To evaluate whether knee flexion contracture (FC) was associated with leg length inequality (LLI) and/or morbidity in knee osteoarthritis (OA).
We accessed 2 databases: (1) the Osteoarthritis ...Initiative (OAI) cohort, including participants with, or at-risk of OA, and (2) the Ottawa Knee Osteoarthritis cross-sectional database (OKOA), including participants with primary advanced knee OA. Both included demographics, radiographic data, knee range of motion, leg length, pain, and function scales.
Tertiary care academic rheumatology and orthopedic clinics.
Patients with or at-risk of primary OA. We included 881 OAI and 72 OKOA participants (N=953).
Not applicable.
The primary outcome tested the association between the difference in knee extensions of the OA and contralateral knees (the knee extension difference, or KExD) and LLI. This was evaluated using bivariate regression, followed by a multivariable linear regression model.
OAI participants had less severe knee OA Kellgren and Lawrence (KL) score 1.9±1.3 vs OKOA (KL score 3.4±0.6). The KExD correlated with LLI for both databases (OAI: R=0.167; P≤.001; OKOA: R=0.339; P=.004). Multivariable regression showed an effect of KExD on LLI in both databases (OAI: β=0.370.18,0.57; P<.001, OKOA: β=0.730.20,1.26; P=.007). When broken down by subgroup, the OAI moderate-severe OA group showed a significant effect of KExD on LLI (β=0.60 0.34,0.85; P<.001).
OA-related loss of knee extension was associated with LLI for those with moderate-severe OA. Because LLI correlates with worse knee OA symptoms, discovering an FC should cue clinicians to evaluate for LLI, an easily-treatable finding that may help reduce OA-associated morbidity for those approaching the need for arthroplasty.
Nerve growth factor β (β-NGF) is a protein which is important to the development of neurons particularly those involved in the transmission of pain and is central to the experience of pain in ...osteoarthritis (OA). Direct NGF antagonism has been shown to reduce OA pain but is associated with rapidly progressive OA. The aim of the study is to investigate the ability of soluble neurotrophin receptors in the NGF pathway to modulate pain in OA.
Synovial fluid (SF) was obtained from the knee joints of 43 subjects who underwent total knee arthroplasty. Visual analogue scale (VAS) pain scores were obtained prior to surgery. Customised-automated-ELISAs and commercial-ELISAs and LEGENDplex™ were used to measure soluble low-affinity nerve growth factor (LNGFR), soluble tropomyosin receptor kinase (TrkA), proNGF, β-NGF, other neurotrophins (NT) and cytokines including inflammatory marker TNF-α.
The VAS score positively correlated with β-NGF (r=0.34) and there was positive association trend with neurotrophin-3 (NT-3), BDNF and negative association trend with ProNGF. sLNGFR positively correlated with VAS (r=0.33). The β-NGF/soluble TrkA ratio showed a strong positive correlation with VAS (r=0.80). In contrast, there was no correlation between pain and the β-NGF/sLNGFR ratio (r=-0.08). TNF-α positively correlated with β-NGF (r=0.83), NT-3 (r=0.66), and brain-derived neurotrophic factor (BDNF) (r=0.50) and negatively with ProNGF (r= -0.74) and positively correlated with both soluble TrkA (r=0.62), sLNGFR (r=0.26).
This study suggests that endogenous or cleaved sLNGFR, but not soluble TrkA may participate in OA pain modulation thus supporting further research into soluble LNGFR as a therapeutic target in OA.
The anterior approach (AA) to total hip arthroplasty (THA) has advantages for patients and healthcare providers. However, some studies have reported high rates of adverse events when introducing ...AA-THA. This was not consistent with our center’s experience, where 4 senior surgeons safely introduced AA-THA into practice. The purpose of this study is to define the adverse event rates associated with the introduction of AA-THA by a group of experienced surgeons at a single tertiary care center and define experiential factors that may modify adverse event rates.
Retrospective review of prospectively collected data for an observational cohort of all patients undergoing a THA between 2006 and 2017 was conducted. Four senior surgeons at a single institution operated on 1087 primary elective hips using AA-THA.
Between 2006 and 2016, AA-THA rose from 1.5% to 53.2% of annual THA. Adverse events included intraoperative events, early postoperative periprosthetic fractures, dislocation, implant failure, early infection, and wound complications. We observed an overall 90-day adverse event rate of 6.4% (of 1087 hips). The adverse event rate was 41.6% (of 12 hips) in the first 12 months of the study period and 3.6% (of 166 hips) in the final 12 months of the study period reviewed. Sixty hips (5.5%) required a reoperation with or without revision of components, 1 (8.3%) in the first 12 months of the study period and 1 (0.6%) in the final 12 months of the study period. Infection and wound complications were the most common causes of reoperation at 1.8% for all cases (20 hips). Higher rates of adverse events are associated with early procedures (n ≤ 15) for all surgeons but showed no statistically significant impact on 5-year survival rate.
Our experience demonstrates that AA-THA can be introduced into practice with an acceptable adverse event rate when compared with other approaches to THA. As expected the incidence of adverse events is higher in the early part of the learning curve. Surgeon mentoring in the first 20 cases should be considered to minimize risk of adverse events.
Therapeutic Level III.
Abstract Background Added modular junction has been associated with implant-related failures. We report our experience with a titanium-titanium modular neck-stem interface to assess complications, ...possible clinical factors influencing use of neck modularity, and whether modularity reduced the incidence of dislocation. Methods A total of 809 total hip arthroplasties completed between 2005 and 2012 from a prospectively collected database were reviewed. The mean follow-up interval was 5.7 years (3.3-10.3 years). Forty-five percent were male (360 of 809), and 55% were female (449 of 809). All stems were uncemented PROFEMUR TL (titanium, flat-tapered, wedge) or PROFEMUR Z (titanium, rectangular, dual-tapered) with a titanium neck. Results Increased modularity (anteverted/retroverted and anteverted/retroverted varus/valgus (anteverted/retroverted + anteverted/retroverted varus/valgus) was used in 39.4% (135 of 343) of cases using the posterior approach compared with 6.8% (20 of 293) of anterior and 23.7% (41 of 173) of lateral approaches. Four males sustained neck fractures at a mean of 95.5 months (69.3-115.6 months) after primary surgery. Overall dislocation rate was 1.1% (9 of 809). The posterior approach had both the highest utilization of increased modularity and the highest dislocation rate (2.3%), of which the most were recurrent. The anterior (0.3%) and lateral (0%) approaches had lower dislocation rates with no recurrences. Conclusion At a mean 5.7 years, our experience demonstrates a low neck fracture (0.5%) and a low dislocation rate (1.1%). Use of increased modularity may not improve dislocation risk for the posterior approach. Continued surveillance of this group will be necessary to determine long term survivorship of this modular titanium implant.
One thousand one hundred ninety patients underwent knee arthroplasty between January 2004 and July 1, 2007, and received an indwelling continuous infusion femoral catheter for postoperative ...ropivicaine pump infusion. Catheters were placed using electrical stimulation guidance. For the initial 469 patients (group 1), the continuous infusion ran for 2 to 3 days. In 721 patients, the infusion was discontinued 12 hours after surgery. There were 9 femoral nerve palsies (2 in group 1, 7 in group 2) and 8 major falls (0.7%). The overall complication rate was 1.5%, and the risk of permanent nerve injury was 0.2%. Patients should be made aware of these complications as part of the usual informed consent process before using this technique for postoperative pain control after knee arthroplasty. We did not observe fewer falls when the continuous infusion was stopped 12 hours after surgery.
The most effective surgical approach to total hip replacement (THR) remains controversial. Most studies that have compared approaches have reported only short-term outcome data. It is therefore ...unclear in the literature if a particular surgical approach offers long-term advantages. The aim of this study was to determine the effect of the 3 main surgical approaches to THR on patient-reported outcomes 5 years after surgery.
All patients who underwent a THR for osteoarthritis or osteonecrosis between 2008 and 2012 by an anterior, posterior or lateral approach at The Ottawa Hospital in Ontario, Canada, were included in the study. All preoperative and postoperative scores for the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) questionnaires were recorded. Analysis of covariance was used to study the relationship between the amount of change in scores on the HOOS and WOMAC subscales (dependent variables) and the surgical approach. The confounding factors of age, sex, American Society of Anesthesiologists (ASA) class, Charnley classification and body mass index were included in the analysis.
There were 138 patients (37.6%) in the posterior approach group, 104 (28.3%) in the lateral approach group and 125 (34.1%) in the anterior approach group. There were no significant differences among the 3 groups in terms of Charnley classification, body mass index, sex, ASA class, surgical side and preoperative functional scores. We did not observe any significant differences in the amount of change in the scores for HOOS and WOMAC subscales among the 3 groups. There were also no differences in the final postoperative scores.
Our findings suggest that the choice of surgical approach in primary THR surgery without revision has no influence on functional outcomes and quality of life after 5 years. Further studies are needed to assess how patient age and sex may influence the functional outcome of individual surgical approaches.
Background
The burden of orthopaedic trauma in the developing world is substantial and disproportionate. SIGN Fracture Care International is a nonprofit organization that has developed and made ...available to surgeons in resource-limited settings an intramedullary interlocking nail for use in the treatment of femoral and tibial fractures. Instrumentation also is donated with the nail. A prospectively populated database collects information on all procedures performed using this nail. Given the challenging settings and numerous surgeons with varied experience, it is important to document adequate alignment and union using the device.
Questions/purposes
The primary aim of this research was to assess the adequacy of operative reduction of closed diaphyseal femur fractures using the SIGN interlocking intramedullary nail based on radiographic images available in the SIGN database. The secondary aims were to assess correlations between postoperative alignment and several associated variables, including fracture location in the diaphysis, degree of fracture site comminution, and time to surgery. The tertiary aim was to assess the functionality of the SIGN database for radiographic analyses.
Methods
A review of the prospectively populated SIGN database was performed for patients with a diaphyseal femur fracture treated with the SIGN nail, which at the time of the study totaled 32,362 patients. After study size calculations, a random number generator was used to select 500 femur fractures for analysis. Exclusion criteria included open fractures and those without radiographs during the early postoperative period. The following information was recorded: location of the fracture in the diaphysis; fracture classification (AO/Orthopaedic Trauma Association OTA classification); degree of comminution (Winquist and Hansen classification); time from injury to surgery; and patient demographics. Measurements of alignment were obtained from the AP and lateral radiographs with malalignment defined as deformity in either the sagittal or coronal plane greater than 5°. Measurements were made manually by the four study authors using on-screen protractor software and interobserver reliability was assessed.
Results
The frequency of malalignment greater than 5° observed on postoperative radiographs was 51 of 501 (10%; 95% CI, 6.5–11.5), and malalignment greater than 10° occurred in eight of 501 (1.6%) of the femurs treated with this nail. Fracture location in the proximal or distal diaphysis was strongly correlated with risk of malalignment, with an odds ratio (OR) of 3.7 (95% CI, 1.5–9.3) for distal versus middle diaphyseal fractures and an OR of 4.7 (95% CI, 1.9–11.5) for proximal versus middle fractures (p < 0.001). Time from injury to surgery greater than 4 weeks also was strongly correlated with risk of malalignment (p < 0.001). Inherent fracture stability, based on fracture site comminution as per the Winquist and Hansen classification (Class 0–1 stable versus 2–4 unstable) showed an OR of 2.3 (95% CI, 1.2–4.3) for malalignment in unstable fractures. Interobserver reliability showed agreement of 88% (95% CI, 83–93) and mean kappa of 0.81 (95% CI, 0.65–0.87). The SIGN database of radiographic images was found to be an excellent source for research purposes with 92% of reviewed radiographs of acceptable quality.
Conclusions
The frequency of malalignment in closed diaphyseal femoral fractures treated with the SIGN nail closely approximated the incidence reported in the literature for North American trauma centers. Increased time from injury to surgery was correlated with increased frequency of malalignment; as humanitarian distribution of the SIGN nail increases, local barriers to timely care should be assessed and improved as possible. Prospective clinical study with followup, despite its inherent challenges in the developing world, would be of great benefit in the future.
Level of Evidence
Level III, therapeutic study.
Background
Numerous cementless femoral stem design variations are in clinical use. Because initial implant instability and micromotion are associated with aseptic loosening of the femoral component, ...migration analysis provides an early assessment of implant survivorship.
Questions/purposes
We determined the (1) migration pattern of the Accolade
®
cementless femoral stem; (2) clinical factors predisposing to stem migration; (3) self-reported patient outcomes; and (4) our current rate of aseptic stem loosening.
Methods
We retrospectively analyzed 81 femoral stems for aseptic migration using Ein-Bild-Roentgen-Analyse-femoral component analysis. Postoperatively, patients completed the WOMAC and SF-12 questionnaires. We assessed radiographic factors potentially associated with subsidence: indices of bone shape and quality, canal fill of the implant, and radiographic signs of loosening. Minimum followup was 24 months (mean, 29 months; range, 24–48 months).
Results
The average subsidence at 24 months was 1.3 mm (range, 0–1.5 mm). In the first 2 years, 36% of stems subsided more than 1.5 mm. Large stem size was associated with subsidence. Radiolucent lines (> 1.5 mm in three zones) were present in 10% of stems and associated with lower questionnaire scores. The 5-year survivorship for aseptic loosening of the 367 stems was 97% with revision as end point and 95% for radiographic failure.
Conclusions
The high incidence of migration and stems with radiographic failure raises concerns about patient clinical function and long-term survivorship of this stem design. This migration pattern may be due to poor initial stability with a subsequent lack of osseointegration. Our results differ from radiographic findings and clinical durability of other similar cementless stem designs.
Level of Evidence
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
IntroductionAnnually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%–10% at 30 days and 10%–20% at 90 days. Observational data suggest that early surgery can ...improve these outcomes in hip fracture patients. We designed a clinical trial—HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications.Methods and analysisHIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients.Ethics and disseminationAll centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources.Trial registration number NCT02027896; Pre-results.
Abstract Our initial experience with mobile bearing medial compartment unicompartmental arthroplasty (UKA) is presented to highlight lessons that have been learned to avoid short-term failures. ...Consecutive cases of the Oxford medial UKA performed between February 2001 and April 2006 were reviewed to derive those cases that were revised to total knee arthroplasty (TKA). There were 545 patients available with mean age and body mass index of 65.0 and 30.1, respectively. At final follow-up, 32 patients were revised for lateral compartment arthritis, aseptic component loosening, persisting medial or anterior pain and dislocated meniscal bearing. Revisions were performed with primary unconstrained TKA implants with no stems or wedges required. Our results seem to reflect those seen in registries confirming an earlier higher revision rate and highlight the technical issues of overstuffing the compartment, inadequate cementation technique, and strict adherence to patient selection.
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