Background
It is unclear whether there are differences in benefits and harms between mobile and fixed prostheses for total knee arthroplasty (TKA). The previous Cochrane review published in 2004 ...included two articles. Many more trials have been performed since then; therefore an update is needed.
Objectives
To assess the benefits and harms of mobile bearing compared with fixed bearing cruciate retaining total knee arthroplasty for functional and clinical outcomes in patients with osteoarthritis (OA) or rheumatoid arthritis (RA).
Search methods
We searched The Cochrane Library, PubMed, EMBASE, CINAHL and Web of Science up to 27 February 2014, and the trial registers ClinicalTrials.gov, Multiregister, Current Controlled Trials and the World Health Organization (WHO) International Clinical Trials Registry Platform for data from unpublished trials, up to 11 February 2014. We also screened the reference lists of selected articles.
Selection criteria
We selected randomised controlled trials comparing mobile bearing with fixed bearing prostheses in cruciate retaining TKA among patients with osteoarthritis or rheumatoid arthritis, using functional or clinical outcome measures and follow‐up of at least six months.
Data collection and analysis
We used standard methodological procedures as expected by The Cochrane Collaboration.
Main results
We found 19 studies with 1641 participants (1616 with OA (98.5%) and 25 with RA (1.5%)) and 2247 knees. Seventeen new studies were included in this update.
Quality of the evidence ranged from moderate (knee pain) to low (other outcomes). Most studies had unclear risk of bias for allocation concealment, blinding of participants and personnel, blinding of outcome assessment and selective reporting, and high risk of bias for incomplete outcome data and other bias.
Knee pain
We calculated the standardised mean difference (SMD) for pain, using the Knee Society Score (KSS) and visual analogue scale (VAS) in 11 studies (58%) and 1531 knees (68%). No statistically significant differences between groups were reported (SMD 0.09, 95% confidence interval (CI) ‐0.03 to 0.22, P value 0.15). This represents an absolute risk difference of 2.4% points higher (95% CI 0.8% lower to 5.9% higher) on the KSS pain scale and a relative percent change of 0.22% (95% CI 0.07% lower to 0.53% higher). The results were homogeneous.
Clinical and functional scores
The KSS clinical score did not differ statistically significantly between groups (14 studies (74%) and 1845 knees (82%)) with a mean difference (MD) of ‐1.06 points (95% CI ‐2.87 to 0.74, P value 0.25) and heterogeneous results. KSS function was reported in 14 studies (74%) with 1845 knees (82%) as an MD of ‐0.10 point (95% CI ‐1.93 to 1.73, P value 0.91) and homogeneous results. In two studies (11%), the KSS total score was favourable for mobile bearing (159 vs 132 for fixed bearing), with MD of ‐26.52 points (95% CI ‐45.03 to ‐8.01, P value 0.005), but with a wide 95% confidence interval indicating uncertainty about the estimate.
Other reported scoring systems did not show statistically significant differences: Hospital for Special Surgery (HSS) score (seven studies (37%) in 1021 knees (45%)) with an MD of ‐1.36 (95% CI ‐4.18 to 1.46, P value 0.35); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score (two studies (11%), 167 knees (7%)) with an MD of ‐4.46 (95% CI ‐16.26 to 7.34, P value 0.46); and Oxford total (five studies (26%), 647 knees (29%) with an MD of ‐0.25 (95% CI ‐1.41 to 0.91, P value 0.67).
Health‐related quality of life
Three studies (16%) with 498 knees (22%) reported on health‐related quality of life, and no statistically significant differences were noted between the mobile bearing and fixed bearing groups. The Short Form (SF)‐12 Physical Component Summary had an MD of ‐1.96 (95% CI ‐4.55 to 0.63, P value 0.14) and heterogeneous results.
Revision surgery
Twenty seven revisions (1.3%) were performed in 17 studies (89%) with 2065 knees (92%). In all, 13 knees were revised in the fixed bearing group and 14 knees in the mobile bearing group. No statistically significant differences were found (risk difference 0.00, 95% CI ‐0.01 to 0.01, P value 0.58), and homogeneous results were reported.
Mortality
In seven out of 19 studies, 13 participants (37%) died. Two of these participants had undergone bilateral surgery, and for seven participants, it was unclear which prosthesis they had received; therefore they were excluded from the analyses. Thus our analysis included four out of 191 participants (2.1%) who had died: one in the fixed bearing group and three in the mobile bearing group. No statistically significant differences were found. The risk difference was ‐0.02 (95% CI ‐0.06 to 0.03, P value 0.49) and results were homogeneous.
Reoperation rates
Thirty reoperations were performed in 17 studies (89%) with 2065 knees (92%): 18 knees in the fixed bearing group (of the 1031 knees) and 12 knees in the mobile group (of the 1034 knees). No statistically significant differences were found. The risk difference was ‐0.01 (95% CI ‐0.01 to 0.01, P value 0.99) with homogeneous results.
Other serious adverse events
Sixteen studies (84%) reported nine other serious adverse events in 1735 knees (77%): four in the fixed bearing group (of the 862 knees) and five in the mobile bearing group (of the 873 knees). No statistically significant differences were found (risk difference 0.00, 95% CI ‐0.01 to 0.01, P value 0.88), and results were homogeneous.
Authors' conclusions
Moderate‐ to low‐quality evidence suggests that mobile bearing prostheses may have similar effects on knee pain, clinical and functional scores, health‐related quality of life, revision surgery, mortality, reoperation rate and other serious adverse events compared with fixed bearing prostheses in posterior cruciate retaining TKA. Therefore we cannot draw firm conclusions. Most (98.5%) participants had OA, so the findings primarily reflect results reported in participants with OA. Future studies should report in greater detail outcomes such as those presented in this systematic review, with sufficient follow‐up time to allow gathering of high‐quality evidence and to inform clinical practice. Large registry‐based studies may have added value, but they are subject to treatment‐by‐indication bias. Therefore, this systematic review of RCTs can be viewed as the best available evidence.
Introduction:
Excellent long-term survival has been reported for both the Taperloc and the Mallory-Head cementless stems. However, little is known about the migration behaviour of these stems which ...have different design rationales. The purpose of this randomised clinical trial was to compare the migration and clinical outcomes of these stems during 5 years of follow-up.
Methods:
42 consecutive hips in 38 patients scheduled to receive cementless THA were randomised to either a Taperloc or a Mallory-Head stem. Evaluation took place preoperatively and postoperatively on the second day, at 6, 12, 26, and 52 weeks, and annually thereafter. Primary outcome was stem migration measured using roentgen stereophotogrammetric analysis (RSA) and secondary outcomes were the Harris Hip Score (HHS) and 36-Item Short-Form Health Survey (SF-36). No patients were lost to follow-up; in 1 patient the THA was removed due to deep infection 3 months postoperatively. In 6 hips migration measurements were not possible due to insufficient marker configuration.
Results:
Throughout the follow-up period of 5 years, 3-dimensional migration was comparable between the Taperloc and the Mallory-Head stems (p-values > 0.05). However, at the 5-year follow-up point the retroversion of the Mallory-Head stem was 0.9° more than the Taperloc stem (p = 0.04). Initial subsidence and retroversion were respectively as large as 6.8 mm and 3.6° for the Taperloc stem and 5 mm and 3.6° for the Mallory-Head stem. After the first postoperative year, both implants had stabilised. The mean increment of HHS, as well as the SF-36 scores during the 5-year follow-up, were comparable between the 2 stems.
Conclusions:
The excellent long-term survival of both designs was confirmed in this study showing comparable initial migration with subsequent stabilisation. However, the Taperloc design with a flat, wedged geometry showed better rotational stability.
Aim: To measure functional recovery and determine risk factors for failure to return to the prefracture level of mobility of hip fracture patients 1 year postoperatively.
Methods: A prospective ...cohort follow‐up study of 390 hip fracture patients aged 65 years and older was carried out. Patients were stratified in categories based on prefracture mobility: mobile without aid, with aid in‐ and outdoors, or only mobile indoors. Immobile patients were excluded. Risk factors for not regaining prefracture mobility were identified.
Results: Nearly half of all patients regained their prefracture level of mobility after 1 year. Mobile patients without an aid were less likely to return to their prefracture mobility level compared with patients who were mobile with aid or mobile indoors. After 1 year, 18.7% of all patients had become immobile. Most important independent risk factors for failure to return to the prefracture level of mobility were a limited prefracture level of activities of daily living and a delirium during admission.
Conclusions: The risk not to regain prefracture mobility is highest in mobile patients without an aid. The risk of becoming immobile is higher in those having a lower prefracture mobility. Activities of daily living dependence and delirium were the main risk factors for not regaining mobility. Geriatr Gerontol Int 2013; 13: 334–341.
To assess the apparent validity of observational studies of elective arthroplasty interventions.
Data from the nationwide Dutch Arthroplasty Register were used. The first case study compared surgical ...approaches for total hip arthroplasty (posterolateral approach vs. straight lateral approach), where allocation of the intervention was assumed to be mostly independent of patient characteristics. The second case study compared fixation methods (cemented vs. uncemented), where choice of fixation method was expected to depend on patient characteristics. The potential for confounding was quantified by differences between intervention groups and the impact of confounding adjustment.
The study of posterolateral approach versus straight lateral approach included 73,750 and 16,557 patients, respectively, and showed no meaningful differences in patient characteristics between treatment groups (standardized mean differences <0.1) and also no relevant impact of confounding adjustment (Z-scores <1). The study of cemented versus uncemented total hip arthroplasty (THA) included 29,579 and 79,360 patients, respectively. Several meaningful imbalances were observed in patient characteristic between the two treatment groups (standardized mean differences >0.1), as well as a relevant impact of confounding adjustment (Z-scores >2).
This study provides insight in the reasoning behind the credibility of observational studies of surgical interventions using routinely collected data and when confounding is expected to have a major impact and thus additional precautions to limit confounding are needed.
Femoroacetabular impingement leads to limited hip motion, pain and progressive damage to the labrum. Assessment of the amount and location of excessive ossification can be difficult, and removal does ...not always lead to pain relief and an increase of function. One of the challenges ahead is to discover why certain cases have poor outcomes.
The technical and clinical results of two consecutive arthroscopic shavings of an osseous cam protrusion are described in our patient, a 50-year-old Caucasian man with complaints of femoroacetabular impingement. At 12 weeks after the first arthroscopic shaving, our patient still experienced pain. Using a range of motion simulation system based on computed tomography images the kinematics of his hip joint were analyzed. Bone that limited range of motion was removed in a second arthroscopic procedure. At six months post-operatively our patient is almost pain free and has regained a range of motion to a functional level.
This case demonstrates the relevance of range of motion simulation when the outcome of primary arthroscopic management is unsatisfactory. Such simulations may aid clinicians in determining the gain of a second operation. This claim is supported by the correlation of the simulations with clinical outcome, as shown in this case report.
ABSTRACT
In a retrospective, case–control cohort study an assessment was made of the clinical outcome of patients with osteomyelitis treated with a new modality of negative pressure wound therapy, so ...called negative pressure instillation therapy. In this approach, after surgical debridement, a site of osteomyelitis is treated with negative pressure of at least 300 mmHg applied through polyvinyl alcohol dressing. The polyvinyl alcohol foam is irrigated through the tubes three times a day with a polyhexanide antiseptic solution. In 30 patients (14 males; mean age 52 range, 26–81) admitted between 1999 and 2003 with osteomyelitis of the pelvis or lower extremity, we assessed time to wound closure, number of surgical procedures and rate of recurrence of infection as well as need for rehospitalizations. For comparison, a control group of 94 patients (males, 58; mean age 47 range, 9–85), matched for site and severity of osteomyelitis, was identified in hospital records between 1982 and 2002. These patients underwent standard surgical debridement, implantation of gentamicin polymethylmethacrylate beads and long‐term intravenous antibiotics. In the Instillation group the rate of recurrence of infection was 3/30 (10%), whereas 55/93 (58.5%) of the controls had a recurrence (p<0.0001). Moreover, in those treated with instillation the total duration of hospital stay was shorter and number of surgical procedures smaller as compared with the controls (all p<0.0001). We conclude that in posttraumatic osteomyelitis negative pressure instillation therapy reduces the need for repeated surgical interventions in comparison with the present standard approach.
Purpose To investigate the outcome of open subscapularis (SSC) repair in terms of complete relief of symptoms, regaining functional range of motion ((ROM), i.e. minimum ROM to complete all tasks of ...daily living) and retear rate. Methods Sixty-one patients who underwent open SSC repair between 2012 and 2019 were included in a retrospective cohort study. Primary outcome measures (complete relief of symptoms, obtaining functional ROM, SSC retears), were assessed at minimum 1-year follow-up. Prognostic factors for these outcome measures were identified. Results At final follow-up, 44 patients (72%) reported complete relief of symptoms. Pre-operatively, 23 patients (40%) had a functional ROM, which increased to 33 patients (54%) post-operatively. Eight Patients (13%) had a retear after a median follow-up of 21 months (range: 3-35). Lafosse type IV tears were associated with having persisting symptoms (OR 5, 95 confidence interval (CI) 1.2–17.9, p = 0.024) and retears (OR 7, 95 CI 1.9–37.7, p = 0.031). Conclusion The majority of patients reported complete relief of symptoms after SSC repair; however, only 54% obtained a functional ROM. Measuring outcome in terms of complete relief symptoms and regaining functional ROM is useful for the surgeon to evaluate the effect of surgical intervention and provides tangible information for patients.
Background and purpose In contrast to early migration, the long-term migration of hydroxyapatite- (HA-) coated tibial components in TKA has been scantily reported. This randomized controlled trial ...investigated the long-term migration measured by radiostereometric analysis (RSA) of HA-coated, uncoated, and cemented tibial components in TKA.
Patients and methods 68 knees were randomized to HA-coated (n = 24), uncoated (n = 20), and cemented (n = 24) components. All knees were prospectively followed for 11-16 years, or until death or revision. RSA was used to evaluate migration at yearly intervals. Clinical and radiographic evaluation was according to the Knee Society system. A generalized linear mixed model (GLMM, adjusted for age, sex, diagnosis, revisions, and BMI) was used to take into account the repeated-measurement design.
Results The present study involved 742 RSA analyses. The mean migration at 10 years was 1.66 mm for HA, 2.25 mm for uncoated and 0.79 mm for the cemented group (p < 0.001). The reduction of migration by HA as compared to uncoated components was most pronounced for subsidence and external rotation. 3 tibial components were revised for aseptic loosening (2 uncoated and 1 cemented), 3 for septic loosening (2 uncoated and 1 cemented), and 1 for instability (HA-coated). 2 of these cases were revised for secondary loosening after a period of stability: 1 case of osteolysis and 1 case of late infection. There were no statistically significant differences between the fixation groups regarding clinical or radiographic scores.
Interpretation HA reduces migration of uncemented tibial components. This beneficial effect lasts for more than 10 years. Cemented components showed the lowest migration. Longitudinal follow-up of TKA with RSA allows early detection of secondary loosening.
Celotno besedilo
Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Aim
A significant loss of instrumental activities of daily living (IADL) after a hip fracture has been reported. The aim of the present study was to identify specific predictors for low IADL after a ...hip fracture, in order to target better postoperative care for these patients.
Methods
A prospective observational cohort study of 480 hip fracture patients was carried out. IADL was measured at baseline, and after 3 and 12 months using the Groningen Activity Restriction Scale. Multivariable logistic regression analysis was carried out using age, sex, American Society of Anesthesiologists classification, prefracture living with a partner, prefracture living situation, prefracture use of walking aids, type of fracture, type of anesthesia, length of hospital stay, postoperative complications and prefracture IADL as potential predictors for low IADL after a hip fracture. The correlation between IADL, mobility and living situation, both at admission, and 3 and 12 months postoperatively, were measured.
Results
Three months after hip fracture treatment, 24% of patients returned to their baseline IADL level, at 12 months postoperative this was 29%. Factors associated with a larger loss in IADL after a hip fracture were older age, prefracture living with a partner, prefracture living at home, prefracture use of walking aids and longer length of hospital stay. The correlation between IADL and living situation was 0.69, and between IADL and use of walking aids was 0.80.
Conclusions
A return to prefracture IADL level was low. Healthier patients have a steeper decline in postoperative IADL. Geriatr Gerontol Int 2018; 18: 1244–1248.
Objective:
To investigate construct validity and test–retest reliability of the parent-rated Hand-Use-at-Home questionnaire (HUH) in children with neonatal brachial plexus palsy or unilateral ...cerebral palsy.
Design and subjects:
For this cross-sectional study, children with neonatal brachial plexus palsy or unilateral cerebral palsy, aged 3–10 years, were eligible.
Main measures:
The HUH, Pediatric Outcome Data Collection Instrument Upper Extremity Scale (neonatal brachial plexus palsy only), and Children’s Hand-Use Experience Questionnaire (unilateral cerebral palsy only) were completed. The HUH was completed twice in subgroups of both diagnoses. Lesion-extent (indication of involved nerve rootlets in neonatal brachial plexus palsy as confirmed during clinical observation and/or nerve surgery) and Manual Ability Classification System levels (unilateral cerebral palsy) were obtained from the medical records. Spearman correlation coefficients between the HUH and all clinical variables, agreement, standard error of measurement, smallest detectable change and intra-class correlation were calculated.
Results:
A total of 260 patients participated (neonatal brachial plexus palsy: 181), of which 56 completed the second HUH (neonatal brachial plexus palsy: 16). Median age was 6.9 years for children with neonatal brachial plexus palsy, 116 had C5-C6 lesions. Median age for children with unilateral cerebral palsy was 6.4 years, 33 had Manual Ability Classification System Level II. The HUH correlated moderately with lesion-extent (rs =−0.5), Pediatric Outcome Data Collection Instrument Upper Extremity Scale (rs = 0.6) and Children’s Hand-Use Experience Questionnaire (rs = 0.5) but weakly with Manual Ability Classification System levels (rs = −0.4). Test–retest reliability was excellent (intra-class correlation2,1 = 0.89, standard error of measurement = 0.599 and smallest detectable change = 1.66 logits) and agreement was good (mean difference HUH1 − HUH2 = 0.06 logits).
Conclusion:
The HUH showed good construct validity and test–retest reliability in children with neonatal brachial plexus palsy or unilateral cerebral palsy.
PDF
