The Role of Peritoneal Scintigraphy in the Detection of Continuous Ambulatory Peritoneal Dialysis Complications

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall.

The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management.

There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.¹ Juergensen PH, Rizvi H, Caride VJ, Kliger AS, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 1999; 55: 1111–1119, [INFOTRIEVE], [CSA][Crossref], [PubMed], [Web of Science ®] , [Google Scholar] Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.² Finkelstein FO, Sorkin M, Cramton CW, Nolph K. Conference report initiatives peritoneal dialysis: where do we go from here?. Perit Dial Int 1991; 11: 274–278, [INFOTRIEVE], [CSA][PubMed], [Web of Science ®] , [Google Scholar] In order to permit the continuation of long-term therapy with CPD, these complications should be resolved.

Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.     

Body mass index changes over 3 years and effect of obesity on community mobility for persons with chronic spinal cord injury

Objective: To identify the prevalence of obesity in persons with chronic spinal cord injury (SCI), determine change in body mass index (BMI) over time, and identify impact of obesity on community mobility.

Design: Prospective three year longitudinal study.

Setting: Outpatient clinic of rehabilitation center.

Participants: Convenience sample of 222 persons with paraplegia between 2–20 years post SCI.

Outcome Measures: BMI at baseline and three years; community mobility (daily wheelchair propulsion distance and velocity, average number of daily transfers and depression raises).

Results: Participants were 34.1 (27.3, 40.3) years of age and median duration of SCI was 8.7 (3.2, 15.1) years. The SCI adjusted BMI classification identified 44% of participants as obese. BMI increased over time with 13% moving into a higher weight category. Median change in BMI was 0.46 (?0.92, 1.50) kg/m^{2 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief. 2012;(82):1–8. [Google Scholar]} (z?=??2.684, P?=?0.007), and increased at a rate of 0.15?kg/m²/yr. Average BMI was negatively correlated with daily wheelchair propulsion distance (r?=??0.179, P?=?0.009), however there was no significant relationship with velocity, number of daily transfers or depression raises.

Conclusion: The majority of participants with chronic SCI were overweight (23%) or obese (44%) and BMI increased by 0.46?kg/m² over three years. Those with higher BMIs pushed their wheelchairs shorter distances, but other mobility measures were not impacted by body weight. Continued mobility activities with increasing body weight can increase risk for shoulder injury. Identifying persons who are obese allows for directed and timely health and mobility intervention.     

Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris

Background and purpose — The initial outcomes following metal-on-metal hip arthroplasty (MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD) were poor. Furthermore, robust thresholds for performing ARMD revision are lacking. This article is the second of 2. The first article considered the various investigative modalities used during MoMHA patient surveillance (Matharu et al. 2018a Matharu G S, Judge A, Eskelinen A, Murray D W, Pandit H G. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? A clinical update. Acta Orthop 2018a; 89 (1): 29–39.[Taylor &; Francis Online], [Web of Science ®] , [Google Scholar]). The present article aims to provide a clinical update regarding ARMD revision surgery in MoMHA patients (hip resurfacing and large-diameter MoM total hip arthroplasty), with specific focus on the threshold for performing ARMD revision, the surgical strategy, and the outcomes following revision.

Results and interpretation — The outcomes following ARMD revision surgery appear to have improved with time for several reasons, among them the introduction of regular patient surveillance and lowering of the threshold for performing revision. Furthermore, registry data suggest that outcomes following ARMD revision are influenced by modifiable factors (type of revision procedure and bearing surface implanted), meaning surgeons could potentially reduce failure rates. However, additional large multi-center studies are needed to develop robust thresholds for performing ARMD revision surgery, which will guide surgeons’ treatment of MoMHA patients. The long-term systemic effects of metal ion exposure in patients with these implants must also be investigated, which will help establish whether there are any systemic reasons to recommend revision of MoMHAs     

No effect of teriparatide on migration in total knee replacement

Background and purpose — Aseptic loosening is a main cause of late revision in total knee replacement (TKR). Teriparatide, a recombinant parathyroid hormone (PTH), stimulates osteoblasts and has been suggested to improve cancellous bone healing in humans. This might also be relevant for prosthesis fixation. We used radiostereometric analysis (RSA) to investigate whether teriparatide influences prosthesis fixation. Early migration as measured by RSA can predict future loosening.

Patients and methods — In a randomized controlled trial with blind evaluation, 50 patients with osteoarthritis of the knee were allocated to a teriparatide treatment group (Forsteo, 20?μg daily for 2 months postoperatively) or to an untreated control group. RSA was performed postoperatively and at 6 months, 12 months, and 24 months. The primary effect variable was maximal total point motion (MTPM) from 12 to 24 months.

Results — Median maximal total point motion from 12 to 24 months was similar in the 2 groups (teriparatide: 0.14?mm, 10% and 90% percentiles: 0.08 and 0.24; control: 0.13?mm, 10% and 90% percentiles: 0.09 and 0.21). [Authors: this is perhaps better than using "10th" and "90th", which looks ugly in print./language editor] The 95% confidence interval for the difference between group means was ?0.03 to 0.04?mm, indicating that no difference occurred.

Interpretation — We found no effect of teriparatide on migration in total knee replacement. Other trials using the same dosing have suggested a positive effect of teriparatide on human cancellous fracture healing. Thus, the lack of effect on migration may have been due to something other than the dose. In a similar study in this issue of Acta Orthopaedica, we found that migration could be reduced with denosumab (Ledin et al. 2017 Ledin H, Good L, Aspenberg P. Denosumab reduces early migration in total knee replacement: a randomized controlled trial in 50 patients. Acta Orthop 2017. [Ahead of print] [Google Scholar]). The difference in response between the anabolic substance teriparatide and the antiresorptive denosumab suggests that resorption has a more important role during the postoperative course than any deficit in bone formation.     

Study protocol: Effectiveness of dual-mobility cups compared with uni-polar cups for preventing dislocation after primary total hip arthroplasty in elderly patients — design of a randomized controlled trial nested in the Dutch Arthroplasty Registry

Background and purpose — Dislocation is the leading reason for early revision surgery after total hip arthroplasty (THA). The dual-mobility (DM) cup was developed to provide more stability and mechanically reduce the risk of dislocation. Despite the increased use of DM cups, high-quality evidence of their (cost-)effectiveness is lacking. The primary objective of this randomized controlled trial (RCT) is to investigate whether there is a difference in the number of hip dislocations following primary THA, using the posterolateral approach, with a DM cup compared with a unipolar (UP) cup in elderly patients 1 year after surgery. Secondary outcomes include the number of revision surgeries, patient-reported outcome measures (PROMs), and cost-effectiveness.Methods and analysis — This is a prospective multicenter nationwide, single-blinded RCT nested in the Dutch Arthroplasty Registry. Patients ≥ 70 years old, undergoing elective primary THA using the posterolateral approach, will be eligible. After written informed consent, 1,100 participants will be randomly allocated to the intervention or control group. The intervention group receives a THA with a DM cup and the control group a THA with a UP cup. PROMs are collected preoperatively, and 3 months, 1 and 2 years postoperatively. Primary outcome is the difference in number of dislocations between the UP and DM cup within 1 year, reported in the registry (revisions), or by the patients (closed or open reduction). Data will be analyzed using multilevel models as appropriate for each outcome (linear/logistic/survival). An economic evaluation will be performed from the healthcare and societal perspective, for dislocation and quality adjusted life years (QALYs).Trial registration — This RCT is registered at www.clinicaltrials.gov with identification number {"type":"clinical-trial","attrs":{"text":"NCT04031820","term_id":"NCT04031820"}}NCT04031820.

Dislocation after total hip arthroplasty (THA) is the leading reason for early revision surgery (Bozic et al. 2009, Gwam et al. 2017). Most dislocations occur during the first year after surgery, of which approximately half within the first 3 months (Woo and Morrey 1982, Phillips et al. 2003, Meek et al. 2006, Hailer et al. 2012). Especially in patients with recurrent dislocation and the need for revision surgery, this leads to reduced physical functioning and quality of life (Enocson et al. 2009). Dislocations also increase healthcare costs (Sanchez-Sotelo et al. 2006, Abdel et al. 2015). A single dislocation adds 19% to the hospital costs of an uncomplicated THA, and of a revision surgery up to 148% (Sanchez-Sotelo et al. 2006).Despite the increased and, in some countries, broad use of DM cups, high-quality evidence of their effectiveness is lacking (Darrith et al. 2018). Recent reviews did not identify any randomized controlled trials (RCT) comparing DM cups with UP cups (De Martino et al. 2017a, 2017b, Darrith et al. 2018, Jonker et al. 2020) and the existing studies are of low methodological quality and at high risk of bias due to the lack of experimental design. So far only one—non randomized—cost-effectiveness study has been performed, suggesting that the DM cup may result in cost savings compared with a UP cup (Epinette et al. 2016). Although promising, the results of this cost-effectiveness database study are not transferrable outside France.Therefore we initiated an RCT to establish the effectiveness of DM cups for primary THA. The primary objective is to investigate whether there is a difference in the number of hip dislocations following primary total hip arthroplasty (THA), using the posterolateral approach, for a DM cup compared with a UP cup in elderly patients within 1 year after surgery. Several secondary outcomes will be specified in the methods section. The registry-nested design will facilitate long-term follow-up for all study participants.     

Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden

Background and purpose — Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses.Patients and methods — We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003–2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision.Results — Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase.Interpretation — Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.

Although the survivorship of knee arthroplasty has improved over the last 15 years, the increased volume of primary knee replacement has led to growing numbers of revision procedures (Kumar et al. 2015, Patel et al. 2015). A prior study we undertook outlined changes in the volume and incidence of revision rates in Sweden, Australia, and the Kaiser Permanente registry from the USA (Lewis et al. 2020b).Factors influencing revision change with time. Patient factors may affect the rate of primary procedures, such as rising patient and surgeon acceptance of knee replacement (Hamilton et al. 2015), increasing rates of osteoarthritis (Hunter and Bierma-Zeinstra 2019), growing use in younger patients (Leyland et al. 2016, Karas et al. 2019), and also survivorship, such as longer life expectancy, increasing obesity, and higher physical activity of those receiving a replacement (Hamilton et al. 2015). In addition, prosthesis designs change to improve perceived shortcomings such as wear, instability, and patellofemoral pain and tracking (Lewis et al. 2020a). Methods to improve surgical precision, such as computer navigation (Jones and Jerabek 2018), image-derived instrumentation (Kizaki et al. 2019), and robotic assistance (Jacofsky et al. 2016) may decrease revision requirements (Price et al. 2018)These changing factors alter the reasons for revision. Previous studies observed a decrease in revisions for wear and loosening (Sharkey et al. 2014, Thiele et al. 2015), and related this to improved prosthesis design and materials. Other studies note infection is now the most common reason for revision (Koh et al. 2017, Postler et al. 2018). Studies of changing knee replacement failure modes are limited by being derived from single institutions or regions and may not accurately reflect what is occurring elsewhere (Sharkey et al. 2014, Thiele et al. 2015, Dyrhovden et al. 2017, Koh et al. 2017, Lum et al. 2018, Postler et al. 2018). Additionally, these studies do not show the true revision burden as they are restricted to 1st revision procedures, or only revisions of previous total knee replacements (TKR), and do not include revisions of partial knee replacement procedures.Combining registry data can be difficult due to inconsistency in the definition of revision (Liebs et al. 2015), and lack of consensus in defining modes of failure, with different terminologies used (Niinimaki 2015, Siqueira et al. 2015). Some have attempted to overcome this by defining equivalent diagnoses (Havelin et al. 2011, Paxton et al. 2011, Rasmussen et al. 2016).We determined variations and trends in reasons for knee replacement revision using data on all knee arthroplasty revision procedures from the national registries of Sweden and Australia and the institutional registry of Kaiser Permanente in the USA by using equivalent diagnosis groups (Table 1, see Supplementary data).     

Greater early migration of a short-stem total hip arthroplasty is not associated with an increased risk of osseointegration failure: 5th-year results from a prospective RSA study with 39 patients,a follow-up study

Background and purpose — Short-stem hip arthroplasty has been a viable alternative to standard stems for the treatment of hip osteoarthritis for over 10 years. This study assessed whether a correlation existed between a greater initial increase in implant migration and inferior clinical outcomes at 5 years postoperatively. Results on these patients after 2 years have been published previously.Patients and methods — Radiostereometry and clinical scoring were undertaken after surgery and at 3, 6, 12, and 24 months, and 5 years postoperatively. The migration and the clinical outcomes data from the patients with initial migrations at 3 months above the 75th percentile (≥ 75% group) were compared with those with migrations at 3 months of less than the 75th percentile (< 75% group).Results — Between 3 months and 5 years after surgery, the mean resultant implant migrations were 0.40 mm (SD 0.32) in the ≥ 75% group and 0.39 mm (SD 0.25) in the < 75% group. The mean Harris Hip Scores and SF-36 physical scores at 5 years postoperatively were 100 (SD 0.4) and 44 (SD 12), respectively, for the ≥ 75% group and 99 (SD 2) and 50 (SD 10), respectively, for the < 75% group. The differences between the patient groups were not statistically significant.Interpretation — There was no correlation between a greater initial migration and inferior clinical outcomes at 5 years postoperatively. Despite a greater initial migration, there were no risks of early aseptic loosening and inferior midterm clinical outcomes associated with a short-stem implant with a primary metaphyseal anchorage.

Short-stem hip prostheses are commonly used to treat hip osteoarthritis, especially among younger patients (Thorey et al. 2013). The proposed advantages of using these prostheses include more physiological proximal load transfers to the surrounding bone that potentially reduce stress shielding and provide better options should revision surgery become necessary (Floerkemeier et al. 2017). Furthermore, implanting a short-stem prosthesis with a partial resection of the femoral neck is particularly compatible with minimally invasive surgery, which not only minimizes the length of the skin incision, but, more importantly, reduces muscle and tendon damage (Mjaaland et al. 2015). Findings from studies involving radiostereometric analysis (RSA) of short stems with primary metaphyseal fixations have suggested greater migration during the first postoperative months, followed by stabilization (Budde et al. 2016, Schwarze et al. 2018). Data describing the migration characteristics of this specific short-stem implant beyond 2 years of follow-up have not been reported (Schwarze et al. 2018). This previous study focused on the effect of surgical approach and did not find an influence on migration or clinical results. Furthermore, it remains questionable whether a greater initial migration of short-stem implants during the first postoperative weeks represents a risk factor for later loosening. In addition, it is unclear whether a greater initial migration is associated with inferior long-term functional outcomes.Hence, this study assessed whether a greater initial migration at the first follow-up assessment after a short-stem total hip arthroplasty (a) signifies a further increase in migration at the midterm follow-up assessment, which would indicate a risk of later aseptic loosening, and (b) is associated with inferior subsequent clinical outcomes and pain.Patients and methodsThe previous study described 2-year follow-up data from 60 patients who underwent total hip arthroplasty using a Metha short-stem prosthesis (Schwarze et al. 2018). To obtain 5-year follow-up data, the same patient cohort was followed for an additional 3 years. The initial 2-year randomized controlled study enrolled 60 patients (34 women and 26 men) with a mean age of 59 years (36–72) and a mean BMI of 26 (21–37) between February 2010 and June 2013. These patients provided written informed consent prior to the operation and before they participated in the 5-year follow-up study. The study’s original inclusion criteria were patients aged 30–75 years with progressive osteoarthritis of the hip that was confirmed by analyzing plain radiographs. The study’s exclusion criteria were neurological disorders, cardiovascular disorders affecting ambulation, sensorimotor disorders, previous bone surgery on the affected joint, allergic reactions to the implant materials, revision surgery, and an unwillingness to participate in the extension of the study.The present study analyzed the use of the Metha short-stem implant (Aesculap AG, Tuttlingen, Germany), which is representative of the partial neck-sparing group of short-stem implants (Lombardi et al. 2009). Likewise, Feyen and Shimmin (2014) classified this implant as a short-stem implant with a subcapital osteotomy. All of the patients received appropriately sized (sizes 1–7) cementless short-stem hip implants. The stem was made of a titanium forged alloy (Ti4Al6V) coated with pure titanium and a 20-µm layer of calcium phosphate in the proximal region, and had a polished tip. The patients included in this study received the nonmodular version of the implant that had a caput-collum-diaphyseal angle of 120°, 130°, or 135°. A Plasmacup SC press-fit acetabular component (Aesculap AG, Tuttlingen, Germany) was used with either a polyethylene or a ceramic insert; ceramic heads of 32-mm diameter were used exclusively.Surgery was performed by 1 of 5 experienced surgeons using either a conventional transgluteal lateral Hardinge approach or an anterolateral modified Watson-Jones approach. The anesthesia protocol, insertion of the tantalum beads that provided a reference for the migrations calculated using RSA, postoperative pain management protocol, rehabilitation program, and the discharge criteria have been described previously (Schwarze et al. 2018). The precision of the RSA setup was determined through duplicate examinations of 15 patients (Table 1, see Supplementary data).The 5-year follow-up appraisals between February 2015 and June 2018 involved examinations of the RSA images and clinical investigations that comprised assessments using the Harris Hip Score (HHS), the physical functioning scale of the Short Form-36 (SF-36), the mental health domain of the SF-36, perceived pain measured in a visual analog scale (VAS), and radiological examinations. A score of 0 on the VAS pain scale corresponds to “no pain,” while 10 corresponds to “maximum pain imaginable.” Implant migration was calculated relative to the first postoperative images that were captured at 3–10 days postoperatively. The implant surface models required for model-based RSA were obtained using reverse engineering techniques. The calibration box’s coordinate system served as the reference for the migration measurements, where x was positive in the medial direction, y was positive in the cranial/proximal direction, and z was positive in the anterior direction. In addition to migration along these axes, implant migration relative to the surrounding bone was calculated as the magnitude of the resultant movement vector (which is (Tx²+Ty²+Tz²)^0.5) of the implant’s geometric center, and it was, therefore, always positive. The RSA parameters and procedures (Table 1, see Supplementary data) were defined in accordance with standard guidelines (ISO 2013).As relatively large initial migrations of implants were observed at 3 months postoperatively in the initial study, which had a 24-month follow-up duration, the patient population was divided into 2 groups for further analysis. One group comprised patients with initial resultant migrations below the 75th percentile, that is, < 1.43 mm, (the < 75% group), and the other group comprised patients with initial resultant migrations that were equal to or above the 75th percentile, that is, ≥ 1.43 mm (the ≥ 75% group). These groups were compared to investigate relationships between the extent of the initial resultant migration and the midterm clinical outcomes.StatisticsThe clinical scores in the groups with low (< the 75th percentile) and high (≥ the 75th percentile) initial migration were compared at each follow-up using two-sided Student’s t-tests with significance levels of α = 0.05. To compare clinical scores and resultant implant migration between follow-up intervals within each group, we used paired t-tests that used a Bonferroni-corrected initial significance level of 0.05.Ethics, registration, funding, and potential conflicts of interestThe local ethics committee approved this study (Amendment to Institutional Review Board No. 4565, February 2015). The initial 2-year randomized controlled study was registered in the German Clinical Trials Register (DRKS00010421). The study was funded by Aesculap AG Tuttingen, Germany. The authors TF, GvL, and HW are paid instructors in lecture courses for Aesculap AG.ResultsOf the 60 patients initially recruited, 11 were excluded from the analysis at the 24-month follow-up stage for a variety of reasons (Schwarze et al. 2018). A further 10 of the 49 remaining patients were lost to follow-up at the 5-year follow-up stage (Figure 1). 252 RSA image pairs were analyzed successfully.Open in a separate windowFigure 1.Flowchart of the 60 study participants and the number of patients at each follow-up assessment. The technical issues associated with the radiostereometric analysis included marker occlusion, caused by unusual positioning of ovarian/testicular radiation protection, and insufficient image quality.Implant migrationThe 2 criteria that defined the quality of the RSA images, namely, the rigid-body error (median: 0.140 mm [0.017–0.316]) and the condition number (median: 24 [13–118]), were within acceptable ranges (< 0.35 mm and < 120, respectively). At 60 months postoperatively, the mean (standard deviation [SD]) resultant migration was 1.12 mm (SD 1.21; 0.15–5.05), which did not statistically significantly differ from the migrations determined at the earlier follow-up intervals, namely, 3, 6, 12, and 24 months (Figure 2). The mean initial resultant migrations were 2.71 mm (SD 1.56) in the ≥ 75% group and 0.47 mm (SD 0.30) in the < 75% group (Figure 2). At 60 months postoperatively, the resultant migrations were 3.08 mm (SD 1.41) in the ≥ 75% group and 0.61 mm (SD 0.33) in the < 75% group. With the 3-month follow-up used as baseline, the resultant migrations were 0.41 mm (SD 0.32) in the ≥ 75% group and 0.39 mm (SD 0.25) in the < 75% group after 60 months. The results did not statistically significantly differ between groups at any follow-up.Figure 2.Box-plots showing resultant implant migration (A) in all patients during follow-up, (B) during follow-up, categorized according to the initial migration percentile, (C) in all patients in relation to the first postoperative follow-up, and (D) in relation to the 3-month follow-up. ν represents the ≥ 75% group, and ν represents the < 75% group.Open in a separate windowOpen in a separate windowOpen in a separate windowOpen in a separate windowThe major contribution to the resultant migration is subsidence in the distal direction, followed by a lateral translation for the ≥ 75% group and a posterior translation for the < 75% group. The largest rotations were observed about the proximal–distal axis (Table 2, see Supplementary data).Clinical outcomesBoth groups’ clinical scores increased postoperatively and plateaued at 12 months postoperatively (Figure 3). At 5 years postoperatively, the mean (SD) HHSs for the ≥ 75% and < 75% groups were 100 (0.4) and 99 (2), respectively, and the mean (SD) VAS scores for the ≥ 75% and < 75% groups were 0.8 (1.0) and 1.3 (1.6), respectively. The mean (SD) physical functioning scale of the SF-36 and the mental health domain of the SF-36 were 44 (12) and 57 (2) for the ≥ 75% group and 50 (10) and 51 (10) for the < 75% group at 5 years postoperatively. Overall, there were no statistically significant differences between the groups in relation to the mean HHSs and the SF-36 and VAS scores, and the extent of the initial migration had no significant effects on the clinical scores (Figure 3).Figure 3.Clinical scores at each follow-up interval. There were no significant differences between the groups. ν represents the ≥ 75% group and ν represents the < 75% group. (Harris Hip score; SF-36-P: Physical functioning scale of the Short Form-36; SF-36-M: Mental health domain of the Short Form-36; VAS: Visual analog scale pain score).Open in a separate windowOpen in a separate windowOpen in a separate windowOpen in a separate windowDiscussionThe RSA findings were similar between the < 75% group and the ≥ 75% group with respect to additional migration; therefore, a greater initial migration was not associated with steadily increasing migration and an increased risk of aseptic loosening. Furthermore, our data did not reveal an association between a greater initial migration and inferior midterm clinical outcomes. We observed that the prosthesis was stable after the first 3 months and that migration did not increase significantly over the 5-year follow-up period. Thus, we did not find that a greater initial migration led to a higher risk of early aseptic loosening or insufficient osseointegration. In fact, good secondary osseointegration and excellent clinical outcomes were observed, regardless of the magnitude of the initial migration.Several publications from studies that used highly accurate RSA have described the migration of uncemented total hip implants (Table 3, see Supplementary data). When comparing studies in relation to the migration patterns associated with different stem systems, it must be remembered that there are several ways to express implant migration data using, for example, the maximum total point motion, orthogonal translations and rotations, or the resultant migration. Subsidence, which is defined as distal translation along the y-axis, was the major contributor to the resultant migration observed among the patients in our study, and it was used to undertake more robust comparisons with the data from previously published studies (Table 3, see Supplementary data). Compared with other uncemented stem systems, the Metha short-stem system seems to possess less primary stability. The key conclusion that can be drawn is that the Metha short-stem implant with a primary metaphyseal anchorage provides stability and enables osseointegration after an initial phase of about 3 months. Even among patients with greater initial migrations of ≥ 1–2 mm immediately after the operation, secondary osseointegration is possible.Kärrholm et al. (1994) established a method for predicting long-term aseptic loosening that was based on the migration of hip stems that exceeded 1.2 mm after 2 years. This method was established using cemented long-stem implants that have different underlying fixation principles compared with uncemented short-stem devices, because the bone-loading patterns differ and initial settling of the implant into the compacted bone can be expected (Salemyr et al. 2015). Our study’s results suggest that a value of 1.2 mm after 2 years is not directly applicable for short stems. These findings confirm the conclusion given by Kroell et al. (2009) that the initial migration patterns associated with short-stem implants and the subsequent secondary stabilization may not predict long-term survival. Similar to our findings, these authors found that excellent secondary osseointegration may occur even among patients with initial migrations of > 2.0 mm within the first 3 months.In our first study, the stem survival rate was 97% after 2 years (n = 2 revisions due to infection). After 5 years, no further revisions were necessary. The cases in the ≥ 75% group did not show any clinical signs of loosening at 5 years’ follow-up. The stems of these patients have been proven to be stable without clinical or radiological hint of further subsidence or loosening.Good clinical outcomes were evident at 60 months regarding both the HHS and SF-36 scores. Whilst other publications found a constant development of the SF-36 physical score towards the 5-year follow-up (Nebergall et al. 2016), the ≥ 75% group revealed a drop at 5 years in that score compared with 2 years. However, due to the small sample size in the group, this should not be overrated, since the difference for the < 75% group is not statistically significant. Regarding the specific stem of our study, several authors have published data describing midterm clinical outcomes at similar follow-up intervals after implanting the Metha short-stem device: Thorey et al. (2013) showed that after a mean follow-up duration of 5.8 years, the mean (SD) HHS had increased from 46 (17) preoperatively to 90 (5) postoperatively, the mean Hip dysfunction and Osteoarthritis Outcome Score (HOOS) had improved from 55 (16) preoperatively to 89 (10) postoperatively, and the Kaplan–Meier survival rate was about 98%. Lacko et al. (2014) showed that within a group that received Metha short-stem implants, the mean preoperative and postoperative HHSs were 42 (10) and 94 (5), respectively, and subsidence of the stem had occurred in 1 patient. Wittenberg et al. (2013) presented clinical and radiological data from 250 patients who received Metha stem devices, and they showed that with a mean follow-up duration of 4.9 years, the average HHS was 97 points, the 5-year Kaplan–Meier survival rate was 96.7%, and 85% of the patients were very satisfied, 14% were satisfied, and 1% were dissatisfied with the treatment.Our study has several limitations. First, the postoperative RSA image set was captured after initial weight-bearing. Thus, it is possible that initial settling of the implant had occurred previously, which was not considered in the data presented. Unfortunately, organizational factors in the clinic meant that no other procedure was possible. Second, a high number of the patients dropped out of the study during follow-up. On average only two-thirds of our patient population were examined at each follow-up. Nonetheless, compared with other RSA studies, the number of patients is quite high and in accordance with requirements (ISO 2013) (Table 3, see Supplementary data).In summary, our data demonstrated that there were no statistically significant differences between the group of patients with minor initial implant migrations and the group of patients with greater initial implant migrations with respect to additional migration over 5 years. Therefore, a greater initial migration was not associated with an increased risk of aseptic loosening and subsequent insufficient osseointegration. Furthermore, this study’s findings did not demonstrate an association between a greater initial implant migration and inferior midterm clinical outcomes. Overall, the migration of the Metha short-stem implant generated promising data in this study, without hints of aseptic loosening.     

Invasive diagnostic and therapeutic measures are unnecessary in patients with symptomatic van Neck–Odelberg disease (ischiopubic synchondrosis): a retrospective single-center study of 21 patients with median follow-up of 5 years

Background and purpose — Van Neck–Odelberg disease (VND) is a self-limiting skeletal phenomenon characterized by a symptomatic or asymptomatic uni- or bilateral overgrowth of the pre-pubescent ischiopubic synchondrosis. It is frequently misinterpreted as a neoplastic, traumatic, or infectious process, often resulting in excessive diagnostic and therapeutic measures. This study assessed the demographic, clinical, and radiographic features of the condition and analyzed diagnostic and therapeutic pathways in a large single-center cohort.Patients and methods — We retrospectively analyzed 21 consecutive patients (13 male) with a median age of 10 years (IQR 8–13) and a median follow-up of 5 years (IQR 42–94 months), who were diagnosed at our department between 1995 and 2019.Results — VND was unilateral in 17 cases and bilateral in 4 cases. Initial referral diagnoses included suspected primary bone tumor (n = 9), fracture (n = 3), osteomyelitis (n = 2), and metastasis (n = 1). The referral diagnosis was more likely to be VND in asymptomatic than symptomatic patients (4/6 vs. 2/15). More MRI scans were performed in unilateral than bilateral VND (median 2 vs. 0). All 15 symptomatic patients underwent nonoperative treatment and reported a resolution of symptoms and return to physical activity after a median time of 5 months (IQR 0–6).Interpretation — By understanding the physiological course of VND during skeletal maturation, unnecessary diagnostic and therapeutic measures can be avoided and uncertainty and anxiety amongst affected patients, their families, and treating physicians can be minimized.

Van Neck–Odelberg disease (VND) is a self-limiting skeletal phenomenon characterized by an asymptomatic or symptomatic uni- or bilateral overgrowth of the pre-pubescent junction between the inferior pubic ramus and ischium, which can be seen on radiographs during skeletal maturation (Figure 1) (Herneth et al. 2004, Wait et al. 2011, Mixa et al. 2017). The condition was first described in the 1920s by Odelberg and Van Neck, who classified it as a “disease” (Odelberg 1923, van Neck 1924). Today, however, VND is considered a physiological normal variant of the ischiopubic synchondrosis (IPS) that is usually obliterated between late childhood and early adolescence by bony fusion or synostosis (Herneth et al. 2000, Mixa et al. 2017).Open in a separate windowFigure 1.Typical enlargement of the IPS in a 14-year-old female patient with right-sided VND.Despite VND being considered a normal variant, unilateral radiographic changes of the IPS are frequently misinterpreted as neoplastic, traumatic, or infectious processes (Herneth et al. 2000, Wait et al. 2011). Particularly in symptomatic patients, this often results in excessive, unnecessary, invasive, and costly diagnostic measures causing uncertainty and anxiety amongst patients and their families, as well as treating physicians (Herneth et al. 2000, Wait et al. 2011).There are several case reports on VND in the literature; however, there are only 1 small series of 10 cases and 1 systematic review of 29 patients available, providing only limited data on demographics, possible diagnostic and therapeutic pathways, and patient outcome (Wait et al. 2011, Mixa et al. 2017). We therefore conducted this study to assess demographic, clinical, and radiographic features of VND, analyze the course of the disease, and evaluate the functional follow-up in a large single-center cohort. Based on these data, we additionally developed a standardized algorithm to help minimize the use of unnecessary diagnostic measures and to simplify diagnosis.     

Influence of day of surgery and prediction of LOS > 2 days after fast-track hip and knee replacement

Background and purpose — Enhanced recovery programs have reduced length of stay (LOS) after hip and knee arthroplasty (THA/TKA). Although risk factors disposing to prolonged LOS are well documented, there is limited information on the role of weekday of surgery. This study analyzed the role of weekday of surgery and other potential risk factors for LOS > 2 days.Patients and methods — We included 10,576 unselected consecutive procedures between January 2016 and August 2017 within a multicenter fast-track THA/TKA collaboration with prospective collection of preoperative characteristics. We used multiple regression analysis of potential risk factors for LOS > 2 days followed by construction of a simple risk score from 0 to 15 points based on the calculated odds ratios.Results — Mean LOS was 1.9 (SD 1.8) days, with 80% of patients having surgery from Monday to Wednesday. Of these, 17% (95% CI 16–18) had a LOS > 2 days vs. 19% (CI 17–21) in those operated on Thursday and Friday. Patients were scheduled evenly throughout the week regardless of risk of LOS > 2 days and despite the fact that 38% (CI 35–40) of patients with ≥ 6 points (16% of the total population) had a LOS > 2 days compared with 14% (CI 13–14) in those with < 6 points. In these “high-risk” patients, the fraction with LOS > 2 days increased when having surgery on Thursdays or Fridays (43% CI 38–49) compared with Monday to Wednesday (37% CI 34–39).Interpretation — A detailed preoperative risk assessment may be helpful to plan the weekday of surgery in order to decrease LOS and weekend hospitalization.

Recent developments in perioperative care have also led to enhanced recovery (ERAS) in hip (THA) and knee replacement (TKA) with a decrease in postoperative length of stay (LOS) to between 0 and 2 days in many centers (Wainwright and Kehlet 2019). These advances have led to several studies showing the feasibility of outpatient THA and TKA in selected patients (Vehmeijer et al. 2018).The positive effects of ERAS programs in THA and TKA remain indisputable, not only by reducing LOS, but also by lowering the risk of medical complications without an increase in readmissions (Wainwright and Kehlet 2019). However, challenges still exist to further improve outcome and where the strategy must be divided between optimizing preoperative comorbidities, perioperative care, and organizational issues, of which the latter has received less attention. Preoperative risk factors have been well assessed over several years in relation to short LOS and generally confirming increased age, obesity, diabetes, cardio-pulmonary diseases, and dependent functional status as risk factors for prolonged LOS (Jørgensen et al. 2016, Cram et al. 2018, Kim et al. 2018, Cizmic et al. 2019, Gkagkalis et al. 2019, Ziemba-Davis et al. 2019, Johnson et al. 2020). However, limited information is available from a fast-track setting on the role of weekday of surgery on LOS when adjusting for the above-mentioned risk factors. In this context, identification of patients unlikely to be discharged within 1–2 days and therefore to be scheduled for surgery at the start of the week may reduce the need for weekend hospitalization and transfer to other departments from otherwise well-functioning 5-day arthroplasty units or ambulatory arthroplasty centers.The Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty (www.fthk.dk) was founded as a multi-institutional collaboration to improve care and outcome after THA and TKA and the most recent high-volume data have shown a median LOS of only 1 day in unselected patients (Petersen et al. 2019). The present study is a specific analysis of the role of preoperative risk factors and the weekday of surgery for a LOS > 2 days within the multicenter fast-track THA and TKA collaboration, in which unselected patients have been assessed in detail preoperatively and with complete registration of LOS in a socialized healthcare system where common practice in Denmark is discharge to home (Petersen et al. 2019).      

Tibial lengthening using a retrograde magnetically driven intramedullary lengthening device in 10 patients with preexisting ankle and hindfoot fusion

Background and purpose — Motorized intramedullary lengthening nails (ILNs) have been developed as an alternative to external fixators for long bone lengthening. The antegrade approach represents the standard method for tibial ILN insertion. In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique that has not been evaluated so far. We report the outcome of this method in 10 patients.Patients and methods — This retrospective study included 10 patients (mean age 18 years [13–25]) with preexisting ankle and hindfoot fusion who underwent tibial lengthening with a retrograde ILN (PRECICE). The mean leg length discrepancy (LLD) was 58 mm (36–80). The underlying conditions were congenital (n = 9) and post tumor resection (n = 1). The main outcome measures were: ILN reliability, distraction achieved, distraction index (DIX), time to bone healing, consolidation index (CIX), complications, and functional results.Results — All patients achieved the goal of lengthening (mean 48 mm [26–80]). Average DIX was 0.6 mm/day (0.5–0.7) and mean CIX was 44 days/cm (26–60). Delayed consolidation occurred in 2 patients and healed after ILN dynamization or nail exchange with grafting. Toe contractures in 2 other patients were resolved with physiotherapy or tenotomy. Until last follow-up (mean 18 months [12–30]) no true complications were encountered, knee motion remained unaffected, and full osseous consolidation occurred in all patients.Interpretation — In patients with LLD and preexisting ankle and hindfoot fusion distal tibial lengthening using a retrograde ILN is a reliable alternative to the standard approach with equivalent bone healing potential and low complication rates leaving the knee unaffected.

Fully implantable intramedullary lengthening nails (ILNs) with mechanical (Guichet and Casar 1997, Cole et al. 2001) and motorized (Baumgart et al. 1997, Schiedel et al. 2014) drive systems have been developed as an alternative to external fixators for bone lengthening (Mahboubian et al. 2012, Black et al. 2015, Laubscher et al. 2016). Recently, magnetically driven ILNs in particular have become increasingly popular (Kirane et al. 2014, Wagner et al. 2017) and in contrast to external fixation provide an equally safe and more comfortable option for limb lengthening and deformity correction (Szymczuk et al. 2019, Horn et al. 2019). Antegrade or retrograde femoral and antegrade tibial lengthening with the PRECICE limb lengthening system (NuVasive, San Diego, CA, USA) has been assessed by several studies (Kirane et al. 2014, Schiedel et al. 2014, Shabtai et al. 2014, Tiefenboeck et al. 2016, Wiebking et al. 2016, Fragomen and Rozbruch 2017, Wagner et al. 2017, Iobst et al. 2018, Cosic and Edwards 2020, Nasto et al. 2020).In tibial lengthening the antegrade approach represents the standard method for ILN implantation (Fragomen and Rozbruch 2017). In patients with preexisting ankle and hindfoot fusion a retrograde approach provides an alternative technique for tibial nail insertion. Approach-associated affections of the knee joint like anterior knee pain (Rothberg et al. 2019) and—in immature patients—damage to the proximal tibial growth plate (Wagner et al. 2017, Frommer et al. 2018) can be avoided. Despite these potential advantages, the use of a retrograde tibial nailing approach and distal tibial osteotomy in patients with preexisting ankle and hindfoot fusion has not been evaluated so far.     

CARVEDILOL AS PRIMARY PROPHYLAXIS FOR GASTRIC VARICEAL BLEEDING IN PORTAL HYPERTENSION MODEL IN RATS

​ Open in a separate windowCorte histológico de fígado sem alteração: A) grupo sham-operated + carvedilol; B) grupo LPVP + carvedilol     

URINARY EPIDERMAL GROWTH FACTOR IN DIFFERENT RENAL CONDITIONS IN CHILDREN

Several studies have demonstrated the important role of growth factors, particularly epidermal growth factor (EGF) and transforming growth factor α (TGFα), in cellular growth after renal damage. EGF is mainly synthesized by the kidney. Many studies indicate that urinary EGF concentration significantly decreases in patients with acute and chronic renal failure. In this study we determined urinary EGF concentrations in children with renal and/or urological pathologies. We investigated 38 patients, 17 males and 21 females, of 3.34 ± 2.96 years (mean ± standard deviation), who were followed in the Nephrologic Unit of the Pediatric Department of the University of Verona for recurrent urinary tract infections: seven of these had vesicoureteric reflux and 4 had hypodysplasia. The results were compared with those from a healthy age-matched group of 44 children. In all patients, we assessed renal function including an examination of the urine with a microbiological evaluation. Moreover, a renal ultrasound and a voiding cystourethrogram were performed. Urinary EGF was measured by a radioimmunoassay, using polyclonal goat antibodies. In all patients, laboratory parameters were within the normal range. In 34 patients the renal ultrasound was negative and in 4 cases structural alterations of the renal parenchyma were found. Voiding cystourethrography detected 7 instances of vesicoureteric reflux. In controls 10°, 50°, 90° percentile uEGF values were 7.3, 19 and 40.4μg/L, respectively. Mean urinary EGF values were 22.22 ± 16 μg/L. Urinary EGF values were 54 ± 35.2 μg/L in patients with recurrent urinary tract infections and without urinary malformations, 81 ± 29.37 μg/L in patients with vesicoureteric reflux and 22.30 ± 22.90μg/L in patients with hypodysplasia, respectively. There was a statistical significant difference between controls and groups A (p < 0.001) and B (p < 0.001) respectively, while the difference between group C and controls wasn't significant (p = 0.044). Results are reported in Figure . We believe that our results could be helpful for further studies on pathophysiology of growth factors in different renal conditions of children.

URINARY EPIDERMAL GROWTH FACTOR IN DIFFERENT RENAL CONDITIONS IN CHILDREN

All authors

V. Fanos, C. Pizzini, M. Mussap, D. Benini & M. Plebani

https://doi.org/10.1081/JDI-100104742

Published online:

07 July 2009

Figure 1. Urinary epidermal growth factor concentrations (uEGF) in the three groups considered (data are expressed as mean values ± standard deviation) compared with the line of the 90° percentile value calculated in the control group. Unpaired t-test: Group A vs. controls, p < 0.001. Group B vs. controls, p < 0.001. Group C vs. controls, n.s. (p = 0.487). Group A vs. Group B, p = 0.044.     

17.

PREDICTIVE FACTORS FOR COMPLETE AND INCOMPLETE EVALUATION OF SMALL INTESTINE BY ENDOSCOPIC CAPSULE     

Andréia Sopran SCOPEL  Fernando Issamu TABUSHI  Luis Fernando Kubrusly  Paula Bechara POLETTI  Artur Adolfo PARADA  Milena Perez MOREIRA  Thiago Festa SECCHI 《Brazilian archives of digestive surgery》2020,33(2)

? Open in a separate windowResults of CE between groups with or without associated comorbidities     

18.

Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments     

Markus W Frost  Ole Rahbek  Jens Traerup  Adriano A Ceccotti  Sren Kold 《Acta orthopaedica》2021,92(1):120

Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different.

Distraction osteogenesis through an externally applied fixator is a well-established treatment for lower limb lengthening (De Bastiani et al. 1987, Paley 1988, Ilizarov 1990). However, complication rates of this treatment are high, amounting to 1–3.2 complications per patient (Tjernström et al. 1994, Noonan et al. 1998). The wires or pins penetrating soft tissues result in complications such as pin site infection, pain, scarring, muscle transfixation, reduced joint movement, and immobility (Paley 1990, Mazeau et al. 2012, Landge et al. 2015). When the external fixator is removed, there is a risk of further complications such as fracture or malalignment (Noonan et al. 1998, Simpson and Kenwright 2000). To reduce complications and improve patient comfort, limb lengthening by fully implantable bone lengthening nails has been introduced (Guichet 1999, Cole et al. 2001). Problems with purely mechanically driven lengthening nails were resolved by the introduction of motorized (FITBONE) or magnetically driven (PRECICE) bone lengthening nails (Baumgart et al. 1997, Kirane et al. 2014, Paley et al. 2014, Shabtai et al. 2014). A few case-control studies have compared these nails with external fixation (13–15 patients), and the largest case series on intramedullary bone lengthening reports on 92 patients (Black et al. 2015, Horn et al. 2015, Calder et al. 2019). However, the majority of reports of complications of the FITBONE and PRECICE lengthening nails are small case series (Krieg et al. 2008, Dinçyürek et al. 2012, Birkholtz and De-Lange 2016, Hammouda et al. 2017). In recent years motorized intramedullary lengthening nails have become increasingly popular, and we thus hypothesized that standardized data on complications could now be extracted from the literature. We performed a systematic literature review of complications using PRECICE and FITBONE bone lengthening nails in lower limb bone lengthening. The primary outcome was risk of complications imposing a new pathology or permanent sequelae in the patient.     

19.

Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity,hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls     

Yasmin D Hailer 《Acta orthopaedica》2020,91(4):457

Background and purpose — Associations between obesity and slipped capital femoral epiphysis (SCFE) during adolescence are described; however, few studies report on the lifetime risk of obesity in patients with SCFE. In addition, with the obesity epidemic in children and adolescents, an increasing incidence of SCFE might be expected. An association of SCFE with hypothyroidism seems ambiguous, and the association between SCFE and depression and all-cause mortality has not yet been evaluated. This study investigates the associations of SCFE with obesity, hypothyroidism, depression, and mortality, and putative changes in the yearly incidence of SCFE.Patients and methods — 2,564 patients diagnosed with SCFE at age 5–16 diagnosed between 1964 and 2011 were identified in the Swedish Patient Register. These were matched for age, sex, and residency with unexposed control individuals. Cox regression models were fitted to estimate the risk of obesity, hypothyroidism, depression, and death, in exposed compared with unexposed individuals.Results — The risk of obesity (HR 9, 95% CI 7–11) and hypothyroidism (HR 3, CI 2–4) was higher in SCFE patients compared with controls. There was no increase in the risk of developing depression (HR 1, CI 1–1.3) in SCFE patients. In contrast, all-cause mortality was higher in SCFE patients than in controls (HR 2, CI 1–2). The incidence of SCFE did not increase over the past decades.Interpretation — Patients with SCFE have a higher lifetime risk of obesity and hypothyroidism and a higher risk of all-cause mortality compared with individuals without SCFE. These findings highlight the lifetime comorbidity burden of patients who develop SCFE in childhood, and increased surveillance of patients with a history of SCFE may be warranted. The incidence of SCFE did not increase over the last decades despite increasing obesity rates.

Slipped capital femoral epiphysis (SCFE) occurs commonly in overweight children and adolescents. The etiology of the disease is still unknown but several studies have concluded that overweight and obesity are catalyzing factors, either by overloading the growth plate (Fishkin et al. 2006) or as an endocrine condition diminishing the stability of the growth plate. The latter would explain the age-dependent relationship between obesity and SCFE onset, where obese children are found to suffer from SCFE at a younger age compared with children of age- and length-adequate weight (Perry et al. 2018). Wensaas et al. (2011) investigated the long-term outcome of 66 patients with a history of SCFE and found that one-third were overweight or obese in adulthood. However, the risk of developing obesity in SCFE patients, not only in childhood but during later life, is still unknown.In contrast, presuming obesity as a causal factor, one would expect higher incidences of SCFE due to epidemic obesity rates in children and adolescents (Murray and Wilson 2008). However, comparisons of incidence rates are often difficult because the calculations are based on different age groups and changes in incidence rates over the past decades have not yet been reported.Inconsistent findings concerning the association between SCFE and hypothyroidism have emerged. Some authors found no association between SCFE and hypothyroidism (Brenkel et al. 1988), whereas others found an association of the 2 diseases (Kadowaki et al. 2017). Congenital hypothyroidism is part of the screening program of newborns in Sweden (National Board of Health and Welfare 2018) but acquired hypothyroidism is often underdiagnosed in children and adolescents (Ghaemi et al. 2015). To my knowledge, there is no study investigating the lifetime risk of hypothyroidism in patients with a history of SCFE.Studies focusing on the long-term outcome after SCFE (Wensaas et al. 2011, Castaneda et al. 2013, Wiemann and Herrera-Soto 2013, de Poorter et al. 2016) attest that SCFE is not only a childhood hip disease: In some patients SCFE transforms into a chronic disease by creating hip joint impingement (Lerch et al. 2019) or premature osteoarthritis, or both (Goodman et al. 1997). It is known that patients with chronic diseases are at greater risk of developing depression (Moussavi et al. 2007, Podeszwa et al. 2015) and die earlier (Ng et al. 2007, Hailer and Nilsson 2014) compared with the general population.Thus, the lifetime burden of obesity, hypothyroidism, and depression in patients exposed to SCFE remains unclear and leads to the following questions: (1) Do patients with SCFE have an increased lifetime risk of obesity and hypothyroidism? (2) Has the average incidence of SCFE in Sweden changed over the past few decades? (3) Is SCFE associated with a higher risk of depression and a higher risk of all-cause mortality?     

20.

Mortality and revision rate of cemented and uncemented hemiarthroplasty after hip fracture: an analysis of the Dutch Arthroplasty Register (LROI)     

Bouke J Duijnisveld  Koen L M Koenraadt  Liza N van Steenbergen  Stefan B T Bolder 《Acta orthopaedica》2020,91(4):408

Background and purpose — Femoral neck fractures are commonly treated with cemented or uncemented hemiarthroplasties (HA). We evaluated differences in mortality and revision rates in this fragile patient group.Patients and methods — From January 1, 2007 until December 31, 2016, 22,356 HA procedures from the Dutch Arthroplasty Register (LROI) were included. For each HA, follow-up until death, revision, or end of follow-up (December 31, 2016) was determined. The crude revision rate was determined by competing risk analysis. Multivariable Cox regression analyses were performed to evaluate the effect of fixation method (cemented vs. uncemented) on death or revision. Age, sex, BMI, Orthopaedic Data Evaluation Panel (ODEP) rating, ASA grade, surgical approach, and previous surgery were included as potential confounders.Results — 1-year mortality rates did not differ between cemented and uncemented HA. 9-year mortality rates were 53% (95% CI 52–54) in cemented HA compared to 56% (CI 54–58) in uncemented HA. Multivariable Cox regression analysis showed similar mortality between cemented and uncemented HA (HR 1.0, CI 0.96–1.1). A statistically significantly lower 9-year revision rate of 3.1% (CI 2.7–3.6) in cemented HA compared with 5.1% (CI 4.2–6.2) in the uncemented HA was found with a lower hazard ratio for revision in cemented compared with uncemented HA (HR 0.56, CI 0.47–0.67).Interpretation — Long-term mortality rates did not differ between patients with a cemented or uncemented HA after an acute femoral neck fracture. Revision rates were lower in cemented compared with uncemented HA.

The number of hemiarthroplasties (HA) after displaced femoral neck fracture increases as a result of global aging, and inferior results and high risk of reoperation after internal fixation. Although the literature on the decision to use cemented or uncemented HA may favor a cemented implant, both techniques are currently used. The use of bone cement is associated with bone cement implantation syndrome (BCIS) characterized by hypoxia, hypotension, loss of consciousness around the time of bone cementation, and intraoperative death (Olsen et al. 2014, Rutter et al. 2014). More intraoperative complications including intraoperative death were found in cemented HA in the Norwegian register (Gjertsen et al. 2012, Talsnes et al. 2013). However, no differences in mortality were found after 1 week (Costain et al. 2011, Yli-Kyyny et al. 2014). More studies including randomized controlled trials (Deangelis et al. 2012, Taylor et al. 2012) and registry studies (Costa et al. 2011, Ekman et al. 2019) did not show differences in mortality between cemented and uncemented HA. Randomized controlled trials (Taylor et al. 2012, Langslet et al. 2014, Inngul et al. 2015) and register studies (Gjertsen et al. 2012, Yli-Kyyny et al. 2014) have shown that the use of uncemented implants could result in a higher risk of periprosthetic fractures. A meta-analysis by Li et al. (2013) concluded that differences in several outcome parameters indicated cemented hemiarthroplasty to be superior to the uncemented counterpart. However, a serious flaw in this analysis is that several studies were included using an outdated stem like the Austin Moore (Sonne-Holm et al. 1982, Emery et al. 1991, Parker et al. 2010) and the experimental uncemented Thomson stem (Sadr and Arden 1977). The use of a prosthesis without Orthopaedic Data Evaluation Panel (ODEP) rating > 3A could influence outcome and is therefore discouraged (Grammatopoulos et al. 2015). A recent review by Rogmark and Leonardsson (2016) included 5 randomized studies comparing modern uncemented and cemented hemiarthroplasties. They found no differences in mortality, but more periprosthetic fractures in uncemented cases. We compared cemented and uncemented HA after an acute hip fracture with primary outcome mortality and revision rate. Data from the Dutch Arthroplasty Register (LROI) were used and the cohort of cemented HAs was compared with uncemented HAs, accounting for the ODEP rating and other confounders.     

PREDICTIVE FACTORS FOR COMPLETE AND INCOMPLETE EVALUATION OF SMALL INTESTINE BY ENDOSCOPIC CAPSULE

? Open in a separate windowResults of CE between groups with or without associated comorbidities     

Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments

Background and purpose — In recent years motorized intramedullary lengthening nails have become increasingly popular. Complications are heterogeneously reported in small case series and therefore we made a systematic review of complications occurring in lower limb lengthening with externally controlled motorized intramedullary bone lengthening nails.Methods — We performed a systematic search in PubMed, EMBASE, and the Cochrane Library with medical subject headings: Bone Nails, Bone Lengthening, and PRECICE and FITBONE nails. Complications were graded on severity and origin.Results — The search identified 952 articles; 116 were full text screened, and 41 were included in the final analysis. 983 segments were lengthened in 782 patients (age 8–74 years). The distribution of nails was: 214 FITBONE, 747 PRECICE, 22 either FITBONE or PRECICE. Indications for lengthening were: 208 congenital shortening, 305 acquired limb shortening, 111 short stature, 158 with unidentified etiology. We identified 332 complications (34% of segments): Type I (minimal intervention) in 11% of segments; Type II (substantial change in treatment plan) in 15% of segments; Type IIIA (failure to achieve goal) in 5% of segments; and Type IIIB (new pathology or permanent sequelae) in 3% of segments. Device and bone complications were the most frequent.Interpretation — The overall risk of complications was 1 complication for every 3 segments lengthened. In 1 of every 4 segments, complications had a major impact leading to substantial change in treatment, failure to achieve lengthening goal, introduction of a new pathology, or permanent sequelae. However, as no standardized reporting method for complications exists, the true complication rates might be different.

Distraction osteogenesis through an externally applied fixator is a well-established treatment for lower limb lengthening (De Bastiani et al. 1987, Paley 1988, Ilizarov 1990). However, complication rates of this treatment are high, amounting to 1–3.2 complications per patient (Tjernström et al. 1994, Noonan et al. 1998). The wires or pins penetrating soft tissues result in complications such as pin site infection, pain, scarring, muscle transfixation, reduced joint movement, and immobility (Paley 1990, Mazeau et al. 2012, Landge et al. 2015). When the external fixator is removed, there is a risk of further complications such as fracture or malalignment (Noonan et al. 1998, Simpson and Kenwright 2000). To reduce complications and improve patient comfort, limb lengthening by fully implantable bone lengthening nails has been introduced (Guichet 1999, Cole et al. 2001). Problems with purely mechanically driven lengthening nails were resolved by the introduction of motorized (FITBONE) or magnetically driven (PRECICE) bone lengthening nails (Baumgart et al. 1997, Kirane et al. 2014, Paley et al. 2014, Shabtai et al. 2014). A few case-control studies have compared these nails with external fixation (13–15 patients), and the largest case series on intramedullary bone lengthening reports on 92 patients (Black et al. 2015, Horn et al. 2015, Calder et al. 2019). However, the majority of reports of complications of the FITBONE and PRECICE lengthening nails are small case series (Krieg et al. 2008, Dinçyürek et al. 2012, Birkholtz and De-Lange 2016, Hammouda et al. 2017). In recent years motorized intramedullary lengthening nails have become increasingly popular, and we thus hypothesized that standardized data on complications could now be extracted from the literature. We performed a systematic literature review of complications using PRECICE and FITBONE bone lengthening nails in lower limb bone lengthening. The primary outcome was risk of complications imposing a new pathology or permanent sequelae in the patient.     

Fate of patients with slipped capital femoral epiphysis (SCFE) in later life: risk of obesity,hypothyroidism, and death in 2,564 patients with SCFE compared with 25,638 controls

Background and purpose — Associations between obesity and slipped capital femoral epiphysis (SCFE) during adolescence are described; however, few studies report on the lifetime risk of obesity in patients with SCFE. In addition, with the obesity epidemic in children and adolescents, an increasing incidence of SCFE might be expected. An association of SCFE with hypothyroidism seems ambiguous, and the association between SCFE and depression and all-cause mortality has not yet been evaluated. This study investigates the associations of SCFE with obesity, hypothyroidism, depression, and mortality, and putative changes in the yearly incidence of SCFE.Patients and methods — 2,564 patients diagnosed with SCFE at age 5–16 diagnosed between 1964 and 2011 were identified in the Swedish Patient Register. These were matched for age, sex, and residency with unexposed control individuals. Cox regression models were fitted to estimate the risk of obesity, hypothyroidism, depression, and death, in exposed compared with unexposed individuals.Results — The risk of obesity (HR 9, 95% CI 7–11) and hypothyroidism (HR 3, CI 2–4) was higher in SCFE patients compared with controls. There was no increase in the risk of developing depression (HR 1, CI 1–1.3) in SCFE patients. In contrast, all-cause mortality was higher in SCFE patients than in controls (HR 2, CI 1–2). The incidence of SCFE did not increase over the past decades.Interpretation — Patients with SCFE have a higher lifetime risk of obesity and hypothyroidism and a higher risk of all-cause mortality compared with individuals without SCFE. These findings highlight the lifetime comorbidity burden of patients who develop SCFE in childhood, and increased surveillance of patients with a history of SCFE may be warranted. The incidence of SCFE did not increase over the last decades despite increasing obesity rates.

Slipped capital femoral epiphysis (SCFE) occurs commonly in overweight children and adolescents. The etiology of the disease is still unknown but several studies have concluded that overweight and obesity are catalyzing factors, either by overloading the growth plate (Fishkin et al. 2006) or as an endocrine condition diminishing the stability of the growth plate. The latter would explain the age-dependent relationship between obesity and SCFE onset, where obese children are found to suffer from SCFE at a younger age compared with children of age- and length-adequate weight (Perry et al. 2018). Wensaas et al. (2011) investigated the long-term outcome of 66 patients with a history of SCFE and found that one-third were overweight or obese in adulthood. However, the risk of developing obesity in SCFE patients, not only in childhood but during later life, is still unknown.In contrast, presuming obesity as a causal factor, one would expect higher incidences of SCFE due to epidemic obesity rates in children and adolescents (Murray and Wilson 2008). However, comparisons of incidence rates are often difficult because the calculations are based on different age groups and changes in incidence rates over the past decades have not yet been reported.Inconsistent findings concerning the association between SCFE and hypothyroidism have emerged. Some authors found no association between SCFE and hypothyroidism (Brenkel et al. 1988), whereas others found an association of the 2 diseases (Kadowaki et al. 2017). Congenital hypothyroidism is part of the screening program of newborns in Sweden (National Board of Health and Welfare 2018) but acquired hypothyroidism is often underdiagnosed in children and adolescents (Ghaemi et al. 2015). To my knowledge, there is no study investigating the lifetime risk of hypothyroidism in patients with a history of SCFE.Studies focusing on the long-term outcome after SCFE (Wensaas et al. 2011, Castaneda et al. 2013, Wiemann and Herrera-Soto 2013, de Poorter et al. 2016) attest that SCFE is not only a childhood hip disease: In some patients SCFE transforms into a chronic disease by creating hip joint impingement (Lerch et al. 2019) or premature osteoarthritis, or both (Goodman et al. 1997). It is known that patients with chronic diseases are at greater risk of developing depression (Moussavi et al. 2007, Podeszwa et al. 2015) and die earlier (Ng et al. 2007, Hailer and Nilsson 2014) compared with the general population.Thus, the lifetime burden of obesity, hypothyroidism, and depression in patients exposed to SCFE remains unclear and leads to the following questions: (1) Do patients with SCFE have an increased lifetime risk of obesity and hypothyroidism? (2) Has the average incidence of SCFE in Sweden changed over the past few decades? (3) Is SCFE associated with a higher risk of depression and a higher risk of all-cause mortality?     

Mortality and revision rate of cemented and uncemented hemiarthroplasty after hip fracture: an analysis of the Dutch Arthroplasty Register (LROI)

Background and purpose — Femoral neck fractures are commonly treated with cemented or uncemented hemiarthroplasties (HA). We evaluated differences in mortality and revision rates in this fragile patient group.Patients and methods — From January 1, 2007 until December 31, 2016, 22,356 HA procedures from the Dutch Arthroplasty Register (LROI) were included. For each HA, follow-up until death, revision, or end of follow-up (December 31, 2016) was determined. The crude revision rate was determined by competing risk analysis. Multivariable Cox regression analyses were performed to evaluate the effect of fixation method (cemented vs. uncemented) on death or revision. Age, sex, BMI, Orthopaedic Data Evaluation Panel (ODEP) rating, ASA grade, surgical approach, and previous surgery were included as potential confounders.Results — 1-year mortality rates did not differ between cemented and uncemented HA. 9-year mortality rates were 53% (95% CI 52–54) in cemented HA compared to 56% (CI 54–58) in uncemented HA. Multivariable Cox regression analysis showed similar mortality between cemented and uncemented HA (HR 1.0, CI 0.96–1.1). A statistically significantly lower 9-year revision rate of 3.1% (CI 2.7–3.6) in cemented HA compared with 5.1% (CI 4.2–6.2) in the uncemented HA was found with a lower hazard ratio for revision in cemented compared with uncemented HA (HR 0.56, CI 0.47–0.67).Interpretation — Long-term mortality rates did not differ between patients with a cemented or uncemented HA after an acute femoral neck fracture. Revision rates were lower in cemented compared with uncemented HA.

The number of hemiarthroplasties (HA) after displaced femoral neck fracture increases as a result of global aging, and inferior results and high risk of reoperation after internal fixation. Although the literature on the decision to use cemented or uncemented HA may favor a cemented implant, both techniques are currently used. The use of bone cement is associated with bone cement implantation syndrome (BCIS) characterized by hypoxia, hypotension, loss of consciousness around the time of bone cementation, and intraoperative death (Olsen et al. 2014, Rutter et al. 2014). More intraoperative complications including intraoperative death were found in cemented HA in the Norwegian register (Gjertsen et al. 2012, Talsnes et al. 2013). However, no differences in mortality were found after 1 week (Costain et al. 2011, Yli-Kyyny et al. 2014). More studies including randomized controlled trials (Deangelis et al. 2012, Taylor et al. 2012) and registry studies (Costa et al. 2011, Ekman et al. 2019) did not show differences in mortality between cemented and uncemented HA. Randomized controlled trials (Taylor et al. 2012, Langslet et al. 2014, Inngul et al. 2015) and register studies (Gjertsen et al. 2012, Yli-Kyyny et al. 2014) have shown that the use of uncemented implants could result in a higher risk of periprosthetic fractures. A meta-analysis by Li et al. (2013) concluded that differences in several outcome parameters indicated cemented hemiarthroplasty to be superior to the uncemented counterpart. However, a serious flaw in this analysis is that several studies were included using an outdated stem like the Austin Moore (Sonne-Holm et al. 1982, Emery et al. 1991, Parker et al. 2010) and the experimental uncemented Thomson stem (Sadr and Arden 1977). The use of a prosthesis without Orthopaedic Data Evaluation Panel (ODEP) rating > 3A could influence outcome and is therefore discouraged (Grammatopoulos et al. 2015). A recent review by Rogmark and Leonardsson (2016) included 5 randomized studies comparing modern uncemented and cemented hemiarthroplasties. They found no differences in mortality, but more periprosthetic fractures in uncemented cases. We compared cemented and uncemented HA after an acute hip fracture with primary outcome mortality and revision rate. Data from the Dutch Arthroplasty Register (LROI) were used and the cohort of cemented HAs was compared with uncemented HAs, accounting for the ODEP rating and other confounders.