Short-Term Follow-Up of Patellar Component Revision in Patients With Isolated Patellar Component Loosening

BackgroundThe etiology of patellar component loosening can be multifactorial, including component malposition, trauma, infection, and poor implant design. These cases may be managed with isolated patellar component revision or simultaneous patellar component with femoral and/or tibial component revision. Isolated patellar revision in the setting of aseptic loosening historically has had limited success with high rates of repeat revision.MethodsWe performed a retrospective cohort study of 75 cases diagnosed with patellar component loosening that underwent revision. Patients were followed for a minimum of 2 years. Cases were categorized as either isolated patellar (IP) revision or patellar with femoral and/or tibial component (P + O) revisions. Survivorship and re-revision causes were compared between groups. Secondary outcomes included surgical time, estimated blood loss, range of motion, and length of stay.ResultsFifty patients underwent IP revision, and 25 patients had P + O revision. Overall survivorship at the 2-year follow-up interval was 94.6%. Survivorship of IP revision undertaken for aseptic loosening was 94%. Survivorship of P + O revision was 96%. Eight percent of patients required reoperation from the P + O revision group, while 12% of patients in the IP revision group underwent a reoperation. Patients undergoing IP revision had better postoperative range of motion, lower surgical times, lower estimated blood loss, and decreased length of stay.ConclusionIP revision demonstrates excellent survivorship and clinical outcomes comparable to P + O revision. When appropriate, IP revision should be considered as a potential treatment option.Level of EvidenceLevel III, retrospective cohort study.     

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BackgroundThe Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.MethodsThis is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.ResultsControlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.ConclusionFor patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.     

Single screw type of lag screw results higher reoperation rate in the osteosynthesis of basicervical hip fracture

BackgroundBasicervical hip fractures are relatively rare with greater biomechanical instability compared to the other types of hip fractures. Several studies have reported ambivalent surgical outcomes of basicervical hip fractures. The purpose of this multicenter study was to analyze surgical outcomes of basicervical hip fractures according to the fixation type of proximal femur and lag screw type.MethodsAmong 3220 hip fractures, 145 were classified as basicervical hip fractures. Of those, 106 patients treated with osteosynthesis were included to analyze the surgical complications according to fixation type of proximal femur: sliding hip screw(SHS) and cephalomedullary nail (CMN) groups. Surgical complications including the excessive displacement of fracture and the occurrence of reoperation were evaluated at the final follow up. We further evaluated surgical complications according to lag screw type with subgroup analysis in CMN group: single screw type, blade type and two integrated screw type.ResultsTen patients (9.4%) sustained surgical complications (5 excessive displacements and 5 reoperations). For fixation type of proximal femur, SHS group showed higher tendency of excessive displacement despite no statistical difference between the two groups (p = 0.060). For lag screw type with subgroup analysis in CMN group, single screw type showed statistically high rates of reoperation compared to the other types of lag screw (p = 0.022).ConclusionBasicervical hip fractures treated with osteosynthesis resulted to high rates of surgical complications in this study. However, they could be drastically reduced if CMN with blade type or two integrated screw type were used in the osteosynthesis of basicervical hip fractures.     

Effects of anterior boundary of the necrotic lesion on the progressive collapse after varus osteotomy for osteonecrosis of the femoral head

BackgroundAnterior localization of the necrotic lesion was recently proposed as an important factor for the occurrence of collapse even in medially located osteonecrosis of the femoral head (ONFH). We examined the effects of the anterior boundary of the necrotic lesion on progressive collapse after varus osteotomy for ONFH.MethodsWe reviewed the outcomes of 31 hips in 27 patients with ONFH treated by transtrochanteric curved varus osteotomy (CVO) from 2000 to 2012 with a mean follow-up of 10.5 years. The occurrence of progressive collapse of the anterior necrotic lesion was defined as the presence of ≥2 mm collapse using follow-up lateral radiographs. Postoperative osteoarthritic change was defined as ≥1 mm progression of joint space narrowing on follow-up radiographs. The location of the anterior boundary of the necrotic lesion was assessed using the anterior necrotic angle (the angle between the midline of the femoral neck shaft and the line passing from the femoral head center to the anterior boundary of the necrotic lesion on a mid-slice oblique magnetic resonance image).ResultsAll hips had a postoperative intact ratio of ≥34% (percentage of the transposed intact articular surface of the femoral head to the weight-bearing area of the acetabulum after femoral osteotomy). Progressive collapse of the anterior necrotic lesion was seen in five hips (16%) during a mean of 2.2 years after CVO. Of these, four hips (80%) proceeded to develop osteoarthritic change at an average of 4.3 years after the collapse. Multivariate analysis revealed that the anterior necrotic angle was independently associated with progressive collapse of the anterior necrotic lesion as well as the postoperative intact ratio.ConclusionsThis study suggests that hips with anterior localization of the necrotic lesion have a possible risk of progressive collapse of the anterior necrotic lesion after CVO, which can frequently lead to subsequent osteoarthritic change.     

A comparative study of weight-bearing and non-weight-bearing 3-dimensional lower extremity alignment in knee osteoarthritis

BackgroundLower extremity alignment is an important variable with respect to the development and progression of knee osteoarthritis. It is very essential for the preoperative planning of realignment surgeries such as total knee arthroplasty and high tibial osteotomy. Nevertheless, there have been no reports comparing 3D lower extremity alignment between weight-bearing upright and non-weight-bearing horizontal states in osteoarthritic knees in the same subject. Therefore, we determined whether the alignment of the lower extremity in the weight-bearing upright state differed from that in the non-weight-bearing horizontal or supine position in patients with knee osteoarthritis.MethodsAdduction–abduction, flexion–extension, and rotational angle of osteoarthritic knees were assessed in weight-bearing upright and non-weight-bearing supine positions. Knee alignment in the supine position was determined from preoperative computed tomography data. In the weight-bearing upright state, alignment was determined using a technique that utilized 2D-3D image-matching with biplanar computed radiography and 3D bone models of the complete lower extremity rebuilt using computed tomography-based information.ResultsWe assessed 81 limbs from osteoarthritic knee patients (74 women, 7 men; mean age 75.3 years, range 59–86 years). In the coronal plane, there were varus deformities in both the supine and standing positions, while there was flexion in both the supine upright state and position at the sagittal plane. In the axial plane, the rotation of the tibia to the femur was neutral in the supine position and internal in the upright state.ConclusionPatient position significantly affects lower extremity alignment in osteoarthritic knees. This study provides important data regarding the preoperative evaluation of realignment surgery in total knee arthroplasty and high tibial osteotomy. We believe that these results are an important contribution to the knowledge regarding knee osteoarthritis.     

Differences in the geometrical spinal shape in the sagittal plane according to age and magnitude of pelvic incidence in healthy elderly individuals

BackgroundSeveral studies indicated the influence of age and sex on spinal alignment using spino-pelvic radiographic parameters. However, information regarding the geometrical assessment of the sagittal spinal plane in the elderly population remains limited. This study aimed to determine the apices of lumbar lordosis and thoracic kyphosis, and spinal inflection point in elderly individuals and clarify the effect of age, sex, and pelvic incidence (PI) on sagittal geometry.MethodsIn total, 440 volunteers (193 men; 247 women) were enrolled. The spino-pelvic radiographic parameters were measured. The apices of thoracic kyphosis and lumbar lordosis, and the inflection point where the vertebral curvature changes from kyphosis to lordosis were investigated. We analyzed the differences in the sagittal curve shape according to the sex, age, and PI magnitude.ResultsOn average, the apices of thoracic kyphosis and lumbar lordosis, and the inflection point were located at the levels of the T8/9 intervertebral disc, L3/4 disc, and L1 vertebra, respectively. Significant differences between men and women were observed with respect to the spino-pelvic parameters; however, the positions of the apices were significantly different only with respect to the lumbar apex offsets among individuals in their 70s. The inflectional point and apex of thoracic kyphosis among individuals aged >80 years were located significantly anteriorly and caudally in comparison to those among individuals aged <69 years. The apex of lumbar lordosis and the inflection point in individuals with high PI were located significantly anteriorly and cranially in comparison to those in individuals with low PI.ConclusionsThe apices of thoracic kyphosis and lumbar lordosis, and the inflection point were located at the T8/9 intervertebral disc, L3/4 disc, and L1 vertebra, respectively. The shape of the sagittal spinal curve varied according to age and the magnitude of PI, and these findings cannot be evaluated using the conventional spino-pelvic parameters. Knowledge of standard geometrical spine shape could be useful for spinal deformity treatment in elderly patients.     

The biomechanical effects of graded upper articular process arthroplasty on lumbar spine: A finite element study

BackgroundSuperior articular process arthroplasty is important for intervertebral foramen microscopy but may lead to spinal instability. Currently, there has been no relevant study in relation to the biomechanical analysis of superior articular process arthroplasty. Hence, this study is intended to verify biomechanical effects after unilateral S1 superior articular process arthroplasty.MethodsEight finite element (FE) models of lumbosacral vertebrae (L4-S) were constructed, and the superior articular process formation was simulated with the help of Geomagic studio. Then, the models were imported into Nastran software after optimization. Normal load and appropriate torque were applied to simulate forward flexion, back extension, lateral flexion and lateral rotation. In the end, changes of lumbar range of motion (ROM) and structural stress were compared with those of normal model.ResultsCompared with the normal model, formed from ventral to dorsal (Longitudinal), the larger motion of lumbar spine and the greater larger stress of articular process showed statistical significance (P < 0.05) in most of directions when the forming range was greater than 3/5. Formed from the apex to the base (transverse), the larger motion of lumbar spine and the greater stress of articular process showed statistical significance (P < 0.05) in most of directions when the forming range was great than 1/5.ConclusionWhen conducting unilateral S1 articular process arthroplasty from ventral to dorsal, the forming range is recommended to be less than 3/5 of the superior articular process. Notably, it is not advisable to form from the apex to the base.     

Subtalar Arthroereisis Implantation in Acquired Neuropathic Pes Planus: A Preliminary Report Detailing a Minimally Invasive Approach to Healing Medial Column Ulcerations

Ulcerations under the medial column in patients with acquired neuropathic pes planus may be intractable to conservative techniques such as regular debridement, offloading, bracing, and accommodative shoes. When surgery becomes necessary for these patients, the foot and ankle surgeon has the option of exostectomy, medial column beaming, medial column fusion, and external fixation, among others. In the case of a flexible midfoot collapse, the option of arthroereisis for indirect medial column support may be warranted. In this preliminary report, the authors detail a technique of Achilles tendon lengthening, arthroereisis implantation, and advanced cellular tissue product application in an attempt at wound coverage and prevention of recurrence. Three patients presenting with intractable medial column ulcerations of ∼1 year's duration underwent this procedure, and within 7 weeks (range 5 to 7), all medial column ulcerations healed. These patients remained healed at last follow-up (average 29 months; range 8 to 44). This preliminary report provides evidence for a minimally invasive procedure aimed at offloading, healing, and preventing recurrence of medial column ulcerations in patients with flexible neuropathic pes planus.     

Multiaxial high-modularity spinopelvis (HMSP) fixation device in neuromuscular scoliosis: a comparative study

Purpose

To compare radiological and clinical results in patients operated for neuromuscular scoliosis with pelvic fixation using high-modularity spinopelvic screw (HMSP) designed by authors.

Methods

Of 54 patients with neuromuscular scoliosis, group 1 comprised of 27 patients with conventional pelvic fixation; and group 2 comprised of 27 patients using HMSP. Results were evaluated radiologically and functionally. We compared preoperative and postoperative complications, especially the loosening or breakage of spinopelvis fixation device, failure of fixation, and the change of shadow around the spinopelvis fixation device.

Results

There was no difference of correctional power, preoperative average Cobb’s angle of each group was 79.8 and 75 to postoperative 30.2 and 28.3 (P < 0.05). Pelvic obliquity improved from average 18.3°–8.9° in group I and average 24.3°–12.5° in group II (P < 0.05). However, there was no difference between two groups (P > 0.05). Average blood loss was 2,698 ml in group 1 and 2,414.8 ml in group 2 (P > 0.05). Average operative time was 360 min in group 1 and 332 min in group 2 (P = 0.30). There was no difference found between two groups regarding gait and functional evaluation. On the all cases of group 1 and 2, the change of shadow around the spinopelvis fixation device was observed. There was one case of the fracture of spinopelvis fixation device in group I.

Conclusion

There was no difference of Cobb’s angle and correctional power between the groups using HMSP when compared with the group using standard spinopelvis fixation device. Therefore, HMSP can be used more effectively in case of neuromuscular scoliosis.     

Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content

Purpose

Spinal deformities and pathologies of the spinopelvic junction are conditions affecting up to 60–70 % of the general aging population. In this review, we discuss the more recent knowledge on sagittal balance and its clinical implications.

Methods

Review of the literature regarding global spine balance.

Results

Global spinal balance and its relationship to the pelvis correlate closely with disability and quality of life. It has been demonstrated that extensive surgery, previously considered to have poor balance between risks and outcomes, causes great improvements in health-related quality of life in the oldest age groups.

Conclusion

Failure to restore normal sagittal alignment in patients primarily operated for other than deformity results in unacceptable rates of poor results and revision surgery.