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1.  MRI does not detect acetabular osteolysis around metal-on-metal Birmingham THA 
Osteolysis has not been recognized as a common failure mode of the Birmingham modular metal-on-metal (MoM) total hip arthroplasty (THA). The clinical value of metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) to assess the periprosthetic soft tissue is well documented; however, the appropriate image modalities to detect periacetabular osteolysis remain unclear.
Case summary
Eleven patients with periacetabular osteolysis within 3–6 years after uncemented Birmingham modular MoM THA with a synergy stem are presented. All 11 patients received corresponding standardized AP pelvis radiographs, high-quality MARS MRIs and CT scans with a metal artifact reduction sequence. While periacetabular osteolysis around MoM THA was not detected on MARS MRI in ten patients, CT imaging identified osteolysis in all patients. Periacetabular osteolysis appears to be a failure mechanism of the Smith & Nephew Birmingham MoM THA.
There is no evidence in the literature to support the effectiveness of MARS MRI to detect periacetabular osteolysis around cobalt chromium alloy metal-on-metal total hip arthroplasties. Osteolysis due to corrosion-related particles seems to be one of the primary modes of failure in modular MoM THA.
MRI is not a sensitive test to identify periacetabular osteolysis. The authors recommend CT for the screening of implants with this failure mode. Our study suggests that patients with a Birmingham modular MoM THA are at increased risk to develop acetabular osteolysis and should be carefully monitored for this failure mode.
PMCID: PMC4062806  PMID: 24838248
Periacetabular osteolysis; Metal-on-metal; Total hip arthroplasty; Screening; MRI; CT
2.  Characteristics and significance of fever during 4 weeks after primary total knee arthroplasty 
Most previous studies on postoperative fever (POF; ≥38 °C) after total knee arthroplasty (TKA) have reported findings from only the immediate postoperative days (PODs). The hypothesis of the current study is that 4 weeks of follow-up may reveal differences in the characteristics of POF and fever-related factors between a normal inflammatory response and an early acute infection-related response.
A total of 400 consecutive TKAs (314 patients) were retrospectively investigated. Patients were stratified into those who developed an early acute periprosthetic infection that required subsequent surgical treatment (STG; n = 5 TKAs) and those who did not (non-STG; n = 395 TKAs).
Among the 400 knees, 149 (37 %) developed POF, with most reaching a maximum temperature (MT) on POD 0. In 13 TKA patients who had POF with a peak daily temperature ≥38 °C during postoperative weeks 2–4, the causes of POF were respiratory and urinary tract infections (n = 5 for each), superficial infection (n = 2), and periprosthetic infection (n = 1). The STG and non-STG differed significantly with regard to the rate of POF (p = 0.0205) and MT (p = 0.0003), including MTs less than 38 °C, during postoperative weeks 2–4. All five STG patients had elevated C-reactive protein levels and local symptomatic findings before the additional surgery.
The occurrence of POF and MT along with elevated C-reactive protein and local symptomatic findings at 2–4 weeks postoperatively may indicate the need for a positive fever workup to recognize early acute periprosthetic infection.
PMCID: PMC3990857  PMID: 24522863
Total knee arthroplasty; Postoperative fever; Maximum temperature; Periprosthetic infection
3.  Recompression in new levels after percutaneous vertebroplasty and kyphoplasty compared with conservative treatment 
Study design
A prospective clinical study assessing new vertebral compression fracture after previous treatment.
The purpose of this study was to investigate the incidence and associated risk factors of new symptomatic osteoporotic vertebral compression fractures (OVCFs) in patients treated by percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) versus conservative treatment, and to elucidate our findings.
Summary of background data
There are a lot of reports concerning the feasibility and efficacy of this minimally invasive procedure compared with conservative treatment, especially in pain soothing. However, it is still unclear whether the risk of subsequent fracture has increased among operative treatment patients in the long term.
From November 2005 to July 2009, 290 consecutive patients with 363 OVCFs were randomly selected for PVP/PKP or conservative treatment and evaluated with a mean follow-up of 49.4 months (36–80 months). Some parameters were characterized and statistically compared in this study. Telephone questionnaires, clinical reexamine, and plain radiographs were performed in the follow-up.
Thirty-one of 290 (10.7 %) patients had experienced 42 newly developed symptomatic secondary OVCFs. Among 169 operation (53.3 % vertebroplasty, 46.7 % kyphoplasty) and 121 comparison patients, there is no significant statistical difference of new OVCFs incidence between the two groups calculated by patient proportion. However, in separate, the rate of secondary adjacent fractures calculated by vertebral refracture number is significantly higher than non-adjacent levels in PVP/PKP group but no significant statistical difference was observed in conservative group. The time interval of recompression after operative procedure was much shorter than that for comparison group (9.7 ± 17.8 versus 22.4 ± 7.99 months, p = 0.017). In addition, older age, gender, fracture times, location of original fracture segment, the amount of cement, cement leakage, operation modality (PVP or PKP),and initial number of OVCFs were documented, but these were not the influencing factors in this study (p > 0.05).
Patients who had experienced PVP/PKP were not associated with an increased risk of recompression in new levels. However, recompression in new levels of PVP/PKP group occurred much sooner than that of conservative group in the follow-up period. The incidence of new vertebral fractures observed at adjacent levels was substantially higher but no sooner than at distant levels in PVP/PKP group. No major risk factors involving new OVCFs have been found in this study and  augmentation for sandwich situation is not necessary.
PMCID: PMC3889698  PMID: 24287674
Percutaneous vertebroplasty; Kyphoplasty; Adjacent fracture; Conservative treatment
4.  Comparison between posterior lumbar interbody fusion and posterolateral fusion with transpedicular screw fixation for isthmic spondylolithesis: a meta-analysis 
Primary aim of this study was to compare long-term pain relief and quality of life in adults with isthmic spondylolisthesis (IS) who were treated with posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF). Secondary aim was to compare the fusion and infection rates of PLIF- or PLF-treated groups.
Materials and methods
We searched four databases and the cited reference lists of the included studies. Inclusion criteria were pain assessment with visual analog scale (VAS), and clinical studies that compared long-term pain relief of PLF and PLIF-treated adults with IS. Exclusion criteria were use of only one treatment and non-English language.
Three of five included studies used VAS to assess the decline in low back pain, radicular pain, or leg pains in PLF- or PLIF-treated patients during the follow-up periods (0.5–6 years). Long-term pain relief significantly improved in both treatment groups. Pooled differences in mean improvement of Oswestry disability index after the operation revealed no significant difference in pain relief between the PLF and PLIF groups (P = 0.856). The five studies together indicated that fusion rate was significantly greater in the PLIF group than that in the PLF group.
The majority of PLIF- and PLF-treated adults with low-grade IS experienced long-term pain relief to a similar extent in most studies. PLIF treatment provided significantly better fusion rates than PLF treatment. This meta-analysis indicates that the use of separate, well-defined scales for pain relief and functional outcomes are needed in studies of PLF or PLIF-treated patients.
PMCID: PMC3828496  PMID: 24136445
Posterior lumbar interbody fusion; PLIF; Posterolateral fusion; PLF; Spondylolisthesis; Pain; Fusion rate; Infection rate; Isthmic
5.  Single-incision technique for the internal fixation of distal fractures of the tibia and fibula: a combined anatomic and clinical study 
To present a novel single anterior-lateral approach for the treatment of distal tibia and fibula fracture via anatomical study and primary clinical application in order to minimize soft tissue complications.
Both a gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited between June 2004 and January 2010.
Level I trauma center.
Twenty-six legs of 14 adult human cadavers and clinical recruitment of 49 patients (29 males, 20 females) with a mean age of 37.6 years (range 11–68) with fracture of distal 1/3 tibia and fibula.
A single anterior-lateral incision technique for open reduction and internal fixations of distal tibia and fibula fractures.
Main outcome measures
To identify the anatomic structures at risk in the anterolateral aspect of the lower leg and explicit the safe dissection distance from the extensor digitorum longus (EDL) to tibia and fibula, 26 legs of 14 adult human embalmed specimens were recruited in the anatomical study with the distance between the EDL and the anterior edge of the distal thirds of the tibia, as well as the distance between the EDL and the anterior edge of the distal thirds of the fibula were measured, and their mutual relationships to the surrounding anatomical structures described. Mean average standard deviations were also calculated. As for the clinical study, the quality of bone union and soft tissue healing were noted.
The mean distances between the distal tibia and the EDL were measured to be 2.96 ± 0.46 cm (proximal), 1.85 ± 0.25 cm (middle), and 2.15 ± 0.30 cm (distal), and that between the fibula and the EDL were 1.82 ± 0.28 cm (proximal), 2.09 ± 0.31 cm (middle), and 2.30 ± 0.27 cm (distal), which means the safe gap from the distal tibia to EDL was1.6–3.4 cm and from the EDL to fibula was 1.5–2.6 cm. The anterior tibial vein and artery and the deep fibular nerve lie on the anterior interosseous membrane over the lateral surface of the distal tibia were excellently visualized. Review of clinical outcomes in 49 patients with combined distal tibial and fibular fractures who underwent reduction and fixation with the single-incision technique, revealed uneventful fracture healings in 47 patients; and two cases of superficial wound necrosis which were treated and healed in 4 months. There was no case of delayed union or non-union.
Distal fibula fracture occurring with distal tibia fracture poses a challenge for stable fixation. This has necessitated the need for dual incisions on the distal leg to approach each fracture for reduction and fixation. However, a single anterolateral incision enables the safe approach to the lateral aspects of the distal tibia and fibula thus eliminating the need for two separate incisions and minimizing the soft tissue complication to some extent. Meanwhile, the neurovascular bundle at risk during operation, distal tibia and fibula is clearly exposed in the single anterior-lateral incision.
PMCID: PMC3828491  PMID: 24121655
Fracture; Distal tibia; Distal fibula; Anatomy; Incision
6.  Subtrochanteric shortening osteotomy combined with cemented total hip arthroplasty for Crowe group IV hips 
Total hip arthroplasty (THA) is a challenging surgical procedure that can be used to treat severely dislocated hips. There are few reports regarding cemented THAs involving subtrochanteric shortening osteotomy (SSO), even though cemented THAs provide great advantages because the femur is generally hypoplastic with a narrow, deformed canal.
We evaluated the utility of cemented THA with SSO for Crowe group IV hips, and assessed the relationship between leg lengthening and nerve injury. Our goal was to describe surgical techniques for optimizing surgical outcomes while minimizing the risk of nerve injury.
We retrospectively reviewed 34 cases of cemented THAs with transverse SSO for Crowe group IV. Prior to surgery, mean hip flexion was 93.1° (40°–130°). The mean follow-up period was 5.2 years (3–10 years).
Bone union took an average of 7.7 months (3–24 months). Mean leg lengthening was 40.5 mm (15–70 mm) and was greater in patients without hip flexion contracture. None of the patients experienced any nerve injuries associated with leg lengthening, and radiographic evidence of loosening was not observed at the final follow-up.
SSO combined with cemented THA is an effective treatment for severely dislocated hips. Leg lengthening is not necessarily associated with nerve injuries, and the likelihood of this surgical complication may be related to the presence of hip flexion contracture.
PMCID: PMC3886399  PMID: 24121623
Subtrochanteric shortening osteotomy; Cemented total hip arthroplasty; Crowe group IV; Leg lengthening; Nerve injury
7.  Proximal radioulnar translocation associated with elbow dislocation and radial neck fracture in child: a case report and review of literature 
Proximal radioulnar translocation with radial neck fracture and elbow dislocation is extremely rare. We report a case of a 5-year-old boy who was presented with elbow dislocation, and proximal radioulnar translocation was diagnosed a day after the injury. Mini-open technique was used to reduce the translocation and radial neck fracture. The patient finally regained full range of elbow motion and forearm rotation. This case had clinical importance in that the reverse instability of the elbow was observed compared with the previous reports.
PMCID: PMC3776268  PMID: 23884463
Radioulnar translocation; Radial neck fracture; Elbow dislocation; Mini-open reduction; Child
8.  Preoperative radiographic and histopathologic evaluation of central chondrosarcoma 
Distinguishing grade 1 chondrosarcoma from grade 2 chondrosarcoma is critical both for planning the surgical procedure and for predicting the outcome. We aimed to review the preoperative radiographic and histologic findings, and to evaluate the reliability of preoperative grading.
We retrospectively reviewed the medical records of 17 patients diagnosed with central chondrosarcoma at our institution between 1996 and 2011. In these cases, we compared the preoperative and postoperative histologic grades, and evaluated the reliability of the preoperative histologic grading. We also assessed the preoperative radiographic findings obtained using plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).
Preoperative histologic grade was 1 in 12 patients, 2 in 4 patients, and 3 in 1 patient. However, 6 of the 12 cases classified as grade 1 before surgery were re-classified as grade 2 postoperatively. In the radiographic evaluation, grade 1 was suspected by the presence of a ring-and-arc pattern of calcification on plain radiography and CT and entrapped fat and ring-and-arc enhancement on MRI. Grades 2 and 3 were suspected by the absence of calcification and the presence of cortical penetration and endosteal scalloping on plain radiography and CT, as well as soft-tissue mass formation on MRI.
Although the combination of radiographic interpretation and histologic findings may improve the accuracy of preoperative grading in chondrosarcoma, the establishment of a standard evaluation system with the histologic and radiographic findings and/or the development of new biologic markers are necessary for preoperative discrimination of low-grade chondrosarcoma from high-grade chondrosarcoma.
PMCID: PMC3751216  PMID: 23820853
Chondrosarcoma; Imaging features; Histopathology; Surgical staging
9.  Treatment of acute ankle ligament injuries: a systematic review 
Lateral ankle sprains are common musculoskeletal injuries.
The objective of this study was to perform a systematic literature review of the last 10 years regarding evidence for the treatment and prevention of lateral ankle sprains.
Data source
Pubmed central, Google scholar.
Study eligibility criteria
Meta-analysis, prospective randomized trials, English language articles.
Surgical and non-surgical treatment, immobilization versus functional treatment, different external supports, balance training for rehabilitation, balance training for prevention, braces for prevention.
A systematic search for articles about the treatment of lateral ankle sprains that were published between January 2002 and December 2012.
Three meta-analysis and 19 articles reporting 16 prospective randomized trials could be identified. The main advantage of surgical ankle ligament repair is that objective instability and recurrence rate is less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. For non-surgical treatment, long-term immobilization should be avoided. For grade III injuries, however, a short period of immobilization (max. 10 days) in a below knee cast was shown to be advantageous. After this phase, the ankle is most effectively protected against inversion by a semi-rigid ankle brace. Even grades I and II injuries are most effectively treated with a semi-rigid ankle brace. There is evidence that treatment of acute ankle sprains should be supported by a neuromuscular training. Balance training is also effective for the prevention of ankle sprains in athletes with the previous sprains. There is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.
Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest re-sprain rate.
PMCID: PMC3718986  PMID: 23712708
Chronic ankle instability; Ankle brace; External support; Surgical treatment; Balance training
10.  Impact of concomitant injuries on outcomes after traumatic brain injury 
Patients with traumatic brain injury (TBI) frequently have concomitant injuries; we aimed to investigate their impact on outcomes.
Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Patients who survived until intensive care unit (ICU) admission and had survivable TBI were selected, and were assigned to “isolated TBI” or “TBI + injury” groups. Six-month outcomes were classified as “favorable” if Glasgow Outcome Scale (GOS) scores were five or four, and were classified as “unfavorable” if GOS scores were three or less. Univariate statistics (Fisher’s exact test, t test, χ2-test) and logistic regression were used to identify factors associated with hospital mortality and unfavorable outcome.
Of the 767 patients, 403 (52.5 %) had isolated TBI, 364 (47.5 %) had concomitant injuries. Patients with isolated TBI had higher mean age (53 vs. 44 years, P = 0.001); hospital mortality (30.0 vs. 27.2 %, P = 0.42) and rate of unfavorable outcome (50.4 vs. 41.8 %, P = 0.02) were higher, too. There were no significant mortality differences for factors like age groups, trauma mechanisms, neurologic status, CT findings, or treatment factors. Concomitant injuries were associated with higher mortality (33.3 vs. 12.5 %, P = 0.05) in patients with moderate TBI, and were significantly associated with more ventilation, ICU, and hospitals days. Logistic regression revealed that age, Glasgow Coma Scale score, pupillary reactivity, severity of TBI and CT score were the main factors that influenced outcomes.
Concomitant injuries have a significant effect upon the mortality of patients with moderate TBI. They do not affect the mortality in patients with severe TBI.
Level of evidence and study type
Evidence level 2; prospective, observational prognostic study.
PMCID: PMC3631113  PMID: 23463257
Traumatic brain injury; Outcome; Concomitant injuries
11.  Meniscus suture provides better clinical and biomechanical results at 1-year follow-up than meniscectomy 
Surgery of meniscus tear results in limitation of function. The aim of study was functional assessment of knee 1 year after surgery with two techniques in cases of the medial meniscus tear followed by the same supervised rehabilitation.
Materials and methods
A total of 30 patients with good KOSS scores constituted two equal groups after partial meniscectomy or meniscus suture. Measurements of knee extensors and flexors muscles peak torques were performed with angular velocities 60, 180, 240 and 300 s−1 using Biodex IV system. One-leg-hop and one-leg-rising tests ascertained the function of operated knee. Results of examinations were compared with reference to healthy volunteers. Results of biomechanical and clinical studies were correlated to create complex and objective method evaluating treatment.
Extensors peak torque values at 60 s−1 angular velocity and H/Q coefficient were decreased after meniscectomy more than meniscus suture in comparison to healthy volunteers (P ≤ 0.001; P ≤ 0.05). Analysis of functional tests revealed that patients after meniscectomy showed difference between operated and non-operated knee (P ≤ 0.01) while patients with meniscus suture differed the least to controls (P ≤ 0.05). Extensors peak torque values at 60 s−1 angular velocity correlated with results of one-leg-rising test.
Results suggest worse functional effects when meniscectomy is applied which implies modification of the rehabilitative methods in a postoperative period.
PMCID: PMC3600124  PMID: 23371398
Meniscectomy; Meniscus suture; Peak torque; One-leg-hop and one-leg-rising tests; H/Q coefficient; Supervised rehabilitation
12.  Shortening spinal column reconstruction through posterior only approach for the treatment of unstable osteoporotic burst lumber fracture: a case report 
Study design
Case report.
Clinical question
This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture.
An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages.
The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication.
Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.
PMCID: PMC3550702  PMID: 23179477
Osteoporotic fracture; Posterior corpectomy; Shortening reconstruction; Unstable burst fracture; Thoracolumbar fracture
13.  Outcome of Autologous Matrix Induced Chondrogenesis (AMIC) in cartilage knee surgery: data of the AMIC Registry 
Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment for localized full-thickness cartilage defects combining the well-known microfracturing with collagen I/III scaffold. The purpose of this analysis was to evaluate the medium-term results of this enhanced microfracture technique for the treatment of chondral lesions of the knee.
Methods and materials
Patients treated with AMIC (Chondro-Gide®, Geistlich Pharma, Switzerland) were followed using the AMIC Registry, an internet-based tool to longitudinally track changes in function and symptoms by the Lysholm score and VAS.
A series of 57 patients was enrolled. The average age of patients (19 females, 38 males) was 37.3 years (range 17–61 years). The mean defect size of the chondral lesions was 3.4 cm2 (range 1.0–12.0 cm2). All defects were classified as grade III (n = 20) or IV (n = 37) according to the Outerbridge classification. Defects were localized at the medial (n = 32) or lateral (n = 6) condyle, at the trochlea (n = 4) and at the patella (n = 15). The follow-up period was 2 years. The majority of patients were satisfied with the postoperative outcome, reporting a significant decrease of pain (mean VAS preop = 7.0; 1 year postop = 2.7; 2 years postop = 2.0). Significant improvement of the mean Lysholm score was observed as early as 1 year after AMIC and further increased values were noted up to 2 years postoperatively (preop. 50.1, 1 year postop. 79.9, 2 year postop. 85.2).
AMIC is an effective and safe method of treating symptomatic chondral defects of the knee. However, further studies with long-term follow-up are needed to determine if the grafted area will maintain structural and functional integrity over time.
Level of evidence
Prognostic study, Level IV.
PMCID: PMC3535369  PMID: 23070222
AMIC; Cartilage; Knee; Surgery; Lysholm score
14.  Osteochondral autograft transplantation for malunited intra-articular fracture of the proximal interphalangeal joint: a case report 
Malunited intra-articular fracture of the proximal inter-phalangeal (PIP) joint sometimes causes problems, such as range of motion (ROM) limitation in the joint or lack of digital dexterity; however, the treatment method has not yet been established. We report a juvenile case of osteochondral autograft tranplantation to treat a malunited intra-articular fracture of the middle finger.
Case report
A 14-year-old boy was injured at the right middle finger by a baseball impact and underwent conservative treatment. At 5 months after the injury, he complained of continuing pain and restricted ROM. Plain X-ray and CT images showed a bony defect in the articular surface of the PIP joint of the right middle finger. He was diagnosed with malunited intra-articular fracture of the PIP joint and underwent surgical treatment. First, through a palmar incision, a columnar-shaped drill hole was made at the recipient site of osteochondral defect. Then a cylindrical osteochondral plug, 4.5 mm in diameter, harvested from the knee, was inserted into the recipient hole and press-fitted. One year after surgery, the patient has neither pain nor ROM limitation of the finger and the knee joint. MRI showed smooth articular surface of the PIP joint.
The benefits of our method include use of articular cartilage as a reconstruction material, availability for a relatively large cartilage defect, and stability of the autograft for the press-fitting method, which enable early mobilization exercise after surgery.
PMCID: PMC3535410  PMID: 23070223
Proximal interphalangeal joint; Knee; Malunion; Osteochondral autograft transplantation
15.  Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay 
To investigate fast-track rehabilitation concept in terms of a measurable effect on the early recovery after total knee arthroplasty (TKA).
This was an open, randomized, prospective clinical study, comparing the fast-track rehabilitation—a pathway-controlled early recovery program (Joint Care®)—with standard postoperative rehabilitation care, after TKA. Overall, 147 patients had TKA (N = 74 fast-track rehabilitation,N = 73 standardrehabilitation). The fast-track rehabilitation patients received a group therapy, early mobilization (same day as surgery) and 1:1 physiotherapy (2 h/day). Patient monitoring occurred over 3 months (1 pre- and 4 post-operative visits). The standard rehabilitation group received individual postoperative care according to the existing protocol, with 1:1 physiotherapy (1 h/day). The cumulative American Knee Society Score (AKSS) was the primary evaluation variable, used to detect changes in joint function and perception of pain. The secondary evaluation variables were WOMAC index score, analgesic drug consumption, length of stay (LOS), and safety.
After TKA, patients in the fast-track rehabilitation group showed enhanced recovery compared with the standardrehabilitation group, as based on the differences between the groups for the cumulative AKSS (p = 0.0003), WOMAC index score (<0.0001), reduced intake of concomitant analgesic drugs, reduced LOS (6.75 vs. 13.20 days, p < 0001), and lower number of adverse events.
For TKA, implementation of pathway-controlled fast-track rehabilitation is achievable and beneficial as based on the AKSS and WOMAC score, reduced intake of analgesic drugs, and reduced LOS.
PMCID: PMC3400756  PMID: 22643801
AKSS score; Fast-track rehabilitation; Controlled pathway; Total knee arthroplasty; TKA; WOMAC score
16.  A new method to measure ligament balancing in total knee arthroplasty: laxity measurements in 100 knees 
Ligament balancing is considered a prerequisite for good function and survival in total knee arthroplasty (TKA). However, there is no consensus on how to measure ligament balance intra-operatively and the degree of stability obtained after different balancing techniques is not clarified.
This study presents a new method to measure ligament balancing in TKA and reports on the results of a try-out of this method and its inter-observer reliability.
After the implantation of the prosthesis, spatulas of different thickness were used to measure medial and lateral condylar lift-off in flexion and extension in 70 ligament-balanced knees and in 30 knees were ligament balancing was considered unnecessary. Inter-observer reliability for the new method was estimated and the degree of medial–lateral symmetry in extension and in flexion, and the equality of the extension gaps and flexion gaps were calculated.
The method was feasible in all operated knees, and found to be very reliable (intraclass correlation coefficient = 0.88). We found no statistically significant difference in condylar lift-off between the ligament-balanced and the non ligament-balanced group, however, there was a tendency to more outliers in flexion in the ligament-balanced group.
Our method for measuring ligament balance is reliable and provides valuable information in assessing laxity intra-operatively. This method may be a useful tool in further research on the relationship between ligament balance, function and survival of TKA.
PMCID: PMC3400753  PMID: 22581351
Total knee arthroplasty; Ligament balance; Soft tissue balance; Flexion–extension gap; Surgical technique; Equipment design
17.  Contralateral hip fractures and other osteoporosis-related fractures in hip fracture patients: incidence and risk factors. An observational cohort study of 1,229 patients 
To report risk factors, 1-year and overall risk for a contralateral hip and other osteoporosis-related fractures in a hip fracture population.
An observational study on 1,229 consecutive patients of 50 years and older, who sustained a hip fracture between January 2005 and June 2009. Fractures were scored retrospectively for 2005–2008 and prospectively for 2008–2009. Rates of a contralateral hip and other osteoporosis-related fractures were compared between patients with and without a history of a fracture. Previous fractures, gender, age and ASA classification were analysed as possible risk factors.
The absolute risk for a contralateral hip fracture was 13.8 %, for one or more osteoporosis-related fracture(s) 28.6 %. First-, second- and third-year risk for a second hip fracture was 2, 1 and 0 %. Median (IQR) interval between both hip fractures was 18.5 (26.6) months. One-year incidence of other fractures was 6 %. Only age was a risk factor for a contralateral hip fracture, hazard ratio (HR) 1.02 (1.006–1.042, p = 0.008). Patients with a history of a fracture (33.1 %) did not have a higher incidence of fractures during follow-up (16.7 %) than patients without fractures in their history (14 %). HR for a contralateral hip fracture for the fracture versus the non-fracture group was 1.29 (0.75–2.23, p = 0.360).
The absolute risk of a contralateral hip fracture after a hip fracture is 13.8 %, the 1-year risk was 2 %, with a short interval between the 2 hip fractures. Age was a risk factor for sustaining a contralateral hip fracture; a fracture in history was not.
PMCID: PMC3400761  PMID: 22526197
Hip fracture; Contralateral; Bilateral; Osteoporosis; Risk factors
18.  Cervical lateral mass screw fixation without fluoroscopic control: analysis of risk factors for complications associated with screw insertion 
To examine the outcome of cervical lateral mass screw fixation focusing on analysis of the risk factors for screw-related complications.
Ninety-four patients who underwent posterior cervical fixation with a total of 457 lateral mass screws were included in the study. The lateral mass screws were placed using a modified Magerl method. Computed tomographic (CT) images were taken in the early postoperative period in all patients, and the screw trajectory angle was measured on both axial and sagittal plane images.
In the postoperative CT analysis for the screw trajectory, 56.5 % of the screws were directed within the acceptable range (within 21–40° on both axial and sagittal planes). As intraoperative screw-associated complications, 9.6 % of the screws were found to contact with or breach the vertebral artery foramen. In this group, the screw trajectory angle on axial plane was significantly lower than in the group without contact. Facet violation was observed in 13 screws (2.8 %). This complication was associated with a significantly lower trajectory angles in the sagittal plane, predominantly at C6 level (69.2 %). In the patient chart review, no serious neurovascular injuries were documented.
In the analysis of potential risk factors for violation of the VA foramen as well as FV during screw insertion, the former incidence was significantly related to the screw trajectory angle (lack of lateral angulation) in the axial plane, while the latter incidence was related to a poor screw trajectory angle in the sagittal plane.
PMCID: PMC3376780  PMID: 22460351
Lateral mass; Cervical spine; Posterior fixation; Complications
19.  Closing the medullary canal after retrograde nail removal using a bioabsorbable bone plug: technical tip 
We describe a simple technique for closure of the intra-articular opening after the removal of a retrograde femur nail. With the use of a gelatine bioabsorbable bone plug the medullary canal is closed, reducing leakage of blood and cancellous bone particles from the bone into the knee joint.
PMCID: PMC3356512  PMID: 22350056
Implant removal; Retrograde nail; Hemarthrosis knee; Bone plug
20.  Risk factors for failure to return to the pre-fracture place of residence after hip fracture: a prospective longitudinal study of 444 patients 
Long-term place of residence after hip fracture is not often described in literature. The goal of this study was to identify risk factors, known at admission, for failure to return to the pre-fracture place of residence of hip fracture patients in the first year after a hip fracture.
This is a prospective longitudinal study of 444 consecutive admissions of hip fracture patients aged ≥65 years. Place of residence prior to admission, at discharge, after 3 and 12 months was registered. Patients admitted from a nursing home (n = 49) were excluded from statistical analysis. Multivariable logistic regression analysis was performed, using age, gender, presence of a partner, ASA-score, dementia, anaemia at admission, type of fracture, pre-fracture level of mobility and level of activities of daily living (ADL) as possible risk factors.
Two hundred eighty-nine patients lived in their own home, 31.8% returned at discharge, 72.9% at 3 months and 72.8% at 12 months. Age, absence of a partner, dementia, and a lower pre-fracture level of ADL or mobility were independent contributors to failure to return to their own home at discharge, 3 or 12 months. 106 patients lived in a residential home; 33.3% returned at discharge, 68.4% at 3 months and 64.4% at 12 months. Age was an independent contributor to failure to return to a residential home.
Age, dementia and a lower pre-fracture level of ADL were the main significant risk factors for failure to return to the pre-fracture residence. As the 3- and 12-month return-rates were similar, 3-month follow-up might be used as an endpoint in future research.
PMCID: PMC3356520  PMID: 22311748
Hip fracture; Place of residence; Risk factors; Longitudinal
21.  Systematic review of the complications of plate fixation of clavicle fractures 
The number of displaced midshaft clavicle fractures treated surgically is increasing and plate fixation is often the treatment modality of choice. The study quality and scientific levels of evidence at which possible complications of this treatment are presented vary greatly in literature.
The purpose of this systematic review is to assess the prevalence of complications concerning plate fixation of dislocated midshaft clavicle fractures.
A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Studies included for review reported complications after plate fixation alone or in comparison to either treatment with intramedullary pin fixation and/or nonoperative treatment. Two quality assessment tools were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence.
After study selection and reading of the full texts, 11 studies were eligible for final quality assessment. Nonunion and malunion rates were less than 10% in all analysed studies but one. The vast majority of complications seem to be implant related, with irritation or failure of the plate being consistently reported on in almost every study, on average ranging from 9 to 64%.
The quantity of relevant high evidence studies is low. With low nonunion and malunion rates, plate fixation can be a safe treatment option for acute dislocated midshaft clavicle fractures, but complications related to the implant material requiring a second operation are frequent. Future prospective trials are needed to analyse the influence of various plate types and plate position on implant-related complications.
PMCID: PMC3332382  PMID: 22237694
Review; Plate fixation; Midshaft dislocated clavicle fractures; Complications; Medicine & Public Health; Orthopedics
22.  Predictors of functional outcome following femoral neck fractures treated with an arthroplasty: limitations of the Harris hip score 
To study the association between potential prognostic factors and functional outcome at 1 and 5 year follow-up in patients with femoral neck fractures treated with an arthroplasty. To analyze the reliability of the Harris hip score (HHS).
Materials and methods
A multicenter analysis which included 252 patients who sustained a femoral neck fracture treated with an arthroplasty. Functional outcome after surgery was assessed using a modified HHS and was evaluated after 1 (HHS1) and 5 (HHS5) years. Several prognostic factors were analyzed and reliability of the HHS was assessed.
After 1 year the presence of co-morbidities was a significant (p = 0.002) predictor for a poor functional outcome (mean HHS1 71.8 with co-morbidities, and 80.6 without co-morbidities). After 5 years none of the potential prognostic factors had significant influence on functional outcome. Internal consistency testing of the HHS showed that when pain and function of the HHS were analyzed together, the internal consistency was poor (HHS1 0.38 and HHS5 0.20). The internal consistency of the HHS solely in function (without pain) improved to 0.68 (HHS1) and 0.46 (HHS5). Analyzing the functional aspect exclusively, age and the existence of co-morbidities could be defined as predictors for functional outcome of femoral neck fractures after 1 and 5 years.
After using the HHS in a modification, age and the existence of pre-operative co-morbidities appeared to be predictors of the functional outcome after 1 and 5 years. The HHS, omitting pain, is a more reliable score to estimate the functional outcome, than HHS analyzing pain and function in one scoring system.
PMCID: PMC3261383  PMID: 22113433
Femoral neck fracture; Arthroplasty; Functional outcome; Predictors; Harris hip score
23.  Cementless total hip arthroplasty in rheumatoid arthritis: a systematic review of the literature 
Compromised rheumatic bone is a potential risk factor for mechanical complications in cementless total hip arthroplasty (THA) in cases of rheumatoid arthritis (RA). Increased rates of intra-operative fractures, component migration and (early) aseptic loosening are to be expected. Despite this, cementless THA is performed in cases of RA.
A literature search on cementless THA in RA was performed in EMBASE (1993–2011), Medline (1966–2011) and the Cochrane Library. A systematic review was conducted with a special emphasis on mechanical complications.
Twenty-three case series and five studies of implant registries were included. Acetabular fractures and/or migration of the cup were reported in 9 out of 22 studies of the cup. Proximal femoral fractures and/or subsidence of the stem were reported in 14 out of 20 studies of the stem. Six studies compared failure rates of uncemented and cemented components due to aseptic loosening. The overall failure rate ratio (uncemented/cemented) for the cup was 0.6 (95% CI: 0.14–2.60) and for the stem 0.71 (95% CI: 0.06–8.55), both favoring uncemented fixation. The failure rates in case series without a control group were compared to the NICE criteria (failure rate/1). The overall failure rate for the cup was 0.97 (95% CI: 0.50–1.88) and for the stem 0.79 (95% CI: 0.44–1.41). Failure rates of aseptic loosening of higher than 1 (favoring cemented fixation) were reported in 6 out of 26 studies of the cup and in 2 out of 25 studies of the stem. In all these studies, the inferior implant designs were blamed, and not the type of fixation or the quality of the bone.
Despite substantial rates of mechanical stem complications, no evidence was found to establish that cementless components perform less well than cemented components. The results justify the use of cementless THA in RA patients.
PMCID: PMC3306565  PMID: 22113434
Rheumatoid arthritis; Total hip arthroplasty; Cementless; Uncemented; Review
24.  Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures 
Treatment of ankle fractures is often based on fracture type and surgeon’s individual judgment. Literature concerning the treatment options and outcome are dated and frequently contradicting. The aim of this study was to determine the clinical and functional outcome after AO-Weber B-type ankle fractures in operatively and conservatively treated patients and to determine which factors influenced outcome.
Patients and methods
A retrospective cohort study in patients with a AO-Weber B-type ankle fracture. Patient, fracture and treatment characteristics were recorded. Clinical and functional outcome was measured using the Olerud–Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS) and a Visual Analog Score (VAS) for overall satisfaction (range 0–10).
Eighty-two patients were treated conservatively and 103 underwent operative treatment. The majority was female. Most conservatively treated fractures were AO-Weber B1.1 type fractures. Fractures with fibular displacement (mainly AO type B1.2 and Lauge-Hansen type SER-4) were predominantly treated operatively. The outcome scores in the non-operative group were OMAS 93, AOFAS 98, and VAS 8. Outcome in this group was independently negatively affected by age, affected side, BMI, fibular displacement, and duration of plaster immobilization. In the surgically treated group, the OMAS, AOFAS, and VAS scores were 90, 97, and 8, respectively, with outcome negatively influenced by duration of plaster immobilization.
Treatment selection based upon stability and surgeon’s judgment led to overall good clinical outcome in both treatment groups. Reducing the cast immobilization period may further improve outcome.
PMCID: PMC3261401  PMID: 21959696
Ankle; Fracture; Outcome; Operative; Non-operative
25.  Interdisciplinary inter-observer agreement and accuracy of MR imaging of the shoulder with arthroscopic correlation 
Differences between radiologists and orthopaedic surgeons in the interpretation of MR images of the shoulder joint are experienced in daily clinical practice. This study set out to evaluate the inter-observer agreement between radiologists and orthopaedic surgeons in assessing pathology on MR imaging of the shoulder joint. Also, we determined the accuracy of the observers with arthroscopy as the standard of reference.
Materials and methods
Two radiologists and one orthopaedic surgeon reviewed 50 MR studies—25 conventional MR examinations and 25 MR arthrographies—of patients with shoulder complaints who had undergone MR imaging and subsequently arthroscopic surgery. The assessment was independent and blinded. All observers evaluated the MR examinations twice. Standard evaluation forms were used to score for pathology of rotator cuff, glenoid labrum, tendon of the long head of the biceps brachii and glenohumeral ligaments. The presence or absence of osteoarthritis, SLAP lesions, Bankart lesions, Hill-Sachs lesions or impingement was also noted. Intra- and inter-observer agreement, the sensitivity and specificity were calculated. Differences in percentages of correctly diagnosed lesions were tested for significance using McNemar’s test.
There was a poor inter-observer agreement between the orthopaedic surgeon and the radiologists in assessing Bankart lesions and ligamentous lesions. We found significant differences between the radiologists and the orthopaedic surgeon in the assessment of osteoarthritis, Hill-Sachs lesions and impingement.
The orthopaedic surgeon and radiologists differed in their interpretation of what defines a Bankart lesion and what defines a ligamentous lesion. The orthopaedic surgeon was significantly more accurate in assessing impingement.
PMCID: PMC3282007  PMID: 21842285
Inter-observer agreement; Accuracy; Orthopaedic surgeons; Radiologists; Shoulder joint; MR imaging

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