Aims. The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA. Methods. A single-centre retrospective observational study was conducted of all orthopaedic oncologic patients undergoing surgical evaluation from March to June 2020. Patients were prioritized as level 0-IV, 0 being elective and IV being emergent. Only priority levels 0 to III were included. Delay duration was measured in days and resulting morbidities were categorized into seven groups: prolonged pain/disability; unplanned preoperative radiation and/or chemotherapy; local tumour progression; increased systemic disease; missed opportunity for surgery due to progression of disease/lost to follow up; delay in diagnosis; and no morbidity. Results. Overall, 25 patients met inclusion criteria. There were eight benign tumours, seven metastatic, seven primary sarcomas, one multiple myeloma, and two patients without a biopsy proven diagnosis. There was no priority level 0, two priority level I, six priority level II, and 17 priority level III cases. The mean duration of delay for priority level I was 114 days (84 to 143), priority level II was 88 days (63 to 133), and priority level III was 77 days (35 to 269). Prolonged pain/disability and delay in diagnosis, affecting 52% and 40%,respectively, represented the two most frequent morbidities. Local tumour progression and increased systemic disease affected 32% and 24% respectively. No patients tested positive for COVID-19. Conclusion. COVID-19 related delays in surgical management led to major morbidity in this studied orthopaedic oncologic patient population. By understanding these morbidities through clearer hindsight, a thoughtful approach can be developed to balance the risk of COVID-19 exposure versus delay in treatment, ensuring optimal care for orthopedic oncologic patients as the pandemic continues with intermittent calls for halting surgery. Cite this article: Bone Jt Open 2021;2(4):236–242

Aims: The study aimed at analyzing the outcome of femoral components in patients with total hip replacement following osteonecrosis of the femoral head with regard to the associated factor of the osteonecrosis. Methods: We reviewed 41 patients with 55 cementless total hip replacements operated for advanced osteonecrosis. According to etiology of the osteonecrosis patients were divided into two groups. The first group included 17 cases with osteonecrosis without a systemic disease and the second group 38 cases with osteonecrosis associated with a systemic disease (alcohol abuse, corticosteroid medication, sickle-cell-disease). Results: The follow-up was on average 6.4 years (range, 2 to 12.8). Eight stem revisions had to be performed, all of them were in the patients with a systemic disease. Ten-year survival rates with femoral revision as the endpoint were in the first group 100%, and in the systemic disease group 68% (p=0.03). Conclusion: The data of this retrospective study supports the notion that the aetiology of osteonecrosis might has an influence on the survival of the femoral component

Background. The diagnosis of periprosthetic joint infection (PJI) remains a challenge in clinical practice and the analysis of synovial fluid (SF) is a useful diagnostic tool. Recently, two synovial biomarkers (leukocyte esterase (LE) strip test, alpha-defensin (AD)) have been introduced into the MSIS (MusculoSkeletal Infection Society) algorithm for the diagnosis of PJI. AD, although promising with high sensitivity and specificity, remains expensive. Calprotectin is another protein released upon activation of articular neutrophils. The determination of calprotectin and joint CRP is feasible in a routine laboratory practice with low cost. Purpose. Our objective was to evaluate different synovial biomarkers (calprotectin, LE, CRP) for the diagnosis of PJI. Methods. In this monocentric study, we collected SF from hip, knee, ankle and shoulder joints of 42 patients who underwent revision or puncture for diagnostic purposes. Exclusion criteria included a joint surgery in the previous 3 months and a diagnosis of a systemic inflammatory disease. PJI was diagnosed in a multidisciplinary consultation meeting (RCP) of the Reference Centers for Osteoarticular Infections of the Great West (CRIOGO). SF was analysed for LE, CRP and calprotectin. The cut-off values used were 50 mg/L for calprotectin, 8.8 mg/L for CRP and 125 WBC/µL for LE. The overall sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for these different synovial markers. Results. Of the 42 patients included, 28 were considered as infected and 14 uninfected. The statistical parameters are presented in Table 1. Conclusion. The present study shows that the synovial calprotectin assay has an excellent sensitivity and a 100% NPV for the diagnosis of PJI, suggesting that a result < 50 mg/L could exclude PJI. This promising study suggests that calprotectin should be included with synovial CRP in a new decision algorithm for the diagnosis of PJI. For any tables or figures, please contact the authors directly

Distal radius fractures are the most common adult fractures, yet there remains some uncertainty surrounding optimal treatment modalities. Recently, the rate of operative treatment of these injuries has been increasing, however, predictors of outcomes in patients treated surgically remain poorly understood. The purpose of this study was to evaluate independent predictors of 30-day readmission and complications following internal fixation of distal radius fractures. Patients ≥18 years who underwent surgical intervention for distal radius fractures between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) using procedural codes. Patient demographics, as well as 30-day readmission, complication, and mortality rates were ascertained. Multivariable logistic regression was used to determine independent predictors of 30-day outcomes while adjusting for patient age, sex, American Society of Anaesthesiologists (ASA) class, functional status, smoking status, comorbidities, and Body Mass Index (BMI). A total of 10,051 patients were identified (average age 58 ±16). All patients received open reduction and internal fixation with no cases of external fixation identified in the data set. Included fractures were 37% extraarticular and 63% intraarticular. Within 30-days of initial fixation 143 (1.42%) patients were readmitted to the hospital, 71 patients experienced a complication, and 18 (0.18%) patients died. After adjusting for relevant covariables, current smoking increased the odds of readmission by 1.73 (95%Confidence interval [95%CI] 1.15 – 2.50), ASA class III/IV vs. I/II increased the odds of readmission by 2.74 (95%CI 1.85 – 4.06), and inpatient surgery vs. outpatient surgery increased the odds of readmission by 2.10 (95%CI 1.46 – 3.03). Current smoking also increased the odds of complications by 2.26 (95%CI 1.32 – 3.87), while ASA class III/IV increased it by 2.78 (95%CI 1.60 – 4.85), inpatient surgery increased it by 2.26 (95%CI 1.37 – 3.74), and dependent functional status increased it by 2.55 (1.16 – 5.64). In conclusion, patients with severe systemic disease, current smokers and patients undergoing inpatient surgery are at risk for 30-day readmissions and complications following operative treatment of distal radius fractures. In addition, patients with dependent functional statuses are more likely to experience a complication within 30-days

The use of endoprosthesis implants is frequent for tumours involving the proximal third of the femur and not amenable to primary arthroplasty or internal fixation. In this population, these implants are preferentially cemented given poor bone quality associated with systemic diseases and treatments. Loosening is a common complication of these implants that have been linked to poor bone quality, type of implants and importantly cementing technique. Thus, these techniques vary between different surgeons and based mainly on previous experience. One of the most successful cementing techniques in the arthroplasty literature is the French paradox. This technique involves removing the cancellous bone of the proximal femoral metaphysis and selects the largest stem to tightly fit the created cavity delineated by cortical bone. Cementing the implant results in a very thin cement layer that fills the inconsistent gaps between the metal and the bone. To our knowledge, no previous report exists in the literature assessing loosening in proximal femur replacement using the French paradox cementing technique. In this study, we sought to examine (1) rates of loosening in proximal femur replacement, and (2) the oncological outcomes including tumour recurrence and implant related complications. A retrospective study of 42 patients underwent proximal femur replacement between 1990 and 2018 at our institution. Of these, 30 patients met our inclusion criteria. Two independent reviewers have evaluated the preoperative and the most recent postoperative radiographs using the International Society of Limb Salvage (ISOLS) radiographic scoring system and Gruen classification for femoral stem loosening. Additionally, the acetabulum was evaluated for erosion according to the criteria of Baker et al. The mean age of this cohort was 60.5 (19–80), with 60% being males. The primary origin was metastatic in 17 (56.7%) patients, bone sarcoma in 10 (33.3%) patients and soft tissue sarcoma in 3 (10%) patients. Pathological fractures were present in 11 (36.7%) patients. Seven (23.3%) patients had prior intramedullary nailing. Preoperative radiotherapy was used in 8 (26.7%) and postoperative radiotherapy in 17 (56.7%) patients. The mean clinical follow-up was 25.2±26.3 months and the mean radiographical follow-up was 24.8±26 months. The mean ISOLS score for both reviewers was found to be 89±6.5% and 86.5±6.1%, respectively. Additionally, the first reviewer found two patients to be possibly loos (6.7%) compared to one (3.3%) patient for the second reviewer. No components scored as probably or definitely loose and non-required revision for either loosening or metal failure. Furthermore, both reviewers showed no acetabular erosion in 25 (83.3%) and 24 (80%) patients, respectively. On the other hand, the overall rate of complications was 36.6% with 11 complications reported in 30 patients. Local recurrence occurred in five (16.6%) patients. Prosthetic Dislocation was the most frequent complications with eight dislocations in four patients. Despite complications, our results showed no radiographic evidence of stem loosening. Cementing proximal femur prosthesis with a tight canal fit and with a thin cement mantle appears to be a viable option at short and medium term

Aim: To assess the functional and radiological outcome of AO wrist Arthrodesis using the AO wrist fusion plate. Method: An 8 year, independent, retrospective, radiological and functional review was performed using The DASH (Disabilities of the Arm, Shoulder and Hand questionnaire) and the Buck-Gramcko/Lohmann outcome scores. Results: Twenty-eight patients were reviewed. The two scoring systems correlated consistently in regards to the functional outcome. However, patients with systemic disease experienced problems completing the DASH questionnaire. Mono-articular arthritis was associated with an excellent/good outcome in 95% of cases. Results for patients with systemic disease were markedly worse. There was one case of plate breakage associated with a delayed union of the second MCP joint. There was a 100% union rate, no significant post-operative infections and no tendon ruptures. Conclusion: The short to mid term clinical outcomes for the AO wrist fusion plate are encouraging and its use can be recommended in a variety of wrist pathologies

Aim. The cut-off values for synovial fluid leukocyte count and neutrophils differential (%PMN) for differentiating aseptic from septic failure in total knee arthroplasties were already defined in the past. Our goal was to determine the cut-off values for synovial fluid leukocyte count and %PMN in failed total hip arthroplasties (THA). Method. Patients undergoing revision THA were prospectively included. In perioperative assessment phase, synovial fluid leukocyte count and %PMN were determined. During the surgery, at least 4 intraoperative samples for microbiological and one for histopathological analysis were obtained. Infection was defined as presence of sinus tract, inflammation in histopathological samples, and ≥2 tissue and/or synovial fluid samples growing the same microorganism. Exclusion criteria were systemic inflammatory diseases, revision surgery performed less than 3 months from index surgery and insufficient tissue sampling. Receiver operating characteristic (ROC) curves were constructed to assess the diagnostic performance and Youden's J statistic was computed to identify optimal cut-off values. Results. During the study period (between June 2006 and June 2011) 227 revision THAs were performed by the senior author. 31 patients were excluded. 196 patients (mean age, 69 years; 68% females) with THA failure were included. Aseptic failure was diagnosed in 150 patients (76,5%) and THA infection was diagnosed in 46 patients (23,5%). Synovial fluid leukocyte counts were significantly higher in the infected group (median, 5.50×10. 6. leukocytes/ml range, 0.05 to 143.9×10. 6. leukocytes/mL) than in the aseptic group (median, 0.23×10. 6. cells/ml; range, 0 to 21.3×10. 6. leukocytes/ml, P<0,0001). The %PMN was also significantly higher in the infected group (median, 83%; range, 6% to 97%) than in the aseptic group (median, 27,5%; range, 0% to 94%, P<0,0001). A synovial fluid leukocyte count of > 1.54×10. 6. leukocytes/ml, had a sensitivity of 63%, specificity of 95%, positive and negative predictive values of 78% and 89%, respectively. A synovial fluid %PMN of > 64%, had a sensitivity of 65%, specificity of 93%, positive and negative predictive values of 73% and 90%, respectively. Conclusion. The synovial fluid leukocyte count of > 1.54×10. 6. leukocytes/ml and %PMN of > 64% are useful and reliable tests for excluding THA infection, having a negative predictive value of around 90%. This tests and calculated cut-off values are highly recommended in the diagnostic process of failed THAs

Epimetaphyseal lesions may occur within congenital dysplasia or can be linked to metabolic, inflammatory and systemic diseases. They can also be caused by trauma or be due to malign or benign neoplasms. Our case-report concerns a 4-year old boy who was x-rayed the day after falling from a chair and twisting his right ankle. X-ray showed an epimetaphyseal lesion of about 2 cm in diameter, located eccentrically in the lateral site of the distal tibia. A unilamellar periostal reaction could be detected in the lateral slices. On MRI, the lesion seemed to be of chondromatous origin and showed smooth borders with no evidence of surrounding oedema. The adjacent epiphyseal plate appeared as untypically fragmented. In CT-scans, the ventrolateral cortical bone was partially perforated and the lesion showed a tender sclerotic border. Due to the benign aspect, we agreed upon radiologic controls in order not to harm the epiphyseal plate by biopsy. MRI follow-ups revealed a slight but continuous growth. The lesion assumed an increasingly eccentric, tongue-shaped configuration with simultaneously increasing calcifications and mineralisations. After 5 years of radiological surveillance, the patient showed no evidence of growth-disturbance and did not report pain, but an increasing feeling of pressure when wearing boots. Traumatic causes as well as metabolic, inflammatory and systemic diseases can, considering the patient’s history and clinical status, be put aside. The benign aspect combined with the long-term follow-up rules out malignancies. A chondroid matrix with increasing areas of mineralisation imply the diagnosis of a chondromatous tumour, although radiomorphology does not support this assumption; especially not, if age, clinical presentation, eccentric epimetaphyseal location and the involvement of the epiphyseal plate are taken into account. Among the entities left for differential-diagnosis, a dysplastic process e.g. Dysplasia hemimelica, must be considered, although doubts remain. For confirmation of diagnosis, further radiological and clinical surveillance will be conducted

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This study was designed to characterize the recurrence incidence and risk factors of antibiotic-loaded cement spacer (ALCS) for definitive bone defect treatment in limb osteomyelitis.

Introduction:. Sinus histiocytosis with massive lymphadenopathy (SHML) also known as Rosai – Dorfman disease is a disease of bone marrow stem cell origin. It affects lymph nodes primarily. Solitary bone lesions are very rare and can cause diagnostic difficulty. Aim:. To increase the awareness of SHML as a cause of cystic bone lesions. Materials and methods:. A 2 year old presented with 4 months history of pain and swelling of the distal forearm. There was no history of tuberculosis or HIV disease. The swelling was 4 × 3 cm firm, non-fluctuant and slightly tender. There were no lymph nodes. Radiographs showed an oval cystic lesion expanding with a well-defined margin. The ulnar cortex was deficient. CT scan confirmed a cystic lesion with contents of granulation tissue. The Hb and WCC were normal, ESR 20 was, CRP<5 and mantoux was negative. At surgery the lesion was curretted. The contents resembled tuberculous granulation but there was no caseation. The borders were well formed, the ulnar cortex was deficient. Results:. The histology revealed granulation tissue with numerous large histiocytes and immuno chemistry confirmed Rosai Dorfman disease. Healing with sclerosis was seen at 6 months. Discussion:. Rosai Dorfman disease is a systemic disease of bone marrow stem cells and lymphadenopathy is the prominent manifestation. Only ±8% of cases have been reported with bone involvement and 4% of these had no lymphadenopathy. The lesions are cystic and medullary but cortical involvement can occur. Solitary ossseous lesions characterized by a background of histocytes without eosinophils can mimic Langerhans histocytosis, localized osteomyelitis, fibrous dysplasia, tuberculosis, simple or aneurysmal bone cysts and metastatic deposits. Conclusion:. Lesions of haematopoetic origin should be considered in the diagnosis of lucent bone lesions in children

Objectives. Osteoporosis and osteomalacia lead to increased fracture risk. Previous studies documented dysregulated osteoblast and osteoclast activity, leading to a high-turnover phenotype, reduced bone mass and low bone mineral content. Osteocytes, the most abundant bone cell type, are involved in bone metabolism by enabling cell to cell interaction. Osteocytes presence and viability are crucial for bone tissue homeostasis and mechanical integrity. Osseo-integration and implant degradation are the main problems in developing biomaterials for systemically diseased bone. This study examines osteocyte localisation, morphology and on the implant surface and at the implant bone interface. Furthermore, the study investigates ECM proteins regulation correlated to osteocytes and mechanical competence in an ovariectomised rat model with a critical size metaphyseal defect. Methodology. After induction of osteoporosis, 60 female Sprague-Dawley rats were randomised into five groups: SrCPC (n=15), CPC (n=15), ScB30 (n=15), ScB30Sr20 (n=15) and empty defect (n=15). The left femur of all animals underwent a 4mm wedge-shaped metaphyseal osteotomy that was internally fixed with a T-shaped plate. The defect was then either filled with the above mentioned implants or left empty. After six weeks, histomorphometric analysis showed a statistically significant increase in bone formation at the tissue-implant interface in the SrCPC group compared to the other groups (p<0.01). Osteocyte morphology and networks were detected using silver and staining. ECM proteins were investigated through immunohistochemistry. Cellular populations were tested using enzyme histochemistry. Mineralisation was assessed using time of flight secondary ion mass spectrometry (TOF-SIMS). Statistical analysis was performed using Mann Whitney U test with Bonferroni correction. Results. In the SrCPC and compared to other test groups, osteocytes presence and morphology was enhanced. An increased osteocytic activity was also seen in ScB30Sr20 when compared to SCB30 alone. Local osteomalatic lesions characterised by the presence of excessive unmineralised osteoid as revealed by the VKVG staining in the intact bone was also seen. A regular pattern of osteocytes distribution reflecting a better bone maturation was also seen in case of the Sr substituted cements. Whereas in case of the ScB30 degenerated osteocytes with a comparatively irregular arrangement were seen. Nonetheless, ECM proteins indicating discrepant bone turnover (RANKL, OPG, BMP2, OCN; ASMA) were noticed to increase within these regions and were accompanied by the presence of apoptotic osteocytes. Interestingly, osteocytes were also localised near the blood vessels within the newly formed woven bone. On the other hand, osteocytes allocation at implant bone interface and on the implant surface were qualitatively better in the Sr substituted groups when compared to the other test groups. Furthermore, this correlates with healing enhancement and implant retention results obtained from the histomorphometry (BV/TV and Osteoclasts count). The first qualitative results of the sclerostin visualisation showed a lower expression in the Sr supplemented biomaterials compared to the Sr free ones. Conclusion. Osteoblasts, osteoclast and osteocytes are the key players to bone metabolism through production and mineralisation of ECM or resorption. The current study indicates the importance in therapeutically targeting osteocytes to regulate bone metabolism in osteoporotic/osteomalatic bone. Sr inhibits osteoclast activity which is important for implant degradation. However, in osteoporotic bone osteoclasts inhibition is crucial to enhance the healing. Our data suggest that osteocytes allocation at the bone implant interface and on the implant surface is aiding in implant degradation through osteocytes dependent resorption. Currently, discrepancies in mechanosensitivity, proliferation and fibrotic tissue formation are being investigated together with several anchorage proteins to quench further effects of osteocyte presence at the implant bone interface

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Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

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This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect.

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The Exeter short stem was designed for patients with Dorr type A femora and short-term results are promising. The aim of this study was to evaluate the minimum five-year stem migration pattern of Exeter short stems in comparison with Exeter standard stems.

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This study aimed to investigate the role and mechanism of meniscal cell lysate (MCL) in fibroblast-like synoviocytes (FLSs) and osteoarthritis (OA).

Aim:. AIS causes a loss of trunk height. This paper documents this loss against sitting height standards and assesses formulae for adjusting height loss back to the standard. Methods:. A total of 334 patients (84% female) with AIS and no other known systemic disease had sitting height measured. This was compared to standards of sitting height with age and the ratio of height to sitting height with age (HSH). The corrected height was calculated using published formulae and replotted against these standards. Results:. Both sexes had significant numbers of patients under the 5th centile compared to those above the 95th centile for sitting height (p<0.05 in males and females) and for HSH centiles (p<0.05 in males and females). All formulae increased the sitting height back to within the standards. In males only the Ylikoski formula demonstrated any significant difference in sitting height and HSH. In females the Kono formula gave the least significant difference between those above and below the 95th and 5. th. centiles for sitting height and the Hwang formula for HSH. Discussion:. Scoliosis causes a loss of sitting height seen with the centile standards for sitting height and height to sitting height ratios. This can be corrected, the most accurate formula being Hwang, correcting the data to lie between the 5th and 95th centiles for sitting height with no significant difference between the number of outliers to these centiles. Outliers after use of this formula may suggest alternative pathology. Conflict Of Interest Statement: No conflict of interest

Background:. Is routine use of suction drain after joint replacement is justified. Material & Methods:. Prospective evaluation was done to compare the effects of postoperative suction drain in 56 patients with no postoperative drain in 56 patients, undergoing total knee arthroplasty at our institute. Patients having severe systemic diseases, disturbed liver function, obesity, unstable diabetes and coagulation disorders were excluded from the study. Comparative evaluation was done for the blood loss, no of units of blood transfusion, wound hematoma, wound healing, duration of hospital stay, pain and range of motions. Results:. All the patients were operated by one surgeon by using midline skin incision, midvastus approach and same method of wound closure. Sex distribution was same and no patient received anticoagulant chemoprophylaxis. Average fall in postoperative hemoglobin was 3.1 gm/dl in the drain group and 2.2 gm/dl in the non drain group. Drains were removed at 48 hrs or at 24 hr when drainage was less than 50 ml. Statistically comparative results were seen in both groups in regard of wound hematoma, wound healing, duration of hospital stay, pain and range of motions. But blood loss, fall of hemoglobin and no of units of blood transfusion was more in drain group. Conclusion. Routine use of suction drainage do not offer any advantages and it should be used in patients with coagulation defects, on heparins, unstable diabetes or other risk factor for postoperative infection and hematoma formation

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To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

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This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists.

Exercise deters systemic diseases such as osteoporosis, sarcopenia, diabetes and obesity. Brief daily periods of low intensity vibration (LIV; <0.4g) is anabolic to bone and muscle, an adaptive response achieved in part by biasing mesenchymal stem cell (MSC) fate selection towards forming higher order connective tissues. In the clinic, LIV has protected the musculoskeletal system even under severe challenges such as Crohn Disease, Cerebral Palsy, and end-stage renal disease. Low magnitude mechanical signals also suppress adipogenesis in the mouse, with reductions in subcutaneous and visceral fat. The starkly distinct response of these tissues (augment bone & muscle; suppress fat) suggests that LIV influences the differentiation pathway of MSCs. Extending this diet induced obesity model to 7 months increased total adiposity, accelerated age-related loss of trabecular bone and severely reduced B & T-cell number in the marrow and blood, shifting hematopoietic stem cells (HSC) towards the myeloid lineage. LIV introduced at 4 months rescued bone and B-cells to those levels measured in regular diet controls. These data emphasise why inactivity can promote osteoporosis, diabetes and obesity, and why a sedentary individual is predisposed to disease sequelae. Protection of MSC and HSC populations by mechanical signals may represent a unique strategy by which adiposity can be suppressed, the immune system protected, and a musculoskeletal system enhanced