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2.  Trends in epidemiology and patho-anatomical pattern of proximal humeral fractures 
International Orthopaedics  2014;38(8):1697-1704.
Purpose
Proximal humeral fractures are common and frequently associated with osteoporosis. Little is known about the association between the patho-anatomical fracture pattern of proximal humeral fractures and patient characteristics. The purpose of this six year longitudinal registry analysis of proximal humeral fractures was to study overall numbers, certain predefined pathoanatomical patterns and distribution compared with specific patient characteristics.
Methods
Data of patients treated between 2006 and 2011 in a country hospital that provides care >95 % of the city’s hospitalised patients with fractures was retrospectively reviewed. Data were analysed according to patient characteristics of age, gender, comorbidity, accompanying injuries and radiological analysis of pathoanatomical fracture patterns based on Neer and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification.
Results
Eight hundred and fifteen proximal humeral fractures (67 % women/33 % men; mean age 66 years, range 19–99) were analysed. During the study period, an overall increase of 42.5 % was found: according to AO classification, 46 % were type A, 22 % type B and 32 % type C. Based on the Neer classification, 86 % were displaced, and 49 % were complex with more than three parts. Of complex fractures, 57 % were female patients >60 years. The number of complex fractures was five times higher in women >60 years than in men of the same age group.
Conclusions
An overall increase of inpatients with displaced proximal tibial fractures was documented. Interestingly, complex displaced proximal humeral fractures, especially in older women with comorbidities, accounted for the majority of cases. These results suggest that health-care planning and hospital-based therapeutic strategies should focus on this patient group.
doi:10.1007/s00264-014-2362-6
PMCID: PMC4115093  PMID: 24859897
Epidemiology; Proximal humeral fractures; Proximal humerus fractures; Shoulder fractures; Classification; Neer; AO; OTA
3.  Clinical importance of impingement deformities for hip osteoarthritis progression in a Japanese population 
International Orthopaedics  2014;38(8):1609-1614.
Purpose
Femoroacetabular impingement is a new disease concept for hip disorders in young adults suggested as a major cause of primary hip osteoarthritis in Western countries. However, significant controversy exists regarding the prevalence and contribution of impingement deformities to osteoarthritis in Japan, owing to the higher prevalence of developmental dysplasia of the hip. Therefore, the aims of this study were to: (1) determine the prevalence of structural abnormalities associated with hip disorders in patients undergoing total hip replacement and (2) analyse the contribution of impingement deformities to osteoarthritis.
Methods
We analysed 250 patients from two different medical centres who underwent primary total hip replacement except those which were due to femoral head necrosis, posttraumatic osteoarthritis and systemic inflammatory disease. The average patient age at surgery was 64 years (range, 40–89 years), with 35 men and 215 women.
Results
Radiographic abnormality related to developmental dysplasia of the hip was associated with the majority of osteoarthritic hips (62 %). Hips with femoroacetabular impingement deformities were present within the cases categorized as unknown etiology. Cam impingement deformity was present in 22 % of unknown aetiology cases when cases with reactive osteophytes were excluded from all cam deformity cases (pistol grip deformity and aspherical femoral heads).
Conclusions
The prevalence of femoroacetabular impingement within primary osteoarthritis cases and gender predominance of impingement deformities are relatively similar to those reported previously in Western populations. This finding indicates that femoroacetabular impingement deformities are associated with osteoarthritis in the Japanese population, although it has a lower frequency among all hip failure patients.
doi:10.1007/s00264-014-2393-z
PMCID: PMC4115094  PMID: 24943460
Osteoarthritis of the hip; Developmental dysplasia of the hip; Femoroacetabular impingement; Cam impingement; Pincer impingement
4.  Are our expectations bigger than the results we achieve? A comparative study analysing potential advantages of ankle arthroplasty over arthrodesis 
International Orthopaedics  2014;38(8):1647-1653.
Purpose
Prior studies have reported improved gait performance and kinematics after total ankle arthroplasty (TAR) compared to ankle arthrodesis (AAD). Given these findings, AAD has been primarily considered as a salvage procedure that may lead to adjacent joint degeneration.
Methods
A total of 101 TAR and 40 screw arthrodeses were enrolled in a retrospective study with a prospectively designed follow-up examination that included gait analysis and outcome assessment with the AOFAS hindfoot score and FAOS questionnaire.
Results
Significant asymmetry in gait and reduced range of motion compared to normal remained after both procedures. Subjective outcome improved after both procedures, and pain was significantly better after TAR. Limited functional gains after TAR and joint degeneration to the same degree after both procedures was seen in the mid-term. Hindfoot fusion seemed to have a greater impact on postoperative function than ankle arthrodesis.
Conclusion
Considering only minor functional gains of TAR compared to AAD the implantation of current TAR designs in large patient series may be questioned.
doi:10.1007/s00264-014-2428-5
PMCID: PMC4115095  PMID: 24984596
Total ankle arthroplasty; Ankle arthrodesis; Comparative analysis; Gait analysis; Clinical outcome
5.  Better results with patelloplasty compared to traditional total knee arthroplasty 
International Orthopaedics  2014;38(8):1621-1625.
Purpose
The aim of this study was to compare the results of primary total knee arthroplasty with or without patelloplasty.
Methods
We retrospectively reviewed 89 patients who had received total knee arthroplasty. In patelloplasty, the patellar cartilage was resected using a tangential saw cut, and in the traditional treatment, only the surrounding osteophytes were removed. The outcome was measured using radiographs, Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, Knee Society Score, Knee Society Function Score and Knee Society Pain Score.
Results
Patelloplasty patients had a better outcome according to the Oxford Knee Score (P = 0.012), Knee Injury and Osteoarthritis Outcome Score (P = 0.003) and all of the Knee Injury and Osteoarthritis Outcome Score subscales (P < 0.05). The patella was significantly thinner (P = 0.001) post-operatively in the patelloplasty patients, but there was no statistically significant correlation between Oxford Knee Score or Knee Injury and Osteoarthritis Outcome Score and post-operative patellar thickness in the patelloplasty group.
Conclusions
In this follow-up, patelloplasty was better than traditional treatment in relieving pain and improving function and quality of life.
doi:10.1007/s00264-014-2366-2
PMCID: PMC4115096  PMID: 24848970
Knee; Patella; Patelloplasty; Total knee arthroplasty
6.  Temporary and definitive external fixation of war injuries: use of a French dedicated fixator 
International Orthopaedics  2014;38(8):1569-1576.
Purpose
External fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx© (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years.
Methods
The tactics of Percy Fx© (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad.
Results
Overall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad.
Conclusion
Temporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.
doi:10.1007/s00264-014-2305-2
PMCID: PMC4115097  PMID: 24615547
External fixation; War trauma; Damage control orthopaedic; Combat
7.  External fixators and sudden-onset disasters: Médecins Sans Frontières experience 
International Orthopaedics  2014;38(8):1551-1554.
Purpose
Carrying out osteosynthesis is challenging, and controlling for results and complications is necessary to define the limits of acceptable complications. Within the context of sudden-onset disasters, comparing internal with external osteosynthesis remains controversial.
Methods
The most recent and significant Médecins Sans Frontières (MSF) experience with osteosynthesis was following the earthquake in Haiti in 2010: 353 external fixators were used in the 12 months following the catastrophe, 62 of which were used in the first month. Carrying out internal osteosynthesis was possible two weeks following the earthquake.
Results
The most common indication for open tibial fracture was Gustillo grade 2 or 3. Conversion rate from external to internal osteosynthesis remains anecdotal for several practical reasons. Advantages and drawbacks of external fixators are discussed in the context of precarious situations frequently encountered by MSF.
Conclusions
External osteosynthesis as a primary and definitive treatment for open fractures, especially of the leg, remains the most frequently used and best-adapted procedure in the context of sudden-onset disasters, even though not ideal.
doi:10.1007/s00264-014-2344-8
PMCID: PMC4115098  PMID: 24817021
External fixation; Sudden-onset disaster; Humanitarian surgery
8.  Genetic polymorphisms of interleukin-1 beta and osteosarcoma risk 
International Orthopaedics  2014;38(8):1671-1676.
Purpose
Osteosarcoma is the most common childhood bone cancer. Interleukin-1 beta (IL-1B) is crucially involved in osteosarcoma carcinogenesis. Whether genetic polymorphisms of IL-1B also influence osteosarcoma risk is unknown. The aim of this study was to investigate the association between IL-1B gene polymorphisms and osteosarcoma risk in Chinese Han patients.
Methods
A hospital-based case–control study involving 120 osteosarcoma patients and 120 controls was conducted. Polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) analysis was performed to detect three IL-1B gene polymorphisms (−31 T/C, −511 C/T and +3954 C/T) in these patients.
Results
Patients with osteosarcoma had a significantly lower frequency of −31 CC genotype [odds ratio (OR) = 0.40, 95 % confidence interval (CI) = 0.17–0.92; P = 0.03] and −31 C allele (OR = 0.67, 95 % CI = 0.46–0.99; P = 0.04) than controls. Patients with osteosarcoma had a significantly lower frequency of −511 TT genotype (OR = 0.40, 95 % CI = 0.17–0.95; P = 0.04) than controls. The +3954 C/T gene polymorphisms were not associated with a risk of osteosarcoma. When stratified by Enneking stage, tumour location, histological type, tumour metastasis of osteosarcoma and family history of cancer, no statistically significant results were found.
Conclusions
This is the first study to provide evidence for an association of IL-1B gene polymorphisms with osteosarcoma risk.
doi:10.1007/s00264-014-2374-2
PMCID: PMC4115099  PMID: 24878968
Osteosarcoma; Interleukin-1 beta; Gene polymorphism; Hospital-based case–control study
9.  Bacterial adherence to different components of total hip prosthesis in patients with prosthetic joint infection 
International Orthopaedics  2014;38(8):1597-1602.
Purpose
The purpose of our study was to evaluate and quantify the bacterial adherence to the different components of total hip prosthesis.
Methods
The bacterial load of 80 retrieved hip components from 24 patients was evaluated by counting of colony-forming units (CFU) dislodged from component surfaces using the sonication culture method.
Results
Micro-organisms were detected in 68 of 80 explanted components. The highest bacterial load was detected on the polyethylene liners, showing a significant difference in distribution of CFU between the liner and metal components (stem and cup). Staphylococcus epidermidis was identified as the pathogen causing the highest CFU count, especially from the polyethylene liner.
Conclusions
Results of our study confirm that sonicate culture of the retrieved liners and heads, which revealed the highest bacterial loads, are reliable and sufficient for pathogen detection in the clinical diagnostic routine.
doi:10.1007/s00264-014-2358-2
PMCID: PMC4115100  PMID: 24817024
Total hip prosthesis; Periprosthetic joint infection; Sonication culture; Microbial biofilm; Bacterial adherence; Biomaterial
10.  Meta-analysis of randomised controlled trials comparing unipolar with bipolar hemiarthroplasty for displaced femoral-neck fractures 
International Orthopaedics  2014;38(8):1691-1696.
Purpose
Unipolar and bipolar hemiarthroplasty (HA) are used to treat displaced femoral-neck fractures. However, which type is best for treating displaced femoral-neck fractures in elderly patients remains a subject for debate. Our aim was to review randomised controlled trials to establish which type provides superior clinical outcome for this patient population.
Methods
We searched PubMed, Embase and Cochrane Register of Controlled Trials databases and Web of Science for randomised controlled trials (RCTs) comparing unipolar with bipolar HA to treat femoral-neck fracture in the elderly. Risk ratios (RRs) and mean differences (MDs) from each trial were pooled using random-effects or fixed-effects models depending on study heterogeneity. Analysis was performed using RevMan5.2 from the Cochrane Collaboration.
Results
A total of 1,100 patients from nine studies were assessed in this meta-analysis. Results showed no significant differences in function score [MD = −0.14, 95% confidence interval (CI) −2.42–2.13], mortality (RR = 0.97, 95% CI 0.65–1.46), dislocation (RR = 1.33, 95 % CI 0.53–3.34), deep infection (RR = 0.79, 95 % CI 0.35–1.79), acetabular erosion (RR = 1.99, 95 % CI 0.61–6.52), operating time (MD = 2.14, 95 % CI −9.85 to14.14), blood loss (MD = 13.40, 95 % CI −49.60 to 76.39) and length of hospital stay (MD = 0.12, 95 % CI −0.49to0.73) between unipolar and bipolar HA.
Conclusions
Unipolar and bipolar HA achieved similar clinical outcomes in patients with displaced femoral-neck fractures.
doi:10.1007/s00264-014-2355-5
PMCID: PMC4115101  PMID: 24817022
Unipolar; Bipolar; Hemiarthroplasty; Displaced femoral-neck fractures
11.  Iliac crest bone grafting: raising awareness of a common pitfall 
International Orthopaedics  2014;38(8):1753.
doi:10.1007/s00264-014-2404-0
PMCID: PMC4115103  PMID: 24957483
12.  Intramedullary repair device against volar plating in the reconstruction of extra-articular and simple articular distal radius fractures; a randomized pilot study 
International Orthopaedics  2014;38(8):1655-1660.
Purpose
This prospective randomized pilot study reports our institutional experience and early results using Sonoma Wrx (Sonoma Orthopedic Products, Santa Rosa, CA) in the treatment of extra-articular and simple intra-articular distal radius fractures.
Material and methods
A total of 64 patients, were enrolled in the study. They were considered eligible if they had; unstable extra-articular distal radius fractures and simple intra-articular distal radius fractures suitable for closed reduction (AO types; A2.2, A2.3, A3.1 C2.1, C2.2). Patients in group I received intramedullary fixation using the Sonoma Wrx® device and patients in group II received standard volar locking plate fixation. Radiographic criteria of acceptable healing were used for evaluation.
Results
Two groups were similar in terms of baseline characteristics. Mean time of operation was significantly shorter in Group 1 vs. in group 2 (36.81 ± 7.11 vs. 48.97 ± 5.9 minutes, p = 0.001). Time to healing of the fracture was not different between two groups (5.45 ± 1.09 vs. 5.70 ± 1.04 weeks for Group 1 vs. 2, respectively p = 0.36). Overall complications occurred in 9 patients in group 1 and in 15 patients in group 2 (p = 0.17). Follow-up was completed in all patients with a median time of 12 months and 13 months in group 1 and 2, respectively. On radiographic evaluation radial inclination, radial height and volar tilt were not significantly different between group 1 and 2, respectively. There were no significant differences between two groups in regard to wrist rotational degrees measured in last follow-up visit.
Conclusion
Sonoma Wrx Device is reliable and effective in terms of achieving satisfactory outcomes in treatment of distal radius fractures. It may be reasonable to use this device to prevent complications that are related to extensive soft tissue dissection.
doi:10.1007/s00264-014-2382-2
PMCID: PMC4115104  PMID: 24910215
Distal radial fracture; Intramedullary nail; Volar locking plate; Complications
13.  Targeted pre-operative autologous blood donation: a prospective study of two thousand and three hundred and fifty total hip arthroplasties 
International Orthopaedics  2014;38(8):1591-1595.
Purpose
Pre-operative donation of autologous blood has been widely used in elective joint replacement procedures to avoid the risks of allogeneic blood transfusions. However, the high percentage of wasted autologous blood questions the general efficacy of pre-operative autologous blood donation (PABD) for all patients undergoing hip replacement. This study prospectively investigates the impact of a targeted pre-operative autologous blood donation protocol for anaemic patients on allogeneic and overall transfusion rates in 2,350 unilateral primary total hip arthroplasty procedures.
Methods
Patients with pre-operative haemoglobin less than 12.5 g/dL were advised to donate one unit of autologous blood seven to 15 days prior to the date of surgery. The targeted protocol was followed by 2,251 patients: 280 out of 367 anaemic patients donated while 1,971 out of 1,983 non-anaemic patients did not donate.
Results
Results showed a significantly lower rate of allogeneic transfusion for anaemic patients who predonated than anaemic patients who did not (13 % vs. 37 % respectively, p < 0.001). Overall transfusion rates for patients who followed the protocol (n = 2,251) were found to be 0.17 units/patient compared to previously reported numbers of 0.75 units/patient when routine donation was used. Among the 2,251 patients who followed the protocol, only 140 patients (6 %) had their autologous blood wasted, in contrast to values reported in the literature ranging from 14 % up to 50 %.
Conclusions
Targeted PABD reduces the need for allogeneic blood transfusion in anaemic patients and significantly reduces the overall number of transfusions compared to routine pre-operative autologous donation.
doi:10.1007/s00264-014-2339-5
PMCID: PMC4115105  PMID: 24722787
Anaemia; Total hip arthroplasty; Blood management; Preoperative autologous blood donation; Allogeneic; Transfusion
14.  Postcards from the past: The Third SICOT Congress, Bologna 1936 
International Orthopaedics  2014;38(8):1745-1750.
This manuscript describes the events and eminent personalities who animated the third Congress of the “Société Internationale de Chirurgie Orthopédique et Traumatologie”, held in Bologna (Italy) in 1936. During this meeting the Society acquired its definitive name and the acronym under which it is now internationally recognized, SICOT. Some of the most illustrious clinicians and scientists of those times gathered in Bologna to discuss the progress of orthopaedic science, thus contributing to highlight the relevance of this discipline in the medical field. Italian surgeon Vittorio Putti was the Congress Chairman and his words, together with some original pictures from his 1936 photo gallery, are shown to celebrate appropriately a prestigious moment in the history of SICOT.
doi:10.1007/s00264-013-2273-y
PMCID: PMC4115106  PMID: 24435819
SICOT; 3rd Congress; Bologna 1936; Vittorio Putti
15.  Does total hip arthroplasty restore native hip anatomy? Three-dimensional reconstruction analysis 
International Orthopaedics  2014;38(8):1577-1583.
Purpose
Component orientations and positions in total hip arthroplasty (THA) are important parameters in restoring hip function. However, measurements using plain radiographs and 2D computed tomography (CT) slices are affected by patient position during imaging. This study used 3D CT to determine whether contemporary THA restores native hip geometry.
Methods
Fourteen patients with unilateral THA underwent CT scan for 3D hip reconstruction. Hip models of the nonoperated side were mirrored with the implanted side to quantify the differences in hip geometry between sides.
Results
The study demonstrated that combined hip anteversion (sum of acetabular and femoral anteversion) and vertical hip offset significantly increased by 25.3° ± 29.3° (range, −25.7° to 55.9°, p = 0.003) and 4.1 ± 4.7 mm (range, −7.1 to 9.8 mm, p = 0.009) in THAs.
Conclusions
These data suggest that hip anatomy is not fully restored following THA compared with the contralateral native hip.
doi:10.1007/s00264-014-2401-3
PMCID: PMC4115107  PMID: 24966079
Total hip arthroplasty; Component orientation; Component position; Computed tomography
16.  Osteoporosis and the orthopaedic surgeon: basic concepts for successful co-management of patients’ bone health 
International Orthopaedics  2014;38(8):1731-1738.
Osteoporosis has been recognised as a public health concern for at least three decades but it has been relatively recent that the push has been for orthopaedic surgeons to take a more active role in the diagnosis and treatment of patients with decreased bone mineral density (BMD). Most often these patients are encountered after they have suffered a fracture making secondary prevention the area where orthopaedists may exert the greatest influence on patient care. The purpose of this article is to provide a succinct framework for the diagnosis and treatment of patients with decreased BMD. Patients are deemed to have decreased BMD if they have suffered a fragility fracture, a fracture caused by a low-energy traumatic event. These patients are often encountered in the emergency department and admitted for further treatment of their fractures or recommended for follow-up in the clinic. Regardless of treatment course these are opportunities for the orthopaedic surgeon to intervene in the osteoporotic disease process and positively affect a patient’s bone health. This article compiles the available literature on osteoporosis and presents it succinctly with the incorporation of both a diagnosis algorithm and treatment profile table. With the use of these two tools, orthopaedic surgeons everywhere should be able to take a more active role in their patients’ bone health.
doi:10.1007/s00264-014-2317-y
PMCID: PMC4115108  PMID: 24652422
Osteoporosis; Orthopaedic surgeon; Early management; Screening; Fragility fracture
17.  SICOT contribution to natural disaster assistance: the external fixator 
International Orthopaedics  2014;38(8):1549-1550.
doi:10.1007/s00264-014-2413-z
PMCID: PMC4115109  PMID: 24966083
18.  Surgical procedures in femoral neck fractures in Finland: a nationwide study between 1998 and 2011 
International Orthopaedics  2014;38(8):1685-1690.
Purpose
For femoral neck fractures, recent scientific evidence supports cemented hemiarthroplasty (HA) over uncemented HA and suggests that total hip arthroplasty (THA) should be performed more frequently. We report the current surgical trends in treating femoral neck fractures in Finland.
Methods
The study was conducted using the Finnish National Hospital Discharge Register and included all Finns at least 50 years of age who underwent surgery for femoral neck fractures from 1998 through 2011. Age- and sex-specific incidence rates and annual proportion of each treatment method were calculated.
Results
During 1998–2011, a total of 49,514 operations for femoral neck fracture were performed in Finland. The proportion of uncemented HA increased from 8.1 % in 2005 to 22.2 % in 2011. During the same time, the proportion of cemented HA decreased from 63.9 to 52.5 %, internal fixation decreased from 23.2 to 16.1 % and THA increased from 4.9 to 9.2 %.
Conclusions
Between 2005 and 2011, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland, while cemented HA and internal fixation declined. During this time, the use of THA nearly doubled. The current evidence-based guidelines for treatment of femoral neck fractures were mainly followed, but the increase in uncemented HA procedures contradicts recent scientific evidence.
doi:10.1007/s00264-014-2346-6
PMCID: PMC4115110  PMID: 24756458
Hip fracture; Population-based; Treatment; Internal fixation; Arthroplasty
19.  Medial patellofemoral ligament anatomy: is it a predisposing factor for lateral patellar dislocation? 
International Orthopaedics  2014;38(8):1633-1639.
Purpose
Because the medial patellofemoral ligament (MPFL) is the primary restraint to lateral dislocation of the patella, we aimed, in this controlled study, to verify whether the MPFL with different measurements could be considered another predisposing factor for patellar dislocation.
Methods
A group of 100 consecutive individuals without the criteria for patellar dislocation (trochlear dysplasia, patella alta and lateral patellar tilt) was recruited as a control group and underwent magnetic resonance imaging (MRI) study and another group of 50 patients with patellar instability. Femoral condyles, interepicondylar distance, length and thickness of the MPFL were measured.
Results
In the control group, the MPFL was 38–60 mm long. Individuals with patellar instability who had no episode of patellar dislocation had a 4.11-mm longer ligament than controls (p = 0.032), while patients with instability with a previous history of dislocation had a 13.54-mm longer MPFL than controls (p < 0.001). Thickness of the MPFL at the patellar insertion was lower in individuals with patellar instability with a history of dislocation (p < 0.001). An instability coefficient (IC) less than 1.3 indicates that the MPFL is insufficient.
Conclusions
Individuals with patellar instability and previous patellar dislocation present with longer MPFL when compared to controls, and an associated IC less than 1.3 can be considered a predisposing factor for patellar dislocation. Treatment of patellar instability is a challenge, and it is difficult to identify what is the predisposing factor. This study has verified the measurements of the MPFL for the first time and presents values of thickness and length that can be considered as indications for surgical reconstruction.
Level of evidence: III.
doi:10.1007/s00264-014-2357-3
PMCID: PMC4115117  PMID: 24817023
Patella; Patellar ligament; Joint instability; Knee
20.  Effectiveness of an autologous transfusion system following cemented and non-cemented revisions of total hip arthroplasty 
International Orthopaedics  2014;38(8):1603-1608.
Purpose
The goal of this study was to analyse the efficacy of blood autotransfusion using a continuous autologous transfusion system in revisions of total hip arthroplasty (THA). We looked at whether administration of allogeneic blood units was reduced in these cases and if there is a difference between cemented and non-cemented revisions.
Methods
Between January 2011 and December 2011, patients being treated with revision THA were included (n = 411). The following parameters were analysed: patient age, gender, weight (kg), height (cm), body mass index (BMI, kg/m2), surgical diagnosis, treatment and American Society of Anesthesiologists (ASA) classification score. The difference between pre- and post-operative haemoglobin (Hb, g/dl), amount of peri-operative blood loss (ml), amount of retransfused washed shed blood and amount of allogeneic and/or autologous transfusion (ml) were recorded.
Results
In both the cemented and non-cemented revision THA groups, there was no significant difference between pre- and post-operative Hb with or without using an autotransfusion system. In 92 of 186 cemented cases using an autologous transfusion system (49.5 %) and 38 of 117 non-cemented cases using an autologous transfusion system (32.5 %), allogeneic blood transfusion (ABT) was required. Cemented procedures using an autologous transfusion system got significantly more ABTs than non-cemented procedures using an autologous transfusion system (p = 0.0042, odds ratio = 2.035).
Conclusions
Use of an autologous transfusion system did not reduce the amount of ABT in revision THA in the patient cohort reported here. In our opinion, general blood management is required before and during surgery to reduce administration of ABT.
doi:10.1007/s00264-014-2359-1
PMCID: PMC4115112  PMID: 24817099
Autologous transfusion system; Revision; THA; Cemented; Non-cemented; ABT administration
21.  Osseointegration of polyethylene implants coated with titanium and biomimetically or electrochemically deposited hydroxyapatite in a rabbit model 
International Orthopaedics  2014;38(8):1739-1744.
Purpose
The aim of this study was to evaluate the osseointegration of a new coating directly deposited on PE at room temperature.
Methods
Thirty-six (36) male New Zealand rabbits were randomly assigned to receive one out of three types of implants: two tested implants, i.e. PE implant coated with TiPVD and biomimetic HA (biomimetic), PE implant coated with TiPVD and electrolytic HA (electrolytic), and positive control made of massive microrough titanium coated with plasma sprayed HA (TiHAPS). Osseointegration was evaluated by histomorphometry (bone tissue in contact [BIC]), mineralized bone area [MBA]) and mechanical testing (push-out test, interfacial shear strength [ISS]) at six and 12 weeks in the distal femurs.
Results
For BIC there were no differences between the groups at six (p = 0.98) and 12 weeks (p = 0.13). For MBA, no statistically significant difference was measured between groups at six (p = 0.52) and 12 weeks (p = 0.57). At six weeks, interfacial shear strength (ISS) was significantly higher (p = 0.01) for TiHAPs implants compared to biomimetic and electrolytic implants. This difference was not significant at 12 weeks (p = 0.92).
Conclusion
The osseointegration of biomimetic and electrolytic implants was equivalent to a positive control at 12 weeks.
doi:10.1007/s00264-014-2364-4
PMCID: PMC4115113  PMID: 24859898
Osseointegration; Polyethylene implant; Biomimetic deposition; Electrolytic deposition; Hydroxyapatite coating; Rabbit model; Hip arthroplasty
22.  Apolipoprotein E gene E2/E2 genotype is a genetic risk factor for vertebral fractures in humans: a large-scale study 
International Orthopaedics  2014;38(8):1665-1669.
Purpose
Although many studies have been performed to evaluate whether or not apolipoprotein E gene (APOE) polymorphisms are differentially associated with bone mineral density (BMD) and fractures, the results have been conflicting. This large-scale study was performed to investigate whether a relationship exists between APOE polymorphisms and risk of fracture.
Methods
A hospital-based case–control study was conducted in 3,000 patients with fractures and 3,000 age- and gender-matched healthy controls. Polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) assay was applied to assess the APOE gene polymorphisms.
Results
Patients with fractures had a significantly higher frequency of APOE E2/E2 genotype [odds ratio (OR) = 2.02, 95 % confidence interval (CI) = 1.30, 3.14; P = 0.002] than healthy controls. When stratifying by fracture type, it was found that patients with vertebral fractures had a significantly higher frequency of APOE E2/E2 genotype (OR = 2.86, 95 % CI = 1.73, 4.73; P < 0.001). No significant differences were found in nonvertebral (hip or wrist or other) fractures.
Conclusions
Our study suggests that APOE E2/E2 genotype is a potential genetic risk factor for vertebral fractures in humans.
doi:10.1007/s00264-014-2380-4
PMCID: PMC4115114  PMID: 24880936
Apolipoprotein E; Fracture; Gene polymorphism; Case–control study
23.  The fifty most cited Latin-American articles in the orthopaedic literature 
International Orthopaedics  2013;38(8):1723-1729.
Purpose
The number of citations of an article is a marker of its academic influence. Several medical specialties, including orthopaedics, have ranked the articles with more citations. We identified the 50 most cited orthopaedic articles from Latin-America and analyzed the characteristics that made them citable.
Methods
Science Citation Index Expanded was searched for citations of articles originated in Latin-America, published in any of the 63 journals in the category “Orthopaedics” from 1988 to 2013. We created a list ranking the 50 most commonly cited articles and determined the citation density (Citations/years since publication). Information noted for each article included authors, year of publication, country of origin, source journal, article type, and field of research.
Results
Latin-American countries were the origin of 1 % of orthopaedic articles. The top 50 most cited articles had between 29 and 150 citations (mean, 44.48); the citation density ranged from 1.43 to 15.5 citations/years (mean, 5.25). The articles were published in 19 of the 63 journals (11 general and eight sub-specialty journals), and all were published in English. Most articles (n = 29) were published in 2000 or later. The majority were clinical articles (n=40), and the most common fields were arthroscopy (n = 15) and hip surgery (n = 13). The top 50 articles originated mainly from Brazil (n = 20) and Argentina (n = 15).
Conclusions
This top 50 list displays articles that have become important references for the orthopaedic scientific community. Researchers may use this work to make their future publications more influential on future investigators.
doi:10.1007/s00264-013-2197-6
PMCID: PMC4115115  PMID: 24271502
Orthopaedic literature; Cited articles; Latin-American orthopaedics
24.  Opening wedge high tibial osteotomy: navigation system compared to the conventional technique in a controlled clinical study 
International Orthopaedics  2014;38(8):1627-1631.
Purpose
This study aimed to verify if the navigation system used in high tibial osteotomy (HTO) adds precision to the procedure regarding mechanical axis correction and prevention of tibial slope increases.
Methods
In this historically controlled study, patients with medial osteoarthrosis and genuvarum underwent HTO between 2004 and 2012; the first 20 were operated with the conventional technique, using pre-planning correction by the Dugdale method and 18 further patients were operated with the navigation system introduced in our hospital.
Results
The two groups were similar for pre-operative mechanical axis (mean 8.10 ± 3.14 for the control and 6.60 ± 2.50 for the navigated group), pre-operative tibial slope (mean 8.95 ± 3.47 versus 8.17 ± 3.11, respectively) and Lyshom score (40.85 ± 15.46 and 44.83 ± 16.86). After surgery, the control group presented mean mechanical axis of 3.35 ± 3.27, tibial slope of 13.75 ± 3.75 and Lyshom score of 87.60 ± 11.12. The navigated group showed a postoperative mechanical axis mean of 3.06 ± 1.70, tibial slope of 10.11 ± 0.18 and Lyshom score of 91.94 ± 11.61.
Conclusions
The navigation system allowed a significantly better control of tibial slope. Patients operated with the navigation system had significantly better Lysholm scores.
doi:10.1007/s00264-014-2341-y
PMCID: PMC4115116  PMID: 24722788
Osteotomy; Knee osteoarthritis; Genu varum; Computer-assisted surgery; Tibia

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