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The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1301 - 1305
1 Nov 2024
Prajapati A Thakur RPS Gulia A Puri A

Aims

Reconstruction after osteoarticular resection of the proximal ulna for tumours is technically difficult and little has been written about the options that are available. We report a series of four patients who underwent radial neck to humeral trochlea transposition arthroplasty following proximal ulnar osteoarticular resection.

Methods

Between July 2020 and July 2022, four patients with primary bone tumours of the ulna underwent radial neck to humeral trochlea transposition arthroplasty. Their mean age was 28 years (12 to 41). The functional outcome was assessed using the range of motion (ROM) of the elbow, rotation of the forearm and stability of the elbow, the Musculoskeletal Tumor Society score (MSTS), and the nine-item abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH-9) score.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1321 - 1326
1 Nov 2024
Sanchez-Sotelo J

Periprosthetic joint infection represents a devastating complication after total elbow arthroplasty. Several measures can be implemented before, during, and after surgery to decrease infection rates, which exceed 5%. Debridement with antibiotics and implant retention has been reported to be successful in less than one-third of acute infections, but still plays a role. For elbows with well-fixed implants, staged retention seems to be equally successful as the more commonly performed two-stage reimplantation, both with a success rate of 70% to 80%. Permanent resection or even amputation are occasionally considered. Not uncommonly, a second-stage reimplantation requires complex reconstruction of the skeleton with allografts, and the extensor mechanism may also be deficient. Further developments are needed to improve our management of infection after elbow arthroplasty.

Cite this article: Bone Joint J 2024;106-B(11):1321–1326.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1333 - 1341
1 Nov 2024
Cheung PWH Leung JHM Lee VWY Cheung JPY

Aims

Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM.

Methods

This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery.


Aims. The efficacy of saline irrigation for treatment of implant-associated infections is limited in the presence of porous metallic implants. This study evaluated the therapeutic efficacy of antibiotic doped bioceramic (vancomycin/tobramycin-doped polyvinyl alcohol composite (PVA-VAN/TOB-P)) after saline wash in a mouse infection model implanted with titanium cylinders. Methods. Air pouches created in female BalBc mice by subcutaneous injection of air. In the first of two independent studies, pouches were implanted with titanium cylinders (400, 700, and 100 µm pore sizes) and inoculated with Staphylococcus aureus (1 × 10. 3. or 1 × 10. 6. colony-forming units (CFU)/pouch) to establish infection and biofilm formation. Mice were killed after one week for microbiological analysis. In the second study, pouches were implanted with 400 µm titanium cylinders and inoculated with S. aureus (1 × 10. 3. or 1 × 10. 6. CFU/pouch). Four groups were tested: 1) no bacteria; 2) bacteria without saline wash; 3) saline wash only; and 4) saline wash plus PVA-VAN/TOB-P. After seven days, the pouches were opened and washed with saline alone, or had an additional injection of PVA-VAN/TOB-P. Mice were killed 14 days after pouch wash. Results. The first part of the study showed that low-grade infection was more significant in 400 µm cylinders than cylinders with larger pore sizes (p < 0.05). The second part of the study showed that saline wash alone was ineffective in eradicating both low- and high-grade infections. Saline plus PVA-VAN/TOB-P eradicated the titanium cylinder-associated infections, as manifested by negative cultures of the washouts and supported by scanning electron microscopy and histology. Conclusion. Porous titanium cylinders were vulnerable to bacterial infection and biofilm formation that could not be treated by saline irrigation alone. Application of PVA-VAN/TOB-P directly into the surgical site alone or after saline wash represents a feasible approach for prevention and/or treatment of porous implant-related infections. Cite this article: Bone Joint Res 2024;13(11):622–631


Bone & Joint 360
Vol. 13, Issue 5 | Pages 39 - 42
1 Oct 2024

The October 2024 Trauma Roundup360 looks at: Early versus delayed weightbearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomized controlled trial; The effect of early weightbearing and later weightbearing rehabilitation interventions on outcomes after ankle fracture surgery; Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?; Periprosthetic fractures of the hip: Back to the Future, Groundhog Day, and horses for courses; Two big bones, one big decision: when to fix bilateral femur fractures; Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation; Unclassified acetabular fractures: do they really exist?


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1084 - 1092
1 Oct 2024
Hammat AS Nelson R Davis JS Manning L Campbell D Solomon LB Gnanamanickam ES Callary SA

Aims

Our aim was to estimate the total costs of all hospitalizations for treating periprosthetic joint infection (PJI) by main management strategy within 24 months post-diagnosis using activity-based costing. Additionally, we investigated the influence of individual PJI treatment pathways on hospital costs within the first 24 months.

Methods

Using admission and procedure data from a prospective observational cohort in Australia and New Zealand, Australian Refined Diagnosis Related Groups were assigned to each admitted patient episode of care for activity-based costing estimates of 273 hip PJI patients and 377 knee PJI patients. Costs were aggregated at 24 months post-diagnosis, and are presented in Australian dollars.


Bone & Joint 360
Vol. 13, Issue 5 | Pages 42 - 44
1 Oct 2024

The October 2024 Oncology Roundup. 360. looks at: Composite reconstruction: is it the answer for pelvic resections?; Can the cartilaginous thickness determine the risk of malignancy in pelvic cartilaginous tumours, and how accurate is the preoperative biopsy of these tumours?; Incidence and survival outcomes of patients with high-grade appendicular bone sarcoma and isolated regional lymph node metastasis; Improved metastatic-free survival after systematic re-excision following complete macroscopic unplanned excision of limb or trunk soft-tissue sarcoma; UK guidelines for the management of soft-tissue sarcomas; Current management of desmoid tumours: a review


The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 907 - 915
1 Sep 2024
Ross M Zhou Y English M Sharplin P Hirner M

Aims

Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient’s blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA.

Methods

A parallel, double-blinded, placebo-controlled randomized controlled trial was conducted, where patients with unilateral moderate knee OA (Kellgren-Lawrence grade 2 or 3) received either nSTRIDE or saline (placebo) injection to their symptomatic knee. The primary outcome was the difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months post-intervention. Secondary outcomes included WOMAC component scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analogue scale (VAS) scores at all follow-up timepoints (three, six, and 12 months).


The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 935 - 941
1 Sep 2024
Ailaney N Guirguis PG Ginnetti JG Balkissoon R Myers TG Ramirez G Thirukumaran CP Ricciardi BF

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

Methods

This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 94 - 94
19 Aug 2024
Orringer M Palmer R Ball J Telang S Lieberman JR Heckmann ND
Full Access

While obesity is associated with an increased risk of complications after total hip arthroplasty (THA) the relationship between body mass index (BMI) and the risk of early postoperative complications has not been fully characterized. This study sought to describe the relationship between BMI and the risk of early postoperative complications, including periprosthetic joint infection (PJI), composite surgical, and composite medical complications. Primary, elective THAs performed from 2016–2021 were identified using the Premier Healthcare Database (PHD). The study's primary outcome was the diagnosis of PJI within 90 days of THA. Using BMI as a continuous variable, logistic regression was used to develop restricted cubic splines (RCSs) to determine the impact of BMI on PJI risk. Bootstrap simulation was used to identify an inflection point in the final RCS model. The same technique was used to characterize the effects of BMI on composite medical and surgical complications. We found that PJI risk increased exponentially beyond a BMI cutpoint of 37.4 kg/m. 2. Relative to the cutpoint, patients with a BMI of 40 or 50 kg/m. 2. were at a 1.22- and 2.55-fold increased risk of developing PJI, respectively. Surgical complications increased at a BMI of 32 kg/m. 2. and medical complications increased at a BMI of 39 kg/m. 2. Relative to these cutpoints, patients with a BMI of 50 kg/m. 2. were at a 1.36- and 2.07-fold increased risk of developing medical and surgical complications, respectively. The results of this study indicate a non-linear relationship between patient BMI and early postoperative risk of PJI, composite medical complications, and composite surgical complications following THA. The identified cutpoints with associated odds ratios can serve as tools to help risk-stratify and counsel patients seeking primary THA


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 45 - 45
19 Aug 2024
Perez SFG Zhao G Tsukamoto I Labott JR Restrepo DJ Hooke AW Zhao C Sierra RJ
Full Access

Previous studies have highlighted differences in the risk of periprosthetic fracture between tapered slip (TS) and composite beam (CB) stems. This biomechanical study explored periprosthetic fractures around these stems and the effect of adding a 16-gauge calcar or diaphyseal wire to TS stems on their resistance to torque. A power analysis determined a sample size of 7 specimens per group, assuming a standard deviation of 14.8 Nm in peak torque, to provide 90% power to detect a difference of at least 30 Nm between groups. Twenty-one TS stems (eight alone, six with calcar wiring, seven with diaphyseal wiring placed 2 cm distal to the lesser trochanter) and seven CB stems were cemented into standard Sawbones. A servo-hydraulic test machine applied a 1000 N load with a 1-degree rotation per second until failure. The peak torque at failure was measured, and the fracture location recorded. Comparisons were performed using two-sample t-tests. CB stems exhibited a significantly higher peak torque at failure (205.3 Nm) than TS stems (159.5 Nm, p=0.020). Calcar-wire-TS (148.2 Nm, p=0.036) and diaphyseal-wire-TS (164.9 Nm, p=0.036) were both weaker than CB stems. Wired-TS stems showed no significant difference from non-wired-TS stems. Additionally, the study could not conclude that calcar wiring is stronger than diaphyseal wiring. All TS fractures occurred at the mid-stem, simulating a B-type fracture, while the addition of the diaphyseal wire shifted the fracture location more distally in four of seven stems (p=0.0699). This biomechanical study supports the clinical evidence that CB stems have stronger resistance to torque than TS stems and may explain lower risk of periprosthetic fracture. The addition of calcar or diaphyseal wires to TS stems resulted in no significant changes in peak torque to fracture. In patients at high risk of periprosthetic fracture, CB cemented stems should be considered


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_16 | Pages 92 - 92
19 Aug 2024
Barrios V Gómez D Jiménez N Guzman J Pesántez R Bonilla G
Full Access

The growth of life expectancy during the last decades has led to an increment in age-related conditions such as hip arthritis and fractures. On the other hand, these elderly patients will present a higher incidence of mental diseases which, in some studies, have been associated with inferior results. This study aims to evaluate the differences in early complication rates between patients with cognitive impairment compared with those without this condition following total hip replacement for osteoarthritis or fracture in the context of contemporary perioperative care protocols. We conducted a retrospective cohort study where cognitively-impaired patients who required primary hip arthroplasty were compared to a propensity-score matched cohort of patients without cognitive alterations. Early major complications were measured and analyzed in order to determine significant differences. Screening and matching. 1196 patients were identified during the study period. After screening for inclusion and exclusion criteria and matching, two cohorts comprising 65 patients each were compared. After performing the propensity-score match, no significant differences were found in covariates between the two groups. Outcomes. The occurrence of delirium was more frequent in patients with cognitive deficit (27.5%) than in the control group (9%), p<0.001. No significant differences were found among groups regarding myocardial infarction, venous thromboembolism, blood transfusion requirement, 30-day readmission, in-hospital death, 90-days death, dislocation or surgical site infection. The composite outcome of any adverse event did not exhibit a significant difference either. To our knowledge, this is the first study which demonstrates similar outcomes between patients with cognitive impairment and those without these alterations. Our results might indicate that contemporary protocols and implants are bridging the traditional gap between these two populations. These findings support the use of total hip arthroplasty in patients with mental alterations when indicated, especially in those institutions with strict perioperative protocols


Bone & Joint Research
Vol. 13, Issue 8 | Pages 392 - 400
5 Aug 2024
Barakat A Evans J Gibbons C Singh HP

Aims

The Oxford Shoulder Score (OSS) is a 12-item measure commonly used for the assessment of shoulder surgeries. This study explores whether computerized adaptive testing (CAT) provides a shortened, individually tailored questionnaire while maintaining test accuracy.

Methods

A total of 16,238 preoperative OSS were available in the National Joint Registry (NJR) for England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey dataset (April 2012 to April 2022). Prior to CAT, the foundational item response theory (IRT) assumptions of unidimensionality, monotonicity, and local independence were established. CAT compared sequential item selection with stopping criteria set at standard error (SE) < 0.32 and SE < 0.45 (equivalent to reliability coefficients of 0.90 and 0.80) to full-length patient-reported outcome measure (PROM) precision.


Bone & Joint 360
Vol. 13, Issue 3 | Pages 37 - 40
3 Jun 2024

The June 2024 Trauma Roundup360 looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients.


The Bone & Joint Journal
Vol. 106-B, Issue 6 | Pages 532 - 539
1 Jun 2024
Lei T Wang Y Li M Hua L

Aims

Intra-articular (IA) injection may be used when treating hip osteoarthritis (OA). Common injections include steroids, hyaluronic acid (HA), local anaesthetic, and platelet-rich plasma (PRP). Network meta-analysis allows for comparisons between two or more treatment groups and uses direct and indirect comparisons between interventions. This network meta-analysis aims to compare the efficacy of various IA injections used in the management of hip OA with a follow-up of up to six months.

Methods

This systematic review and network meta-analysis used a Bayesian random-effects model to evaluate the direct and indirect comparisons among all treatment options. PubMed, Web of Science, Clinicaltrial.gov, EMBASE, MEDLINE, and the Cochrane Library were searched from inception to February 2023. Randomized controlled trials (RCTs) which evaluate the efficacy of HA, PRP, local anaesthetic, steroid, steroid+anaesthetic, HA+PRP, and physiological saline injection as a placebo, for patients with hip OA were included.


Aims

In this investigation, we administered oxidative stress to nucleus pulposus cells (NPCs), recognized DNA-damage-inducible transcript 4 (DDIT4) as a component in intervertebral disc degeneration (IVDD), and devised a hydrogel capable of conveying small interfering RNA (siRNA) to IVDD.

Methods

An in vitro model for oxidative stress-induced injury in NPCs was developed to elucidate the mechanisms underlying the upregulation of DDIT4 expression, activation of the reactive oxygen species (ROS)-thioredoxin-interacting protein (TXNIP)-NLRP3 signalling pathway, and nucleus pulposus pyroptosis. Furthermore, the mechanism of action of small interfering DDIT4 (siDDIT4) on NPCs in vitro was validated. A triplex hydrogel named siDDIT4@G5-P-HA was created by adsorbing siDDIT4 onto fifth-generation polyamidoamine (PAMAM) dendrimer using van der Waals interactions, and then coating it with hyaluronic acid (HA). In addition, we established a rat puncture IVDD model to decipher the hydrogel’s mechanism in IVDD.


Current advice regarding implant choice is based on estimates of cost-benefit derived from implant survival to an endpoint of revision. Current estimates do not account for many implant failures which are treated with non-revision surgery and may not be accurate. The aim of this study was to estimate survival of major stem implant design groups to an endpoint of reoperation. Primary total hip replacement and linked revision form the National Joint Registry (NJR) and Hospital Episode Statistics (HES) data linked by unique identifier were used. Survival of femoral implant groups (cemented stainless steel polished taper [PTSS], cemented cobalt chrome polished taper [PTCC], cemented composite beam [CB], collarless cementless [NCOL] and collared cementless [COL]) was estimated using Kaplan-Meier method. 809,832 patients with valid NJR and HES data from England, were included. Cumulative failure at ten years for PTSS increased overall from 2.9% (95%CI 2.8–2.9) to 3.6% (95%CI 3.6–3.7) after inclusion of reoperations. Cumulative failure at ten years for PTSS increased from 2.5% (95%CI 2.5–2.6) to 3.3% (95%CI 3.2–3.4), for PTCC increased from 3.8% (95%CI 3.5–4.0) to 5.4% (95%CI 5.1–5.6), for CB increased from 3.1% (95%CI 2.9–3.3) to 4.1% (95%CI 3.8–4.3), for NCOL increased from 3.4% (95%CI 3.3–3.5) to 3.9% (95%CI 3.8–4.0), and for COL increased from 2.5% (95%CI 2.4–2.6) to 3.1% (95%CI 2.9–3.2), after inclusion of reoperations. Re-operation for internal fixation is as significant life event for the patient as revision. When a more inclusive metric is used, the patient and clinician's perspective on what constitutes a GIRFT implant may not be the same. Further work is required to update implant selection guidance in view of the change in implant performance


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 64 - 64
2 May 2024
Lamb J West R Relton S Wilkinson M Pandit H
Full Access

Current estimates of periprosthetic fracture risk associated with femoral implants is mostly limited to revision only estimates and does not accurately represent stem performance. The aim of this study was to estimate the risk of surgically treated post-operative periprosthetic femoral fracture (POPFF) more accurately associated with frequently used femoral implants used for total hip arthroplasty (THA). A cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020. Periprosthetic fractures were identified from prospectively collected revision records and national procedure coding records. Survival modelling was used to estimate POPFF incidence rates, adjusting for potential confounders. Subgroup analyses were performed for patients over 70 years, with non-osteoarthritic indications, and neck of femur fracture. POPFF occurred in 0.6% (5100/809,832) of cases during a median (IQR) follow up of 6.5 (3.9 to 9.6) years. The majority of POPFF were treated with fixation after implantation of a cemented stem. Adjusted patient time incidence rates (PTIR) for POPFF varied by stem design, regardless of cement fixation. Cemented composite beam stems (CB stems) demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF versus the current gold standard polished taper slip cemented stem. POPFF account for a quarter of all revisions following primary THA. Cemented CB stems are associated with the lowest POPFF risk. Stem design is strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when recommending femoral implants in those most at risk of POPFF


The Bone & Joint Journal
Vol. 106-B, Issue 5 Supple B | Pages 74 - 81
1 May 2024
Callary SA Broekhuis D Barends J Ramasamy B Nelissen RGHH Solomon LB Kaptein BL

Aims

The aim of this study was to compare the biomechanical models of two frequently used techniques for reconstructing severe acetabular defects with pelvic discontinuity in revision total hip arthroplasty (THA) – the Trabecular Metal Acetabular Revision System (TMARS) and custom triflange acetabular components (CTACs) – using virtual modelling.

Methods

Pre- and postoperative CT scans from ten patients who underwent revision with the TMARS for a Paprosky IIIB acetabular defect with pelvic discontinuity were retrospectively collated. Computer models of a CTAC implant were designed from the preoperative CT scans of these patients. Computer models of the TMARS reconstruction were segmented from postoperative CT scans using a semi-automated method. The amount of bone removed, the implant-bone apposition that was achieved, and the restoration of the centre of rotation of the hip were compared between all the actual TMARS and the virtual CTAC implants.


Aims

The aims of this study were to evaluate the incidence of reoperation (all cause and specifically for periprosthetic femoral fracture (PFF)) and mortality, and associated risk factors, following a hemiarthroplasty incorporating a cemented collarless polished taper slip stem (PTS) for management of an intracapsular hip fracture.

Methods

This retrospective study included hip fracture patients aged 50 years and older treated with Exeter (PTS) bipolar hemiarthroplasty between 2019 and 2022. Patient demographics, place of domicile, fracture type, delirium status, American Society of Anesthesiologists (ASA) grade, length of stay, and mortality were collected. Reoperation and mortality were recorded up to a median follow-up of 29.5 months (interquartile range 12 to 51.4). Cox regression was performed to evaluate independent risk factors associated with reoperation and mortality.