Hemiarthroplasty (HA) is an effective procedure for treatment of femoral neck fracture. However, it is debatable whether unipolar or bipolar HA is the most suitable implant.
Objective
The purpose of this study was to compare the causes of failure and longevity in both types of HA.
Materials and methods
We retrospectively reviewed 133 cases that underwent revision surgery of HA between 2002 and 2012. The causes of revision surgery were identified and stratified into early (≤?5 years) failure and late (>?5 years) failure. Survival analyses were performed for each implant type.
Results
The common causes for revision were aseptic loosening (49.6%), infection (22.6%) and acetabular erosion (15.0%). Unipolar and bipolar HA were not different in causes for revision, but the unipolar group had a statistically significantly higher number of acetabular erosion events compared with the bipolar group (p?=?0.002). In the early period, 24 unipolar HA (52.9%) and 28 bipolar HA (34.1%) failed. There were no statistically significant differences in the numbers of revised HA in each period between the two groups (p?=?0.138). The median survival times in the unipolar and bipolar groups were 84.0?±?24.5 and 120.0?±?5.5 months, respectively. However, the survival times of both implants were not statistically significantly different.
Conclusions
Aseptic loosening was the most common reason for revision surgery after hemiarthroplasty surgery in early and late failures. Unipolar and bipolar hemiarthroplasty were not different in terms of causes of failure and survivorship except bipolar hemiarthroplasty had many fewer acetabular erosion events.
Various techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine.
Methods
Prospective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded.
Results
Thirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone–implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2–16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis.
Conclusion
Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
A tapered straight cementless stem was used for revision in a group of old and very old patients. We wanted to know whether the use of this implant could achieve satisfactory results despite age and osteoporosis.
Methods
We retrospectively analysed data of 77 elderly patients (77 hips) who underwent revision in cemented and uncemented primary total hip arthroplasties (THA). The patients had a mean age of 82.2 years (range, 75–92 years) at revision surgery. They were monitored for a mean follow up of 7.1 years (range, 5.0–10.2 years). During the minimum follow-up period 11 patients died of unrelated causes, leaving 66 patients (66 hips) for evaluation.
Results
During the period of study three stems failed due to aseptic loosening, three hips dislocated and were successfully treated by closed reduction and bracing. No infection, osteolysis or significant stress shielding around the stems was observed. The survivorship at an average of 7.1-year follow-up was 95.5%.
Conclusions
These results indicate that this stem is an excellent alternative in revision THA in patients of 75 years or older.
Although large series from national joint registries may accurately reflect indications for revision TKAs, they may lack the granularity to detect the true incidence and relative importance of such indications, especially periprosthetic joint infections (PJI).
Questions/purposes
Using a combination of individual chart review supplemented with New Zealand Joint Registry data, we asked: (1) What is the cumulative incidence of revision TKA? (2) What are the common indications for revising a contemporary primary TKA? (3) Do revision TKA indications differ at various followup times after primary TKA?
Methods
We identified 11,134 primary TKAs performed between 2000 and 2015 in three tertiary referral hospitals. The New Zealand Joint Registry and individual patient chart review were used to identify 357 patients undergoing subsequent revision surgery or any reoperation for PJI. All clinical records, radiographs, and laboratory results were reviewed to identify the primary revision reason. The cumulative incidence of each revision reason was calculated using a competing risk estimator.
Results
The cumulative incidence for revision TKA at 15 years followup was 6.1% (95% CI, 5.1%–7.1%). The two most-common revision reasons at 15 years followup were PJI followed by aseptic loosening. The risk of revision or reoperation for PJI was 2.0% (95% CI, 1.7%–2.3%) and aseptic loosening was 1.2% (95% CI, 0.7%–1.6%). Approximately half of the revision TKAs secondary to PJI occurred within 2 years of the index TKA (95% CI, 0.8%–1.2%), whereas half of the revision TKAs secondary to aseptic loosening occurred 8 years after the index TKA (95% CI, 0.4%–0.7%).
Conclusions
In this large cohort of patients with comprehensive followup of revision procedures, PJI was the dominant reason for failure during the first 15 years after primary TKA. Aseptic loosening became more important with longer followup. Efforts to improve outcome after primary TKA should focus on these areas, particularly prevention of PJI.
Delayed infections after spinal instrumentation typically require complete implant removal and extensive wound debridement due to the difficulties in establishing an early diagnosis. We report a case of occult late infection after posterior spinal instrumentation that was detected early using PET/CT and therefore was successfully treated with antibiotics alone.
Methods
A 26-year-old woman who underwent posterior spinal instrumentation and fusion for scoliosis correction had superficial pseudomonal infection that healed with ceftazidime and levofloxacin and was admitted 4 months later with mild back pain. She had no fever and the surgical wound healed well. Laboratory tests were compatible with late infection but radiographs showed no signs of implant infection. The patient was suspected of having ongoing occult late infection and thus, underwent a PET/CT.
Results
PET/CT revealed a significant pathological FDG uptake at the T5 vertebral body and the area surrounding proximal end of the T5 instrumentation. The maximal standardized uptake value (SUV) was 7.9 for the T5 vertebra and only 2.3 for the patient’s liver, suggesting an infection pathology. A conclusive diagnosis of delayed onset infection after spinal instrumentation was established and the patient was immediately started on oral anti-pseudomonal treatment. The scoliosis correction was well maintained 10 months after the index surgery and she had no signs of implant infection.
Conclusions
PET/CT provides detailed diagnostic information for occult infections in the absence of morphological changes and thus, is valuable for an early diagnosis of late infection after spinal instrumentation. It is possible to retain the instrumentation in the case of late infection, if early detection and efficacious treatment can be achieved timely.
Modified postural stability after retaining the posterior cruciate ligament (PCL) in total knee arthroplasty is still discussed controversially. The objective of this study was to evaluate whether a PCL-retaining implant design should be preferred over a PCL-substituting implant design regarding postural stability in one-leg stance and clinical outcome.
Methods
Forty patients underwent total knee arthroplasty, 20 of them with a cruciate-retaining (CR) and 20 of them with a cruciate-substituting (PS) implant system. Postural stability was analysed 6 months postoperatively in one-leg stance using the Biodex Balance System. In addition, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score were completed.
Results
This study shows that there is no significant difference in postural stability between CR and PS) implant systems with PS implants showing better results in WOMAC score.
Conclusions
In case it is necessary to use a PS implant, no negative influence on postural stability is to be expected compared to a CR implant.
Cervical artificial discs (CADs) represent an established surgical option in selected patients with cervical spinal disc degeneration. Though CADs have been available for many years, there is a lack of information concerning long-term safety, durability and implant-related failure rates.
Materials and methods
The authors describe the failure of a M6-C CAD (Spinal Kinetics, Sunnyvale, CA, USA).
Results
Eight years after implantation of a CAD of the M6 type, a 39-year-old female presented with new clinical signs of cervical myelopathy. Radiologically, medullar compression due to posterior core herniation was the suspected cause. The damaged CAD was removed and the segment fused. During revision surgery, rupture of the posterior structures could be detected. Possible mechanisms leading to implant failure are discussed.
Conclusion
As there is no standard regarding clinical and radiological follow-up for patients with CADs, radiological long-term follow-up investigations seem to be justified for exclusion of implant failure.
Pedicle screws’ stability, especially in osteoporotic fractures, is a really problem for spinal surgeons. Nowadays, little is known about the influence of different screw types and amount of cement applied. This single-center retrospective observational study has the aim of evaluating the middle- to long-term mechanical performances of different types of screws in elderly patients with thoracolumbar fractures.
Materials and methods
A total of 91 patients (37 males and 54 females), treated between 2011 and 2016, affected by somatic osteoporotic fractures aged over 65 years were treated. We divided patients into three different populations: solid screws, cannulated screws and cannulated screws augmented with poly methyl methacrylate cement (PMMA). Patients were radiologically evaluated with X-rays in pre- and post-surgery and at the follow-up (FU). Clinical evaluations were made with VAS and Oswestry Disability Index.
Results
A total of 636 screws were implanted (222 pedicle screws, 190 cannulated and 224 cannulated screws with PMMA augmentation). At FU, we found significative differences between populations in terms of mechanical performances. We founded five cases of loosening; these were reported in solid screws group and in cannulated screws one. No mechanical failures were reported in cannulated screws with augmentation of PMMA. No rods breakage cases were reported.
Conclusion
All stabilization methods showed good clinical results, but cannulated screws augmented with PMMA seem to provide better implant stability with the lowest rate of loosening.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
In this paper, the authors propose classifying the epiphenomenon of spinal deformity in two different categories: structural deformity, when the main driver of the observed deformity is a fixed and stiff alteration of the spinal segments, and compensatory deformity, which includes cases where the observed deformity is due to focal abnormalities. This last category comprises, but is not limited to, spinal stenosis, spondylolisthesis, disc herniation, infection or tumor, hip disease or neurological disease (such as Parkinson’s disease).
Method
Narrative review article.
Results
We analyzed the focal diseases of the spine that may cause a compensatory deformity inducing adaptation in the unaffected part of the spine.
Conclusion
The compensatory mechanisms involved in adaptive deformity represent an attempt to maintain a global alignment, to escape from pain or to control body posture.
Graphical abstract
These slides can be retrieved under Electronic Supplementary material.
The treatment of postoperative deep spinal wound infection involves debridement and intravenous antibiotics. Authors have previously reported success in a small series of patients treated with vacuum-assisted closure (VAC) therapy, but its use over exposed dura is controversial and the outcome has not been reported in large series.
Purpose
To review the outcomes following the treatment of postoperative spinal infections with VAC therapy, particularly those with exposed dura.
Methods
This is a review of prospectively collected data in 42 patients, all of whom had deep postoperative spinal infections. 30 of these patients had exposed dura. All patients had an initial debridement followed by application of VAC Whitefoam (with exposed dura) or grey Granufoam (where no dura was exposed). Pressure was set at 50 mmHg with exposed dura or 125 mmHg where no dura was exposed. All patients underwent a minimum 6 week course of antibiotics. We report on the number of visits to theatre required for dressing changes and debridement and the eventual outcomes.
Results
Five patients required a flap reconstruction. Two patients died before definitive final closure due to other complications (pneumonia and stroke). In all the other patients, their wounds healed fully. A mean of 2.3 infection surgeries were required to eradicate infection and achieve wound closure.
Conclusions
This is one of the largest studies which confirms the safety and efficacy of VAC dressings in patients with spinal wound infections, even when the dura is exposed.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
The first purpose of this study is to confirm whether the spinal cord and the surrounding tissues can be visualized clearly after laminoplasty using percutaneous ultrasonography. And second purpose is to evaluate the changes in the status of the spinal cord over time.
Methods
Fifty patients who underwent cervical laminoplasty with suture anchors were evaluated using intraoperative ultrasonography and postoperative (1 week, 2 weeks, 3 months, 6 months, and 1 year) percutaneous ultrasonography. We classified the decompression status of the spinal cord into three grades and the pattern of the spinal cord pulsation into six categories. Clinical outcomes were evaluated using the Japanese Orthopaedic Association Score for cervical myelopathy, and the recovery rate was calculated.
Results
In all cases and all periods, we could observe the status of the spinal cord using percutaneous ultrasonography after cervical laminoplasty. The decompression status of the spinal cord improved until 3 months postoperatively, and the clinical outcomes improved up to 6 months postoperatively. Although the pulsation pattern of the spinal cord varied in each individual and in each period, spinal pulsation itself was observed in all cases and all periods, except one, when an epidural hematoma caused quadriplegia and a revision surgery was needed. Decompression status and pulsation pattern of the spinal cord were not associated with clinical outcomes as far as pulsation was observed.
Conclusions
Percutaneous ultrasonography was very useful method to evaluate the postoperative status of the spinal cord, particularly in the diagnosis of the postoperative epidural hematoma.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Guidelines on the management of displaced intracapsular fractures recommend using an Orthopaedic Data Evaluation Panel-rated cemented implant. Prior to the National Institute for Health and Care Excellence guidelines, uncemented implants were commonly used in the UK.
Methods
We retrospectively examined the outcomes of patients with uncemented Thompson’s hemiarthroplasties at our unit, between April 2005 and December 2010. Patients who underwent revision surgery before December 2011 were identified. Implant survival calculation utilised the primary outcome of revision to total hip arthroplasty, revision hemiarthroplasty or excision arthroplasty. Patients who died post-operatively were identified and censored.
Results
A total of 1445 patients received uncemented Thompson’s implant. Patient mean age was 82 years with 76% female. Forty-six (3.2%) patients required revision with 15% performed within 30 days of surgery and 62% within 1 year. Reasons for revision were infection (0.83%), acetabular erosion (0.83%) and loosening (0.62%). Twenty-seven patients (59% of total revisions) underwent revision to THA, 14 (30%) to excision arthroplasty and 5 (11%) to revision hemiarthroplasty. Cumulative survival rate was 98% at 1 year and 95% at 5 years. Thirty-day mortality was 7.1%. One-year mortality was 28.1%.
Conclusion
Current guidelines strongly favour cemented hemiarthroplasty. Recognition that fractured hip patients are a non-homogeneous group is important. In patients with limited life expectancy, an uncemented Thompson is a quick, simple, palliative solution to early mobilisation. Correct surgical technique avoids using cement in this cohort, which is most vulnerable to bone cement implantation syndrome. Cost-effective resource utilisation with an increasingly elderly population remains a surgical responsibility.
In recent years, the number of lung transplants has increased rapidly, with higher quality of life and improved survival rates in transplant recipients, including patients with advanced age. This, in turn, means that more transplant recipients will seek musculoskeletal care to treat degenerative joint disease and also trauma incidents. Safety concerns regarding elective and posttraumatic hip arthroplasty in transplant patients include an increased risk of infection, wound healing problems, periprosthetic fractures and loosening of the implants.
Methods
Clinical outcomes and safety aspects were retrospectively reviewed for five primary total hip arthroplasties (THA) in lung transplant recipients with minimal follow-up of two years at average of 2.6 (2–11) years. Patients were recruited from the Zurich Lung Transplant Center comprising of a cohort of 253 patients between January 1st, 2004 and December 31st, 2013.
Results
All five patients subjectively reported excellent outcomes after THA with a final average Harris Hip Score of 97 (86–100). One 71-year-old patient died 26 months after THA unrelated to arthroplasty. One superficial wound healing disturbance was documented. No periprosthetic fractures, no dislocations, no periprosthetic infections, no further revision surgery, no implant loosening was observed.
Conclusions
In conclusion, THA can be safely and successfully performed even in lung transplant patients under long-term immunosuppressive therapy and polymedication, provided a multidisciplinary approach can be granted.
Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.
Study design
Case report.
Objective
To report a clinical case with adjacent level infection after spinal fusion.
Methods
We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.
Results
After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.
Conclusion
Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.
We compared the midterm results after total knee arthroplasty (TKA) using PFC Sigma RP-F mobile model with PFC Sigma PS fixed model.
Materials and methods
In this randomized controlled trial, we analyzed 50 knees that underwent TKA with PFC Sigma RP-F and 60 knees with PFC Sigma PS fixed model. The follow-up period ranged from 76 to 104 months.
Results
The knee score, function score, and radiographic evaluation were significantly not different between the two groups at final follow-up. No revisions, subluxations, dislocations, or infections were seen. Also, no radiographic evidence of component loosening, osteolysis, or malalignment was observed in any knee. The results for both groups show good patient satisfaction.
Conclusions
The midterm clinical and radiographic results of the two prostheses did not show significant differences between the two groups.
Anatomic shoulder arthroplasty in osteoarthritis with biconcave glenoid wear results in decreased functional results and a higher rate of early glenoid loosening.
Aim
The aim of the data analysis of the German shoulder arthroplasty register was to clarify whether reverse shoulder arthroplasty can provide better functional results and a lower complication rate than anatomic arthroplasty in osteoarthritis with biconcave glenoid wear.
Methods
The analysis included 1052 completely documented primary implanted arthroplasties with a minimum follow-up of 2 years. In 119 cases, a B2-type glenoid was present. Out of these cases, 86 were treated with an anatomic shoulder arthroplasty, and in 33 cases a reverse shoulder arthroplasty was implanted. The mean follow-up was 47.6 months.
Results
The Constant score with its subcategories, as well as the active range of movement improved significantly after anatomic and after reverse shoulder arthroplasty.
Discussion
We observed no difference in functional results between both types of arthroplasty; however, reverse arthroplasty showed a significant higher revision rate (21.2%) (3% glenoid loosening, 6% prosthetic instability) than anatomic shoulder arthroplasty (12.8%) (11.6% glenoid loosening, 1.2% prosthetic instability), whereas anatomic shoulder arthroplasty showed a higher rate of glenoid loosening. Functional and radiographic results of both types of arthroplasty are comparable with the results reported in the literature, although our analysis represents results from an implant registry (data pertaining to medical care quality).
Aseptic loosening after total hip arthroplasty is likely related to nicotine ingestion. However, aseptic loosening as a direct consequence of smoking habits has not been described with regard to proximal mega-prosthetic femoral replacement. The aim of the present study was to evaluate the association between nicotine consumption and aseptic loosening rates after proximal mega-prosthetic femoral replacement.
Materials and methods
A consecutive series of patients who received mega-prosthetic replacement of the proximal femur at our hospital between 2005 and 2015 were included. Their files were reviewed and evaluated for the influence of smoking on aseptic loosening rates. All living patients were invited to complete a functional follow-up assessment at our clinic.
Results
Twenty-six patients with 27 prostheses were included. Five patients were active smokers, and 21 patients were non-smokers. Aseptic loosening was observed in three patients in the smoking group, whereas none of the non-smokers developed aseptic loosening. Fisher’s exact test showed a relationship between nicotine consumption and aseptic loosening of the prostheses (p = 0.003).
Conclusions
Smoking increases the likelihood of aseptic loosening after proximal mega-prosthetic femoral replacement.
Level of evidence
Level 4 according to Oxford Centre of Evidence-Based Medicine 2011.
We report early results using a second generation locking plate, non-contact bridging plate (NCB PH®, Zimmer Inc. Warsaw, IN, USA), for the treatment of proximal humeral fractures. The NCB PH® combines conventional plating technique with polyaxial screw placement and angular stability.
Design
Prospective case series.
Setting
A single level-1 trauma center.
Patients
A total of 50 patients with proximal humeral fractures were treated from May 2004 to December 2005.
Intervention
Surgery was performed in open technique in all cases.
Main outcome measures
Implant-related complications, clinical parameters (duration of surgery, range of motion, Constant–Murley Score, subjective patient satisfaction, complications) and radiographic evaluation [union, implant loosening, implant-related complications and avascular necrosis (AVN) of the humeral head] at 6, 12 and 24 weeks.
Results
All fractures available to follow-up (48 of 50) went to union within the follow-up period of 6 months. One patient was lost to follow-up, one patient died of a cause unrelated to the trauma, four patients developed AVN with cutout, one patient had implant loosening, three patients experienced cutout and one patient had an axillary nerve lesion (onset unknown). The average age- and gender-related Constant Score (n = 35) was 76.
Conclusions
The NCB PH® combines conventional plating technique with polyaxial screw placement and angular stability. Although the complication rate was 19%, with a reoperation rate of 12%, the early results show that the NCB PH® is a safe implant for the treatment of proximal humeral fractures.
