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.

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.

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

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.

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.

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.

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.

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.

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 &lt; 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 &lt; 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.

General: Mucho mejor si estás entrenado

Fundamental Arthroscopic Skill Differentiation With Virtual Reality Simulation.

Rose K, Pedowitz R
Arthroscopy. 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.

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.

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.

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.

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

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.

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.

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

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.

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.

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.