Rodilla/Knee: ¿Revisar las prótesis de rodilla infectadas en centros especializados sólo?

Revision of infected knee arthroplasties in Denmark: Outcome of 105 partial revisions (open debridement and exchange of tibial insert) and 215 two-stage revisions 

Martin LINDBERG-LARSEN, Christoffer C JØRGENSEN, Jens BAGGER, 

Henrik M SCHRØDER, Henrik KEHLET 

Acta Orthopaedica 2016; 87 

Background and purpose — The surgical treatment of periprosthetic knee infection is generally either a partial revision procedure (open debridement and exchange of the tibial insert) or a  2-stage exchange arthroplasty procedure. We describe the failure rates of these procedures on a nationwide basis.

Patients and methods — 105 partial revisions (100 patients) and 215 potential 2-stage revision procedures (205 patients) performed due to infection from July 1, 2011 to June 30, 2013 were identifi ed from the Danish Knee Arthroplasty Register (DKR). Failure was defined as surgically related death  90 days postoperatively, re-revision due to infection, or not reaching the second stage for a planned 2 stage procedure within a median follow-up period of 3.2 (2.2–4.2) years

Results — The failure rate of the partial revisions was 43%. 71 of the partial revisions (67%) were revisions of a primary prosthesis with a re-revision rate due to infection of 34%, as compared to 55% in revisions of a revision prosthesis (p = 0.05). The failure rate of the 2-stage revisions was 30%. Median time interval between stages was 84 (9–597) days. 117 (54%) of the 2-stage revisions were revisions of a primary prosthesis with a re-revision rate due to infection of 21%, as compared to 29% in revisions of a previously revised prosthesis (p = 0.1). Overall postoperative mortality was 0.6% in high-volume centers (> 30 procedures within 2 years) as opposed to 7% in the remaining centers (p = 0.003). 

Interpretation — The failure rates of 43% after the partial revision procedures and 30% after the 2-stage revisions in combination with the higher mortality outside high-volume centers call for centralization and reconsideration of surgical strategies.

Antecedentes y propósito - El tratamiento quirúrgico de la infección periprotésica por lo general  es , o bien una revisión parcial (desbridamiento abierto y recambio del polietileno) o una artroplastia de revisión en dos tiempos. Describimos los índices de fracaso nacional de estos procedimientos.

Pacientes y métodos - Desde el 1 de julio de 2011 al 30 de junio de 2013, se identificaron 105 revisiones parciales (100 pacientes) y 215 procedimientos potenciales de revisión en dos tiempos (205 pacientes) debidos a infección en el Registro Danés de Artroplastia de Rodilla (DKR). Se definió el fracaso como la muerte acaecida en los 90 días del posoperatorio, la re-revisión por infección o no alcanzar el segundo tiempo de la revisión; el periodo medio de seguimiento fue de 3.2 años (2.2-4.2)

Resultados - El porcentaje de fracaso de las revisiones parciales fue del 43%. 71de las revisiones parciales (67%) fueron revisiones de prótesis primarias con un porcentaje de re-revisión por infección del 34 %, en comparación del 55% en revisiones de una prótesis de revisión (p = 0.05%). El porcentaje de fracaso de las revisiones en dos tiempos fue del 30%. La mediana temporal entre los dos fases de la revisión en dos tiempos fue 84 días (9-597). 117(54%) de las revisiones en dos tiempos eran revisiones de una prótesis primaria con un porcentaje de re-revisión por infección del 21%, en comparación con el 29% de revisiones de una prótesis revisada previamente (p=0.1). La mortalidad posoperatoria global fue del 0.6% en los centros de gran volumen quirúrgico (más de 30 procedimientos en dos años) frente al 7% en los centros restantes (p=0.003).

Interpretación - El porcentaje de fracaso del 43% tras la revisión parcial y del 30% tras la revisión en dos tiempos, junto a la mayor mortalidad en centros que no son de gran volumen quirúrgico, suponen una llamada a la centralización y reconsideración de las estrategias quirúrgicas

Cadera/Hip: hay sitio para las prótesis de cadera de recubrimiento m/m

Current expert views on metal-on-metal hip resurfacing arthroplasty. Consensus of the 6th advanced Hip resurfacing course, Ghent, Belgium, May 2014 

Van Der Straeten, Catherine De Smet, Koen A.

Hip Int 2016; 26(1): 1 - 7. DOI:10.5301/hipint.5000288

Abstract

This paper reports the consensus of an international faculty of expert metal-on-metal (MoM) hip resurfacing surgeons, with a combined experience of over 40,000 cases, on the current status of hip resurfacing arthroplasty. 

Indications, design and metallurgy issues, release of metal ions and adverse soft tissue reactions to particles, management of problematic cases and revisions, as well as required experience and training are covered. 

The overall consensus is that MoM hip resurfacing should not be banned and should be viewed separately from MoM total hip arthroplasty (THA) with a large diameter head because of the different design and wear behaviour related to the taper/trunnion connection. The use of hip resurfacing has decreased worldwide but specialist centres continue to advocate hip resurfacing in young and active male patients. Regarding age the general recommendation is to avoid hip resurfacing in men older than 65 and in women older than 55, depending on the patient activity and bone quality. Female gender is considered a relative contraindication. Most surgeons would not implant a MoM hip in women who would still like a child. Regardless of gender, there is a consensus not to perform hip resurfacing in case of a femoral head size smaller than 46 mm and in patients with renal insufficiency or with a known metal allergy. Regarding follow-up of hip resurfacing and detection of adverse local tissue reactions, metal ion measurements, MRI and ultrasound are advocated depending on the local expertise. The consensus is that hip resurfacing should be limited to high volume hip surgeons, who are experienced in hip resurfacing or trained to perform hip resurfacing in a specialist centre.

Rodilla/Knee: joven muy deportista con una ligamentoplastia, una bomba

Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis.

Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD.

Am J Sports Med. 2016 Jan 15. pii: 0363546515621554

Abstract

BACKGROUND: Injury to the ipsilateral graft used for reconstruction of the anterior cruciate ligament (ACL) or a new injury to the contralateral ACL are disastrous outcomes after successful ACL reconstruction (ACLR), rehabilitation, and return to activity. Studies reporting ACL reinjury rates in younger active populations are emerging in the literature, but these data have not yet been comprehensively synthesized.

PURPOSE: To provide a current review of the literature to evaluate age and activity level as the primary risk factors in reinjury after ACLR.

STUDY DESIGN: Systematic review and meta-analysis.

METHODS: A systematic review of the literature was conducted via searches in PubMed (1966 to July 2015) and EBSCO host (CINAHL, Medline, SPORTDiscus [1987 to July 2015]). After the search and consultation with experts and rating of study quality, 19 articles met inclusion for review and aggregation. Population demographic data and total reinjury (ipsilateral and contralateral) rate data were recorded from each individual study and combined using random-effects meta-analyses. Separate meta-analyses were conducted for the total population data as well as the following subsets: young age, return to sport, and young age + return to sport.

RESULTS: Overall, the total second ACL reinjury rate was 15%, with an ipsilateral reinjury rate of 7% and contralateral injury rate of 8%. The secondary ACL injury rate (ipsilateral + contralateral) for patients younger than 25 years was 21%. The secondary ACL injury rate for athletes who return to a sport was also 20%. Combining these risk factors, athletes younger than 25 years who return to sport have a secondary ACL injury rate of 23%.

CONCLUSION: This systematic review and meta-analysis demonstrates that younger age and a return to high level of activity are salient factors associated with secondary ACL injury. These combined data indicate that nearly 1 in 4 young athletic patients who sustain an ACL injury and return to high-risk sport will go on to sustain another ACL injury at some point in their career, and they will likely sustain it early in the return-to-play period. The high rate of secondary injury in young athletes who return to sport after ACLR equates to a 30 to 40 times greater risk of an ACL injury compared with uninjured adolescents. These data indicate that activity modification, improved rehabilitation and return-to-play guidelines, and the use of integrative neuromuscular training may help athletes more safely reintegrate into sport and reduce second injury in this at-risk population.

Rodilla/Knee: las suturas con anclaje ganan terreno

Biomechanical Evaluation of Suture Anchor Versus Transosseous Tunnel Quadriceps Tendon Repair Techniques.
Sherman SL, Copeland ME, Milles JL, Flood DA, Pfeiffer FM.
Arthroscopy. 2016 Feb 16. pii: S0749-8063(15)00973-1. doi: 10.1016/j.arthro.2015.11.038.

PURPOSE:
To evaluate the biomechanical fixation strength of suture anchor and transosseous tunnel repair of the quadriceps tendon in a standardized cadaveric repair model.

METHODS:
Twelve "patella-only" specimens were used. Dual-energy X-ray absorptiometry measurement was performed to ensure equal bone quality amongst groups. Specimens were randomly assigned to either a suture anchor repair of quadriceps tendon group (n = 6) or a transosseous tunnel repair group (n = 6). Suture type and repair configuration were equivalent. After the respective procedures were performed, each patella was mounted into a gripping jig. Tensile load was applied at a rate of 0.1 mm/s up to 100 N after which cyclic loading was applied at a rate of 1 Hz between magnitudes of 50 to 150 N, 50 to 200 N, 50 to 250 N, and tensile load at a rate of 0.1 mm/s until failure. Outcome measures included load to failure, displacement at 1st 100 N load, and displacement after each 10th cycle of loading.

RESULTS:
The measured cyclic displacement to the first 100 N, 50 to 150 N, 50 to 200 N, and 50 to 250 N was significantly less for suture anchors than transosseous tunnels. There was no statistically significant difference in ultimate load to failure between the two groups (P = .40). Failure mode for all suture anchors except one was through the soft tissue. Failure mode for all transosseous specimens but one was pulling the repair through the transosseous tunnel.

CONCLUSIONS:
Suture anchor quadriceps tendon repairs had significantly decreased gapping during cyclic loading, but no statistically significant difference in ultimate load to failure when compared with transosseous tunnel repairs. Although suture anchor quadriceps tendon repair appears to be a biomechanically superior construct, a clinical study is needed to confirm this technique as a viable alternative to gold standard transosseous techniques.

CLINICAL RELEVANCE:
Although in vivo studies are needed, these results support the suture anchor technique as a viable alternative to transosseous repair of the quadriceps tendon.

Knee/Rodilla: una pasada de clorexidina puede bajar el riesgo de infección local

Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Hip Arthroplasty?
Bhaveen H Kapadia, Julio J Jauregui, Daniel P Murray, Michael A Mont
Clinical Orthopaedics and related Research 2016 February 18

BACKGROUND: Periprosthetic hip infections are among the most catastrophic complications after total hip arthroplasty (THA). We had previously proven that the use of chlorhexidine cloths before surgery may help decrease these infections; hence, we increased the size of the previously reported cohort.

QUESTIONS/PURPOSES: (1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing THA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol?

METHODS: Between 2007 and 2013, a group of 998 patients used chlorhexidine cloths before surgery, whereas a group of 2846 patients did not use them and underwent standard perioperative disinfection only. Patient records were reviewed to determine the development of periprosthetic infection in both groups of patients.

RESULTS: Patients without the preoperative chlorhexidine gluconate disinfection protocol had a higher risk of infections (infections with protocol: six of 995 [0.6%]; infections in control: 46 of 2846 [1.62%]; relative risk: 2.68 [95% confidence interval {CI}, 1.15-0.26]; p = 0.0226). When stratified based on risk category, no differences were detected; preadmission chlorhexidine preparation was not associated with reduced infection risk for low, medium, and high NHSN risk categories (p = 0.386, 0.153, and 0.196, respectively).

CONCLUSIONS: The results of our study suggest that this cloth application appears to reduce the risk of infection in patients undergoing THA. When stratified by risk categories, we found no difference in the infection rate, but these findings were underpowered. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and so might be considered on the basis of this retrospective, comparative study.

LEVEL OF EVIDENCE: Level III, therapeutic study.

Rodilla/Knee: al fin una prueba de que el PRP sirve

Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review.

Meheux CJ, McCulloch PC, Lintner DM, Varner KE, Harris JD. 

Arthroscopy. 2015 Sep 29

Abstract

PURPOSE: To determine (1) whether platelet-rich plasma (PRP) injection significantly improves validated patient-reported outcomes in patients with symptomatic knee osteoarthritis (OA) at 6 and 12 months postinjection, (2) differences in outcomes between PRP and corticosteroid injections or viscosupplementation or placebo injections at 6 and 12 months postinjection, and (3) similarities and differences in outcomes based on the PRP formulations used in the analyzed studies.

METHODS: PubMed, Cochrane Central Register of Controlled Trials, SCOPUS, and Sport Discus were searched for English-language, level I evidence, human in vivo studies on the treatment of symptomatic knee OA with intra-articular PRP compared with other options, with a minimum of 6 months of follow-up. A quality assessment of all articles was performed using the Modified Coleman Methodology Score (average, 83.3/100), and outcomes were analyzed using 2-proportion z-tests.

RESULTS: Six articles (739 patients, 817 knees, 39% males, mean age of 59.9 years, with 38 weeks average follow-up) were analyzed. All studies met minimal clinical important difference criteria and showed significant improvements in statistical and clinical outcomes, including pain, physical function, and stiffness, with PRP. All but one study showed significant differences in clinical outcomes between PRP and hyaluronic acid (HA) or PRP and placebo in pain and function. Average pretreatment Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were 52.36 and 52.05 for the PRP and HA groups, respectively (P = .420). Mean post-treatment WOMAC scores for PRP were significantly better than for HA at 3 to 6 months (28.5 and 43.4, respectively; P = .0008) and at 6 to 12 months (22.8 and 38.1, respectively; P = .0062). None of the included studies used corticosteroids.

CONCLUSIONS: In patients with symptomatic knee OA, PRP injection results in significant clinical improvements up to 12 months postinjection. Clinical outcomes and WOMAC scores are significantly better after PRP versus HA at 3 to 12 months postinjection. There is limited evidence for comparing leukocyte-rich versus leukocyte-poor PRP or PRP versus steroids in this study.

LEVEL OF EVIDENCE: Level I, systematic review of Level I studies.

Rodilla/Knee: Una sola oportunidad a la calza

Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for the Treatment of Recurrent Lateral Patellar Dislocations: A Systematic Review and Meta-analysis.

Schneider DK, Grawe B, Magnussen RA, Ceasar A, Parikh SN, Wall EJ, Colosimo AJ, Kaeding CC, Myer GD.

Am J Sports Med. 2016 Feb 12. pii: 0363546515624673

Abstract

BACKGROUND: A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is decreasing, and surgical intervention is more commonly recommended for those patients who fail initial nonoperative management with recurrent patellar dislocations. Medial patellofemoral ligament (MPFL) reconstruction has become increasingly utilized in this regard.

PURPOSE: To evaluate outcomes, particularly return to sports and its relationship to postoperative instability, of isolated MPFL reconstruction for the treatment of recurrent patellar dislocations.

STUDY DESIGN: Systematic review and meta-analysis.

METHODS:  A review of the current literature was performed using the terms "medial patellofemoral ligament reconstruction" and "MPFL reconstruction" in the electronic search engines PubMed and EBSCOhost (CINAHL, MEDLINE, SPORTDiscus) on July 29, 2015, yielding 1113 abstracts for review. At the conclusion of the search, 14 articles met the inclusion criteria and were included in this review of the literature. Means were calculated for population size, age, follow-up time, and postoperative Tegner scores. Pooled estimates were calculated for postoperative Kujala scores, return to play, total risk of postoperative instability, risk of positive apprehension sign, and risk of reoperation.

RESULTS: The mean patient age associated with MPFL reconstruction was 24.4 years, with a mean postoperative Tegner score of 5.7. The pooled estimated mean postoperative Kujala score was 85.8 (95% CI, 81.6-90.0), with 84.1% (95% CI, 71.1%-97.1%) of patients returning to sports after surgery. The pooled total risk of recurrent instability after surgery was 1.2% (95% CI, 0.3%-2.1%), with a positive apprehension sign risk of 3.6% (95% CI, 0%-7.2%) and a reoperation risk of 3.1% (95% CI, 1.1%-5.0%).

CONCLUSION: A high percentage of young patients return to sports after isolated MPFL reconstruction for chronic patellar instability, with short-term results demonstrating a low incidence of recurrent instability, postoperative apprehension, and reoperations.