postoperatively with use of the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for twenty-three ankles.
Results: The average age was thirty-seven years (range, fifteen to sixty-eight years), and the average lesion area was 38 mm2 (range, 7.1 to 113 mm2). Twelve ankles had a kissing lesion on the opposing surface of the talus, and two ankles had a concomitant osteochondral lesion elsewhere on the talus. FAOS and SF-12 scores were significantly improved (p < 0.01) at the time of follow-up, at an average of forty-four months. The average postoperative MOCART score was 69.4 (range, 10 to 95), with a lower score in the ankles with kissing lesions (62.8) than in the ankles with an isolated lesion (73.6). Increasing age negatively impacted improvement in SF-12 (p < 0.01) and MOCART (p = 0.04) scores. Increasing lesion area was negatively correlated with MOCART scores (p = 0.04) but was not associated with FAOS or SF-12 scores. Lesion location and the presence of kissing lesions showed no association with functional or MRI outcomes.
Conclusions: Arthroscopic microfracture provided functional improvements, but the optimal treatment strategy for tibial osteochondral lesions remains unclear. The repair tissue assessed on MRI was inferior to normal hyaline cartilage. The MRI outcomes appeared to deteriorate with increasing lesion area, and both functional and MRI outcomes appeared to deteriorate with increasing age.
Level of Evidence: Therapeutic Level IV
26 octubre 2014
Cadera/Hip/Hüfte/Hanche: Vástagos cortos con mucho cuidado
Short Bone-Conserving Stems in Cementless Hip Arthroplasty
Harpal S. Khanuja, Samik Banerjee, Deepak Jain, Robert Pivec, Michael A. Mont
J Bone Joint Surg Am, 2014 Oct 15; 96(20):1742-1752
Abstract
➤ Short bone-conserving femoral stems in total hip arthroplasty were designed to preserve proximal bone stock.
➤ Given the distinct fixation principles and location of loading among these bone-conserving stems, a classification system is essential to compare clinical outcomes.
➤ Due to the low quality of currently available evidence, only a weak recommendation can be provided for clinical usage of certain stem designs, while some other designs cannot be recommended at this time.
➤ A high prevalence of stem malalignment, incorrect sizing, subsidence, and intraoperative fractures has been reported in a subset of these short stem designs.
➤ Stronger evidence, including prospective multicenter randomized trials comparing standard stems with these newer designs, is necessary before widespread use can be recommended.
Harpal S. Khanuja, Samik Banerjee, Deepak Jain, Robert Pivec, Michael A. Mont
J Bone Joint Surg Am, 2014 Oct 15; 96(20):1742-1752
Abstract
➤ Short bone-conserving femoral stems in total hip arthroplasty were designed to preserve proximal bone stock.
➤ Given the distinct fixation principles and location of loading among these bone-conserving stems, a classification system is essential to compare clinical outcomes.
➤ Due to the low quality of currently available evidence, only a weak recommendation can be provided for clinical usage of certain stem designs, while some other designs cannot be recommended at this time.
➤ A high prevalence of stem malalignment, incorrect sizing, subsidence, and intraoperative fractures has been reported in a subset of these short stem designs.
➤ Stronger evidence, including prospective multicenter randomized trials comparing standard stems with these newer designs, is necessary before widespread use can be recommended.
23 octubre 2014
General: No se infectan las protesis por infiltrar antes la articulación
Do Intra-Articular Steroid Injections Increase Infection Rates in Subsequent Arthroplasty? A Systematic Review and Meta-Analysis of Comparative Studies
Charalambos P. Charalambous, Apostolos D. Prodromidis, Tariq A. Kwaees
J of Arthroplasty Published Online: August 02, 2014
Abstract
Intra-articular steroid injections are widely used in joint arthritis. The safety of such injections has been questioned as they may increase infection rates in subsequent arthroplasty. We carried out a meta-analysis of studies examining the relation between intra-articular steroid injections and infection rates in subsequent joint arthroplasty. A literature search was undertaken. Eight studies looking at hip and knee arthroplasties were analyzed. Meta-analysis showed that steroid injection had no significant effect on either deep (risk ratio = 1.87; 95% CI 0.80–4.35; P = 0.15) or superficial infection rates (risk ratio = 1.75; 95% CI 0.76–4.04; P = 0.19) of subsequent arthroplasty. Further large cohort studies would be of value in further examining whether steroid injections close to the time of arthroplasty are safe.
15 octubre 2014
Hombro/Shoulder/Schulter/Épaule: anestésicos citotóxicos para el hombro
Cytotoxic Effects of Ropivacaine, Bupivacaine, and Lidocaine on Rotator Cuff Tenofibroblasts.
Sung CM, Hah YS, Kim JS, Nam JB, Kim RJ, Lee SJ, Park HB.
Am J Sports Med. 2014 Oct 8 [Epub ahead of print]
Abstract
BACKGROUND:
Concern has recently arisen over the safety of local anesthetics used on human tissues.
HYPOTHESIS:
Aminoamide local anesthetics have cytotoxic effects on human rotator cuff tenofibroblasts.
STUDY DESIGN:
Controlled laboratory study.
METHODS:
Cultured human rotator cuff tenofibroblasts were divided into control, phosphate buffered saline (PBS), and local anesthetic study groups; the PBS study group was further subdivided by pH level (pH 7.4, 6.0, and 4.4). The 6 local anesthetic subgroups (0.2% and 0.75% ropivacaine, 0.25% and 0.5% bupivacaine, and 1% and 2% lidocaine) were also studied at 10% dilutions of their original concentrations. Exposure times were 5, 10, 20, 40, or 60 minutes for the higher concentrations and 2, 6, 12, 24, 48, or 72 hours for the lower concentrations. Cell viability was evaluated through live, apoptotic, and necrotic cell rates using the annexin V-propidium iodide double-staining method. Intracellular reactive oxygen species (ROS) and the activity of mitogen-activated protein kinases (MAPKs) and caspase-3/7 were investigated.
RESULTS:
The control and PBS groups showed no significant differences in cell viability (P > .999). In the local anesthetic study groups, cell viability decreased significantly with increases in anesthetic concentrations (P < .001) and exposure times (P < .001), with the exception of the lidocaine subgroups, where this effect was masked by the very high cytotoxicity of even low concentrations. Among the studied local anesthetic subgroups, 0.2% ropivacaine was the least toxic. The levels of intracellular ROS of each local anesthetic subgroup also increased significantly (P < .05). The studied local anesthetics showed increases in the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), c-Jun N-terminal kinase (JNK), and p38 as well as in levels of caspase-3/7 activity (P < .001).
CONCLUSION:
The cytotoxicity of the anesthetics studied to tenofibroblasts is dependent on exposure time and concentration. Of the evaluated anesthetics, ropivacaine is the least toxic in the clinically used concentration. The studied anesthetics induce tenofibroblast cell death, mediated by the increased production of ROS, by the increased activation of ERK1/2, JNK, and p38 and by the activation of caspase-3/7.
CLINICAL RELEVANCE:
This study identified the cytotoxic mechanisms of aminoamide local anesthetics acting on rotator cuff tenofibroblasts. The greatest margin of safety was found in lower anesthetic concentrations in general and more specifically in the use of ropivacaine.
KEYWORDS:
Sung CM, Hah YS, Kim JS, Nam JB, Kim RJ, Lee SJ, Park HB.
Am J Sports Med. 2014 Oct 8 [Epub ahead of print]
Abstract
BACKGROUND:
Concern has recently arisen over the safety of local anesthetics used on human tissues.
HYPOTHESIS:
Aminoamide local anesthetics have cytotoxic effects on human rotator cuff tenofibroblasts.
STUDY DESIGN:
Controlled laboratory study.
METHODS:
Cultured human rotator cuff tenofibroblasts were divided into control, phosphate buffered saline (PBS), and local anesthetic study groups; the PBS study group was further subdivided by pH level (pH 7.4, 6.0, and 4.4). The 6 local anesthetic subgroups (0.2% and 0.75% ropivacaine, 0.25% and 0.5% bupivacaine, and 1% and 2% lidocaine) were also studied at 10% dilutions of their original concentrations. Exposure times were 5, 10, 20, 40, or 60 minutes for the higher concentrations and 2, 6, 12, 24, 48, or 72 hours for the lower concentrations. Cell viability was evaluated through live, apoptotic, and necrotic cell rates using the annexin V-propidium iodide double-staining method. Intracellular reactive oxygen species (ROS) and the activity of mitogen-activated protein kinases (MAPKs) and caspase-3/7 were investigated.
RESULTS:
The control and PBS groups showed no significant differences in cell viability (P > .999). In the local anesthetic study groups, cell viability decreased significantly with increases in anesthetic concentrations (P < .001) and exposure times (P < .001), with the exception of the lidocaine subgroups, where this effect was masked by the very high cytotoxicity of even low concentrations. Among the studied local anesthetic subgroups, 0.2% ropivacaine was the least toxic. The levels of intracellular ROS of each local anesthetic subgroup also increased significantly (P < .05). The studied local anesthetics showed increases in the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), c-Jun N-terminal kinase (JNK), and p38 as well as in levels of caspase-3/7 activity (P < .001).
CONCLUSION:
The cytotoxicity of the anesthetics studied to tenofibroblasts is dependent on exposure time and concentration. Of the evaluated anesthetics, ropivacaine is the least toxic in the clinically used concentration. The studied anesthetics induce tenofibroblast cell death, mediated by the increased production of ROS, by the increased activation of ERK1/2, JNK, and p38 and by the activation of caspase-3/7.
CLINICAL RELEVANCE:
This study identified the cytotoxic mechanisms of aminoamide local anesthetics acting on rotator cuff tenofibroblasts. The greatest margin of safety was found in lower anesthetic concentrations in general and more specifically in the use of ropivacaine.
KEYWORDS:
Hombro/Shoulder/Schulter/Èpaule: donde pones el ojo sueles poner la aguja
Accuracy of Palpation-Directed Intra-articular Glenohumeral Injection Confirmed by Magnetic Resonance Arthrography
Scott E Powell, Shane M Davis, Emily H Lee, Robert K Lee, Ryan M Sung, Claire McGroder, Shalen Kouk, Christopher S Lee
Arthroscopy: the Journal of Arthroscopic & related Surgery 2014 October 8 [Epub ahead of print]
PURPOSE: The aim of this study was to determine the accuracy of anatomic palpation-directed injections in the office setting.
METHODS: Two hundred twenty-six shoulders in 208 patients were studied using a 0.2-Tesla extremity scanner after the injection of gadolinium-diethylene triamine pentaacetic acid-saline. All patients were injected in a sterile fashion by a single board-certified shoulder surgeon using an anterior approach by palpating the rotator interval anterior to the acromioclavicular joint and angling the needle 45° lateral and 45° caudad. All injections, successful or otherwise, were single injections. Magnetic resonance (MR) arthrograms were retrospectively read by 2 musculoskeletal fellowship-trained, board certified radiologists to determine whether the injection was in the glenohumeral joint.
RESULTS: Two hundred one of the 226 injections were successful (88.9%). Of the 25 unsuccessful injections, the contrast material extravasated out of the capsule in 5 cases and into the subscapularis tendon in 10 cases. The contrast material was injected into the subacromial space in 9 cases, into the rotator interval fat in 9 cases, and into extracapsular tissue in 6 cases. There was insufficient volume of contrast material in 10 cases. The accuracy rate was 88.9%. There were no complications.
CONCLUSIONS: The palpation-directed rotator interval anterior approach technique for intra-articular glenohumeral MR arthrogram injections performed by a single surgeon was 88.9% accurate.
LEVEL OF EVIDENCE: Level IV, therapeutic case series.
Scott E Powell, Shane M Davis, Emily H Lee, Robert K Lee, Ryan M Sung, Claire McGroder, Shalen Kouk, Christopher S Lee
Arthroscopy: the Journal of Arthroscopic & related Surgery 2014 October 8 [Epub ahead of print]
PURPOSE: The aim of this study was to determine the accuracy of anatomic palpation-directed injections in the office setting.
METHODS: Two hundred twenty-six shoulders in 208 patients were studied using a 0.2-Tesla extremity scanner after the injection of gadolinium-diethylene triamine pentaacetic acid-saline. All patients were injected in a sterile fashion by a single board-certified shoulder surgeon using an anterior approach by palpating the rotator interval anterior to the acromioclavicular joint and angling the needle 45° lateral and 45° caudad. All injections, successful or otherwise, were single injections. Magnetic resonance (MR) arthrograms were retrospectively read by 2 musculoskeletal fellowship-trained, board certified radiologists to determine whether the injection was in the glenohumeral joint.
RESULTS: Two hundred one of the 226 injections were successful (88.9%). Of the 25 unsuccessful injections, the contrast material extravasated out of the capsule in 5 cases and into the subscapularis tendon in 10 cases. The contrast material was injected into the subacromial space in 9 cases, into the rotator interval fat in 9 cases, and into extracapsular tissue in 6 cases. There was insufficient volume of contrast material in 10 cases. The accuracy rate was 88.9%. There were no complications.
CONCLUSIONS: The palpation-directed rotator interval anterior approach technique for intra-articular glenohumeral MR arthrogram injections performed by a single surgeon was 88.9% accurate.
LEVEL OF EVIDENCE: Level IV, therapeutic case series.
Rodilla/Knee/Knie/Genou: ¿Un remedio milagroso para la rodilla lesionada?
Platelet Rich Plasma and Knee Surgery
Mikel Sánchez, Diego Delgado, Pello Sánchez, Nicolás Fiz, Juan Azofra, Gorka Orive, Eduardo Anitua, Sabino Padilla
Biomed Res Int. 2014; 2014: 890630.
Published online Sep 2, 2014
Abstract
In orthopaedic surgery and sports medicine, the knee joint has traditionally been considered the workhorse. The reconstruction of every damaged element in this joint is crucial in achieving the surgeon's goal to restore the knee function and prevent degeneration towards osteoarthritis. In the last fifteen years, the field of regenerative medicine is witnessing a boost of autologous blood-derived platelet rich plasma products (PRPs) application to effectively mimic and accelerate the tissue healing process. The scientific rationale behind PRPs is the delivery of growth factors, cytokines, and adhesive proteins present in platelets and plasma, as well as other biologically active proteins conveyed by the plasma such as fibrinogen, prothrombin, and fibronectin; with this biological engineering approach, new perspectives in knee surgery were opened. This work describes the use of PRP to construct and repair every single anatomical structure involved in knee surgery, detailing the process conducted in ligament, meniscal, and chondral surgery.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167644/
Mikel Sánchez, Diego Delgado, Pello Sánchez, Nicolás Fiz, Juan Azofra, Gorka Orive, Eduardo Anitua, Sabino Padilla
Biomed Res Int. 2014; 2014: 890630.
Published online Sep 2, 2014
Abstract
In orthopaedic surgery and sports medicine, the knee joint has traditionally been considered the workhorse. The reconstruction of every damaged element in this joint is crucial in achieving the surgeon's goal to restore the knee function and prevent degeneration towards osteoarthritis. In the last fifteen years, the field of regenerative medicine is witnessing a boost of autologous blood-derived platelet rich plasma products (PRPs) application to effectively mimic and accelerate the tissue healing process. The scientific rationale behind PRPs is the delivery of growth factors, cytokines, and adhesive proteins present in platelets and plasma, as well as other biologically active proteins conveyed by the plasma such as fibrinogen, prothrombin, and fibronectin; with this biological engineering approach, new perspectives in knee surgery were opened. This work describes the use of PRP to construct and repair every single anatomical structure involved in knee surgery, detailing the process conducted in ligament, meniscal, and chondral surgery.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167644/
08 octubre 2014
Cadera/Hip/Hüfte/Hanche: Cerámica contra polietileno: ¿combinación aceptable?
The case for ceramic-on-polyethylene as the preferred bearing for a young adult hip replacement
David J.W. Cash, Vikas Khanduja
Hip Int 2014; 24(5): 421 - 427
Article Type: REVIEW
Abstract
The optimum choice of bearing surfaces in total hip arthroplasty, particularly in the younger and more active patient, remains controversial. Despite several studies demonstrating good long-term results for the metal-on-polyethylene articulation, there has been a recent vogue towards the utilisation of hard-on-hard bearings for younger patients due, in part, to concerns regarding polyethylene induced osteolysis. However, well-documented complications concerning metal-on-metal bearings and the risk of fracture in ceramic-on-ceramic bearings have raised concerns regarding the principle of the hard-on-hard bearing in the active patient. With recent technological advancements in the manufacture of both polyethylene and alumina ceramics, the in vitro properties of each material with regards to strength and toughness have been significantly improved. In addition, ceramic femoral heads have consistently been shown to produce less in vivo polyethylene wear than similar sized metal heads. This paper aims to critically review the biomechanical, in vivo and clinical studies related to the use of the ceramic on polyethylene bearing, and highlights its potential use as the preferred bearing for a young adult hip replacement.
Rodilla/Knee/Knie/Genou: Abrir o cerrar la osteotomía de tibia; hay diferencias
Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee: A Randomized Controlled Trial with a Six-Year Follow-up.
Duivenvoorden T, Brouwer RW, Baan A, Bos PK, Reijman M, Bierma-Zeinstra SM, Verhaar JA.
J Bone Joint Surg Am. 2014 Sep 3;96(17)
J Bone Joint Surg Am. 2014 Sep 3;96(17)
Abstract
BACKGROUND:
Varus deformity increases the risk of progression of medial compartment knee osteoarthritis. The aim of this study was to investigate the clinical and radiographic mid-term results of closing-wedge and opening-wedge high tibial osteotomy when used to treat this condition.
METHODS:
From January 2001 to April 2004, ninety-two patients were randomized to receive either a closing-wedge or an opening-wedge high tibial osteotomy. The clinical outcome and radiographic results were examined preoperatively; at one year; and, for the present study, at six years postoperatively. The outcomes that we reviewed included maintenance of the achieved correction, progression of osteoarthritis (based on the Kellgren and Lawrence classification), severity of pain (as assessed on a visual analog scale [VAS]), knee function (as measured with the Hospital for Special Surgery [HSS] score and Knee injury and Osteoarthritis Outcome Score [KOOS]), walking distance, complications, and survival with conversion to a total knee arthroplasty as the end point. The results were analyzed on the basis of the intention-to-treat principle.
RESULTS:
Six years postoperatively, the mean hip-knee-ankle (HKA) angle (and standard deviation) was 3.2° ± 4.1° of valgus after a closing-wedge high tibial osteotomy and 1.3° ± 5.0° of valgus after an opening-wedge high tibial osteotomy (p = 0.343). In both groups, the six-year postoperative HKA angles did not differ from the respective one-year postoperative angles. No difference in the severity of pain or in knee function was found between the two groups. Four complications (9%) occurred in the closing-wedge group and seventeen (38%), in the opening-wedge group. Ten (22%) of the patients in the closing-wedge group and three (8%) in the opening-wedge group needed conversion to a total knee arthroplasty within the six-year period (p = 0.05). The difference in the percentage of cases with conversion to total knee arthroplasty was 14% (95% confidence interval [CI] = 21.7 to 0.2).
CONCLUSIONS:
In the group of patients without conversion to a total knee arthroplasty, there was no difference between the high tibial closing-wedge and opening-wedge osteotomies in terms of clinical outcomes or radiographic alignment at six years postoperatively. Opening-wedge osteotomy was associated with more complications, but closing-wedge osteotomy was associated with more early conversions to total knee arthroplasty.
LEVEL OF EVIDENCE:
Therapeutic Level I
Pie /Foot/Fuss/Tarte: Osteotomías del primer metacarpiano para el juanete
Proximal opening wedge osteotomy with wedge-plate fixation compared with proximal chevron osteotomy for the treatment of hallux valgus: a prospective, randomized study
Mark Glazebrook, Peter Copithorne, Gordon Boyd, Timothy Daniels, Karl-André Lalonde, Patricia Francis, Michael Hickey
Journal of Bone and Joint Surgery. American Volume 2014 October 1, 96 (19): 1585-92
BACKGROUND:
Hallux valgus with an increased intermetatarsal angle is usually treated with a proximal metatarsal osteotomy. The proximal chevron osteotomy is commonly used but is technically difficult. This study compares the proximal opening wedge osteotomy of the first metatarsal with the proximal chevron osteotomy for the treatment of hallux valgus with an increased intermetatarsal angle.
METHODS:
This prospective, randomized multicenter (three-center) study was based on the clinical outcome scores of the Short Form-36, the American Orthopaedic Foot & Ankle Society forefoot questionnaire, and the visual analog scale for pain, activity, and patient satisfaction. Subjects were assessed prior to surgery and at three, six, and twelve months postoperatively. Surgeon preference was evaluated based on questionnaires and the operative times required for each procedure.
RESULTS:
No significant differences were found for any of the patients' clinical outcome measurements between the two procedures. The proximal opening wedge osteotomy was found to lengthen, and the proximal chevron osteotomy was found to shorten, the first metatarsal. The intermetatarsal angles improved (decreased) significantly, from 14.8° ± 3.2° to 9.1° ± 2.9 (mean and standard deviation) after a proximal opening wedge osteotomy and from 14.6° ± 3.9° to 11.3° ± 4.0° after a proximal chevron osteotomy (p < 0.05 for both). Operative time required for performing a proximal opening wedge osteotomy is similar to that required for performing a proximal chevron osteotomy (mean and standard deviation, 67.1 ± 16.5 minutes compared with 69.9 ± 18.6 minutes; p = 0.510).
CONCLUSIONS:
Opening wedge and proximal chevron osteotomies have comparable radiographic outcomes and comparable clinical outcomes for pain, satisfaction, and function. The proximal opening wedge osteotomy lengthens, and the proximal chevron osteotomy shortens, the first metatarsal. The proximal opening wedge osteotomy was subjectively less technically demanding and was preferred by the orthopaedic surgeons in this study.
LEVEL OF EVIDENCE: Therapeutic Level I
Mark Glazebrook, Peter Copithorne, Gordon Boyd, Timothy Daniels, Karl-André Lalonde, Patricia Francis, Michael Hickey
Journal of Bone and Joint Surgery. American Volume 2014 October 1, 96 (19): 1585-92
BACKGROUND:
Hallux valgus with an increased intermetatarsal angle is usually treated with a proximal metatarsal osteotomy. The proximal chevron osteotomy is commonly used but is technically difficult. This study compares the proximal opening wedge osteotomy of the first metatarsal with the proximal chevron osteotomy for the treatment of hallux valgus with an increased intermetatarsal angle.
METHODS:
This prospective, randomized multicenter (three-center) study was based on the clinical outcome scores of the Short Form-36, the American Orthopaedic Foot & Ankle Society forefoot questionnaire, and the visual analog scale for pain, activity, and patient satisfaction. Subjects were assessed prior to surgery and at three, six, and twelve months postoperatively. Surgeon preference was evaluated based on questionnaires and the operative times required for each procedure.
RESULTS:
No significant differences were found for any of the patients' clinical outcome measurements between the two procedures. The proximal opening wedge osteotomy was found to lengthen, and the proximal chevron osteotomy was found to shorten, the first metatarsal. The intermetatarsal angles improved (decreased) significantly, from 14.8° ± 3.2° to 9.1° ± 2.9 (mean and standard deviation) after a proximal opening wedge osteotomy and from 14.6° ± 3.9° to 11.3° ± 4.0° after a proximal chevron osteotomy (p < 0.05 for both). Operative time required for performing a proximal opening wedge osteotomy is similar to that required for performing a proximal chevron osteotomy (mean and standard deviation, 67.1 ± 16.5 minutes compared with 69.9 ± 18.6 minutes; p = 0.510).
CONCLUSIONS:
Opening wedge and proximal chevron osteotomies have comparable radiographic outcomes and comparable clinical outcomes for pain, satisfaction, and function. The proximal opening wedge osteotomy lengthens, and the proximal chevron osteotomy shortens, the first metatarsal. The proximal opening wedge osteotomy was subjectively less technically demanding and was preferred by the orthopaedic surgeons in this study.
LEVEL OF EVIDENCE: Therapeutic Level I
07 octubre 2014
Trauma: Abordaje modificado de Stoppa para las fracturas acetabulares
Treatment of acetabulum fractures through the modified stoppa approach: strategies and outcomes
Mark J Isaacson, Benjamin C Taylor, Bruce G French, Attila Poka
Clinical Orthopaedics and related Research 2014, 472 (11): 3345-52
BACKGROUND:
Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.
QUESTIONS/PURPOSES:
We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.
METHODS:
Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.
RESULTS:
Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.
CONCLUSIONS:
In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.
LEVEL OF EVIDENCE: Level IV, therapeutic study
Mark J Isaacson, Benjamin C Taylor, Bruce G French, Attila Poka
Clinical Orthopaedics and related Research 2014, 472 (11): 3345-52
BACKGROUND:
Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.
QUESTIONS/PURPOSES:
We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.
METHODS:
Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.
RESULTS:
Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.
CONCLUSIONS:
In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.
LEVEL OF EVIDENCE: Level IV, therapeutic study
Cadera/Hip/Hüfte/Hanche: Tras la artroscopia de cadera, habría que cerrar bien la cápsula
Anterior hip dislocation 5 months after hip arthroscopy
Daniel C Austin, John G Horneff, John D Kelly
Arthroscopy: the Journal of Arthroscopic & related Surgery 2014, 30 (10): 1380-2
Hip dislocation subsequent to hip arthroscopy is a rare complication. We report on a case of low-energy anterior hip dislocation that occurred 5 months after hip arthroscopy, a period notably longer than any previously reported event. The patient was a track and field athlete who presented and received treatment for a labral tear and cam lesion. The athlete then dislocated her hip postoperatively during competitive jumping, a motion that requires significant hip flexion and extension. The most likely cause of the anterior dislocation was failure to close the capsule at the completion of surgery, lending credibility to recent trends in the literature suggesting routine capsular closure. We believe that a partial psoas release also contributed to dynamic hip instability because of increased femoral anteversion in this patient. This case suggests that hip capsule closure should be considered at the completion of every procedure and that a psoas release should be avoided in patients with significant anteversion. Furthermore, the biomechanics of competitive jumping may make these athletes more prone to dislocation and require more conservative return-to-sport recommendations.
Daniel C Austin, John G Horneff, John D Kelly
Arthroscopy: the Journal of Arthroscopic & related Surgery 2014, 30 (10): 1380-2
Hip dislocation subsequent to hip arthroscopy is a rare complication. We report on a case of low-energy anterior hip dislocation that occurred 5 months after hip arthroscopy, a period notably longer than any previously reported event. The patient was a track and field athlete who presented and received treatment for a labral tear and cam lesion. The athlete then dislocated her hip postoperatively during competitive jumping, a motion that requires significant hip flexion and extension. The most likely cause of the anterior dislocation was failure to close the capsule at the completion of surgery, lending credibility to recent trends in the literature suggesting routine capsular closure. We believe that a partial psoas release also contributed to dynamic hip instability because of increased femoral anteversion in this patient. This case suggests that hip capsule closure should be considered at the completion of every procedure and that a psoas release should be avoided in patients with significant anteversion. Furthermore, the biomechanics of competitive jumping may make these athletes more prone to dislocation and require more conservative return-to-sport recommendations.
06 octubre 2014
Cadera/Hip/Hüfte/Hanche: Bloquear el dolor de la cadera con necrosis avascular
Bloqueo intraarticular y de ramas sensoriales del nervios obturador y femoral en cuadro de osteonecrosis y artrosis de la cabeza femoral
M. Cortiñas-Sáenz, G. Salmerón-Vélez, I.A. Holgado-Macho
Rev Esp Cir Ortop Traumatol. 2014; 58(5):319-342
RESUMEN
La inervación sensitiva de la articulación de la cadera es compleja. El bloqueo intraarticular y de las ramas sensitivas de los nervios obturador y femoral es eficaz para tratar el dolor producido por diversas enfermedades de cadera, y pudiera ser una opción a considerar en determinadas circunstancias. Estas circunstancias pueden ser alto riesgo quirúrgico-anestésico por el estado basal del paciente o la existencia de sobrepeso importante, en otras ocasiones el médico traumatólogo considera que es mejor retrasar la artroplastia, al menos durante algún tiempo.
M. Cortiñas-Sáenz, G. Salmerón-Vélez, I.A. Holgado-Macho
Rev Esp Cir Ortop Traumatol. 2014; 58(5):319-342
RESUMEN
La inervación sensitiva de la articulación de la cadera es compleja. El bloqueo intraarticular y de las ramas sensitivas de los nervios obturador y femoral es eficaz para tratar el dolor producido por diversas enfermedades de cadera, y pudiera ser una opción a considerar en determinadas circunstancias. Estas circunstancias pueden ser alto riesgo quirúrgico-anestésico por el estado basal del paciente o la existencia de sobrepeso importante, en otras ocasiones el médico traumatólogo considera que es mejor retrasar la artroplastia, al menos durante algún tiempo.
General: Proteger las manos y los ojos del traumatólogo, incluso corazón y cerebro
Radiation safety in orthopedic operating theaters: What is the current situation?
Radioprotección en quirófanos de traumatología: ¿en qué situación estamos?
M. Torres-Torres, J. Mingo-Robinet, M. Moreno Barrero, J.Á. Rivas Laso, I. Burón Álvarez, M. González Salvador
Rev Esp Cir Ortop Traumatol 2014;58(5):309-313
Abstract
Objective
To analyze the exposure of two Orthopedic Surgeons to ionizing radiations in their daily work, and to review the main national and international recommendations on this subject.
Material and methods
A retrospective study was conducted on the surgical treatments that use fluoroscopy performed by two orthopedic surgeons during a one year period. An evaluation was made of the radiation received, based on measurements of the processes published in the bibliography section. A literature review of international recommendations and regulations is also presented.
Results
The radiation received by the two orthopedic surgeons during one year did not exceed the limits of present-day legislation or the new European and international recommendations. The exposure was asymmetrical, with the hands being the most radiated part. The new recommendations reduce the permitted level of radiation on eyes.
Discussion
The evaluation of the radiation received demonstrates the need for radiation protection, paying particular attention to the hands and eyes. Good knowledge of operating a fluoroscope and radiation safety measures are also essential.
Nivel de evidencia IV
Radioprotección en quirófanos de traumatología: ¿en qué situación estamos?
M. Torres-Torres, J. Mingo-Robinet, M. Moreno Barrero, J.Á. Rivas Laso, I. Burón Álvarez, M. González Salvador
Rev Esp Cir Ortop Traumatol 2014;58(5):309-313
Abstract
Objective
To analyze the exposure of two Orthopedic Surgeons to ionizing radiations in their daily work, and to review the main national and international recommendations on this subject.
Material and methods
A retrospective study was conducted on the surgical treatments that use fluoroscopy performed by two orthopedic surgeons during a one year period. An evaluation was made of the radiation received, based on measurements of the processes published in the bibliography section. A literature review of international recommendations and regulations is also presented.
Results
The radiation received by the two orthopedic surgeons during one year did not exceed the limits of present-day legislation or the new European and international recommendations. The exposure was asymmetrical, with the hands being the most radiated part. The new recommendations reduce the permitted level of radiation on eyes.
Discussion
The evaluation of the radiation received demonstrates the need for radiation protection, paying particular attention to the hands and eyes. Good knowledge of operating a fluoroscope and radiation safety measures are also essential.
Nivel de evidencia IV
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