Aims

The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

Hypermobility Spectrum Disorder (HSD or hEDS) is attributed to a collagen abnormality associated with excessive joint flexibility. Approximately 90% of females with hip dysplasia have hypermobility. Manifestations of hypermobility in various body systems are unique to every patient, affecting different tissues of the body with varying degrees of severity. Our purposes were to identify the manifestations of hypermobility across multiple body systems and to study the recognition of hypermobility in the medical literature of multiple specialties over multiple decades. A literature search of the major medical disciplines for key words associated with HSD was performed. These specialties included gastroenterology, gynecology, neurology, psychiatry, oral-maxillofacial surgery, cardiology, and orthopaedic surgery. A specialty-specific impact factor (IF) score was calculated as the percentage of research articles that referenced hypermobility as a comorbidity over all articles within that specialty. Statistical differences were identified using single factor ANOVA with significance determined at p<0.05. We reviewed many published, specialty-specific manifestations of hypermobility, and describe them. All six non-orthopaedic specialties demonstrated a continually increasing relative IF ratio throughout the study period with a peak impact average of 0.22 (p<0.05 compared with other time ranges). There was a 93.3% overall increase in IF scores from the 1992–1998 period to the most recent period examined (p<0.05). Hypermobility is increasingly recognized as a significant health issue in multiple disciplines. Since dysplasia is associated with approximately 40% of all primary total hip arthroplasty cases, understanding the multi-system manifestations, and broad impact of hypermobility on patients, is relevant for every hip surgeon. We are expanding our research into other medical disciplines, including urology, ophthalmology, dermatology, clinical psychology, and others

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Cite this article: Bone Joint J 2023;105-B(4):361–364.

Aims

In this study, we aimed to evaluate incidence trends and potential risk factors associated with Perthes’ disease in Denmark, using publicly available data.

Introduction. Treatment of prosthetic joint infection (PJI) following total knee arthroplasty (TKA) may guided by PJI classification, taking into account infection duration and potential for biofilm formation. Debridement, antibiotics and implant retention (DAIR) is recommended for ‘post-operative’ and ‘acute’ haematogenous PJI. However, the time cut-off for ‘post-operative’ PJI varies across classification systems. Furthermore, poor DAIR success rates have been reported in acute haematogenous PJIs. This study aimed to determine the success of DAIR in a large cohort of PJIs, and assess the utility of current classification systems for predicting DAIR outcomes. Method. In this multicentre retrospective, cohort study, we identified 230 patients undergoing DAIR for first episode PJI following primary TKA. Patient demographics, disease and surgical factors were identified, and PJI subtype, post-operative antibiotic regime and treatment outcomes were recorded. Statistical analysis was performed to identify factors associated with failed DAIR, and success rates were analysed by multiple classification systems using receiver operating characteristic (ROC) curves. Results. At average follow-up of 6.9 years, DAIR failed in 46% of cases. ROC analysis found 3 month and 1 year cut-offs for ‘post-operative’ PJIs were equally predictive of outcomes (AUC=0.63). On multivariate survival analysis, DAIR failed in 63% of late haematogenous PJIs (implant age>1 year) compared to 36% of early (<1year) PJIs (OR=1.78, p=0.01). Staphylococcus aureus (OR=4.70, p<0.001) and gram negative infections (OR=2.56, p=0.031) were risk factors for DAIR failure in late PJIs. Conclusions. We found a high failure rate in late infections following TKA, irrespective of their classification as ‘acute haematogenous’ or ‘chronic’. Higher DAIR success rates were seen with implant age <1year. These findings call into question the utility of current classification systems based on duration of bacterial presence. For late infections (>1year), PJI caused by S. aureus or gram negative bacteria have a higher failure rate when treated with DAIR

Aims

The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution.

Aims

Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach.

INTRODUCTION. Although several meta-analyses have been performed on total knee arthroplasty (TKA) using computer-assisted orthopaedic surgery (CAOS) [1], understanding the inter-site variations of the surgical profiles may improve the interpretation of the results. Moreover, information on the global variations of how TKA is performed may benefit the development of CAOS systems that can better address geographic-specific operative needs. With increased application of CAOS [2], surgeon preferences collected globally offers unprecedented opportunity to advance geographic-specific knowledge in TKA. The purpose of this study was to investigate geographic variations in the application of a contemporary CAOS system in TKA. Materials and Methods. Technical records on more than 4000 CAOS TKAs (ExactechGPS, Blue-Ortho, Grenoble, FR) between October 2012 and January 2016 were retrospectively reviewed. A total of 682 personalized surgical profiles, set up based on surgeon's preferences, were reviewed. These profiles encompass an extensive set of surgical parameters including the number of steps to be navigated, the sequence of the surgical steps, the definition of the anatomical references, and the parameters associated with the targeted cuts. The profiles were compared between four geographic regions: United States (US), Europe (EU), Asia (AS), and Australia (AU) for cruciate-retaining (CR) and posterior-stabilized (PS) designs. Clinically relevant statistical differences (CRSD, defined as significant differences in means ≥1°/mm) were identified (significance defined as p<0.05). Results. For resection parameters, CRSDs were found between regions in posterior tibial slope (PTS), tibial resection depth, as well as femoral flexion for both CR and PS profiles (marked in Table 1). Regarding anatomical references, US was the only region using posterior cruciate ligament (PCL) as the reference for CR resection depth (Table 1). Differences in percentage of preference were found in the anatomical references for tibial varus/valgus, tibial resection depth, femoral varus/valgus, femoral axial rotation, and ankle center (Table 1,2). For surgical steps, EU and AU were found to apply gap balancing technique as a common practice for the PS designs, while for the CR designs, EU and AU considerably adopted this technique (Table 2). For PS designs, EU and AU profiles preferred tibial first in the resection workflow, compared to a more balanced preference for other regions. For CR designs, US profiles were in favour of performing the femoral resection first in the workflow, compared to a strong favouring of tibial first resection workflow in EU and AS Am regions. Discussion. This study demonstrated clinically significant geographic differences may exist in the surgeons' preference of surgical parameters, anatomical references, and surgical workflow steps during TKA. These differences may reflect the geographic variations of surgeon training, surgical philosophy, or the specific characteristics of the patient population, which warrants further investigation. The strength of this study was that it is the first study to date that covered all the available surgical profiles spanning the application history of a specific CAOS system. As such, variation due to the operational differences of multiple systems was avoided. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims

We assessed the value of the Clinical Frailty Scale (CFS) in the prediction of adverse outcome after hip fracture.

Peri-prosthetic fractures around implants in the proximal humerus can present substantial challenges. Most individuals who undergo upper limb arthroplasty tend to be osteopenic to begin with, and the anatomy of the proximal humerus does not provide an excess of bone to work with. Therefore, peri-prosthetic fractures pose difficulties to rotator cuff function and implant stability. There are multiple classification systems, but series are small and the classification does not always lead to treatment algorithms. Risk factors for humeral fractures after shoulder arthroplasty include endosteal notching, cortical perforation, varus malalignment, stem perforation, ipsilateral shoulder and elbow arthroplasties, and loose stems. Many of these risk factors are directly related to technical errors at the time of surgery. Poor exposure can lead to aberrant starting point and errors in reaming. Oversized prostheses can lead to cortical perforation or even stem perforation. Proper positioning of the patient on the table and surgical releases help avoid these technical errors. Peri-prosthetic fractures should be carefully evaluated radiographically for stability. Two important considerations: 1. Is the implant stable? 2. Is the fracture stable? Generally, if the implant is unstable, the implant must be revised. In the setting of a stable implant, many humeral fractures can be treated nonoperatively. Many fractures at or below the level of the tip of the implant can be treated as typical humeral fractures. Options for fixation include plates with cables or long stem prostheses which bypass the fracture. Displaced tuberosity fractures are treated with suture or wire fixation. Risk factors for a poor outcome include increased time to union, skin breakdown, and stiff shoulder

Purpose of the study: Increased cost of care and limited resources have become important factors in patient treatment. We wanted to ascertain the cost of hospital care, the duration of the hospital stay, the number of rest days, and the degree of correction achieved in a group of patients with idiopathic scoliosis treated surgically over a period of 40 years using four different surgical techniques: Hibbs, Harrington, Harri-Luque, and a multiple hook system. Material and methods: This retrospective analysis included 50 patients treated in the same center (Scoliosis Center of the Buenos Aires Italian Hospital. Duration of hospitalization before surgery, total duration of the hospital stay, duration of rest, degree of correction, updated hospital cost and updated expenditures for implants and physician fees were noted

There are several concerns about the current simulators for TKA. First, the knee is flexed in a “passive way” under the condition of applying constant muscular tension forces. Second, the effects of hip joint motion are not taken into account. Thirdly, the external load for example, upper body weight is not applied in a natural way. Finally, few simulators are capable of knee flexion greater than about 100°. To this end, we have developed a novel knee simulator system that reproduces the active and natural knee motion to evaluate kinematics and joint forces of TKA. Our simulator system has the following advantages and innovative features. First, it is driven directly by muscles' tension forces, and the knee is capable of active flexion. Secondly, a hip joint is incorporated into it and the lower limb motion is achieved in a synergistic way between the hip and knee joints. Thirdly, it is capable of complete deep knee flexion up to 180°. Figure 1 shows the structure of the system. Both the hip and knee joints are moved by the tension forces of four wires that simulate the functions of the mono-articular muscles ((1), (3)) and the bi-articular muscles ((2), (4)) by means of a multiple pulley system (Fig 2). The femoral and tibial components of TKA are secured in the distal end of the upper link (thigh) and the proximal end of the lower link (shank) respectively. The ankle assembly has three sets of rotary bearings whose axes intersect at a fixed point, the center of the ankle, allowing spherical movement of the tibia about the ankle center. Springs were stretched around the ankle center to substitute the muscles around the ankle. Weights I and II are counterweights so as to duplicate the weights of the human upper body, thigh and shank respectively. The wires are pulled to produce the hip and knee motions. The linear bearings running along vertical rods also prevent the system from collapsing. In the experiment, a custom-designed posterior stabilized type TKA was attached to the simulator system for evaluation. The system was operated so as to reproduce the sit-to-stand features in a quasi-static manner in order to study the kinematics of TKA. Beyond 130°, the knee proceeded to flex passively because of upper body weight. Conspicuous internal/external rotation or valgus/varus motion of the tibia relative to the femur was not observed as the knee flexed. When our simulator system was driven in a quasi-static manner, it was able to measure the kinematics of TKA however, when the system was driven in a dynamic manner, it oscillated because the springs around the ankle were not stiff enough to hold the inverted pendulum-like system upright and the ratios of the tension force exerted by the four wires simulating muscles could not be determined appropriately

Introduction: Multiple scoring systems are available to evaluate arthritic hip pain and to assess outcome after arthroplasty. These scores focus on evaluating hip pain and function in elderly patients with degenerative joint disease. They are not specific for sports-related or mechanical hip symptoms in young people, or sensitive to change after new treatments such as arthroscopic hip surgery. Methods: We systematically reviewed the literature since 1980, searching for systems used to measure severity of symptoms and outcome of treatment in these patients. We collected reports of performance of these systems. We then used the best of them to collect symptom scores from 200 patients, and measured the agreement of systems. We performed an item reduction process to identify the question items most associated with overall scores. Results: Systematic review yielded 4 scoring systems which have been used to evaluate sports-related or mechanical hip symptoms: the Non-arthritic Hip Score (NHS), Hip Outcome Score (HOS), Hip disability and Osteoarthritis Outcome Score (HOOS)and a modified Harris Hip Score (mHHS). All scores are self administered and symptom related, requiring no physical examination. All but the mHHS have some evidence of reliability and validity. There is a great deal of overlap among the variables selected by the authors and agreement between the various scoring systems is surprisingly good. Most of the variability of all of the systems could be captured with ten simple questions. Conclusion: We have developed a simple set of ten questions which capture outcome information as well as existing more complex systems. This will be useful is assessing outcome after new treatments such as hip arthroscopy in young active people

We have developed a novel knee simulator that reproduces the active knee motion to evaluate kinematics and joint reaction forces of TKA. There have been developed many kinds of knee simulators; Most of them are to predict TKA component wear and the others are to evaluate the kinematics and/or kinetics of TKA. The most simulators have been operated using the data of the loading and kinematics profile of the knee obtained from normal gait. Here a problem is that such variables as joint force and kinematics are the outcome caused by the application of muscles' and external forces. If so, a simulator should be operated by the muscles' and external forces so as to duplicate the in vivo condition. Other disadvantages for the current knee simulators are; a knee joint motion is made passively, the effects of the hip joint motion are not taken into account, and the maximum flexion angle is usually limited at about 100°. Considering the above, we have developed a knee simulator with the following advantages and innovative features. First, the simulator is driven by the muscles' forces and an active knee motion is made with bearing the upper body weight. As a result, the knee shows a 3D kinematics and generates the tibio-femoral contact forces. Under this condition, the TKA performance is to be assessed. Secondly, a hip joint mechanism is also incorporated into the simulator. The lower limb motion is achieved by the synergistic function between the hip and knee joints. Under this condition, a natural knee motion is to be reproduced. Thirdly, the simulator can make complete deep knee flexion up to 180°. Thus not only the conventional TKA but also a new TKA for high flexion can be attached to it for the evaluation. Figure 1 shows the structure of the simulator, in which both the hip and knee joints are moved in a synergistic fashion by the pull forces of four wires. The four wires are pulled by the four servomotors respectively and reproduce the functions of the mono-articular muscles ((1), (3)) and the bi-articular muscles ((2), (4)) through the multiple pulley system. It should be noted that weight A and B are not heavy enough for the inverted double pendulum to stand up straight. They are applied as counter weights so that each segment duplicate the each segmental weight of the human lower limb. Figure 2 shows a sequential representation of stand to sit features: (a) at standing, (b) at high flexion, and (c) at deep flexion. At a state of 130° knee flexion between (b) and (c), hamstrings wire (4) becomes shortest and then exhibits an eccentric contraction, thereby attaining deep flexion. Our knee simulator can be a useful tool for the evaluation of TKA performance and may potentially substitute the in vivo experiments

1. A survey of genetic and other etiological factors has been carried out in 589 index patients with congenital dislocation of the hip and their families, with special investigation of acetabular dysplasia, familial joint laxity and a comparison of neonatal and late-diagnosis cases. 2. It is believed that there are two etiological groups with congenital dislocation of the hip, i) a group with acetabular dysplasia which is inherited as a multiple gene system and is responsible for a high proportion of cases diagnosed late, and ii) a group with joint laxity which is responsible for a high proportion of neonatal cases. 3. Evidence is presented to show that acetabular dysplasia is a separate heritable system in some families. 4. Other findings relating to the genetic aspects of the survey are summarised

Introduction: Multiple classification systems for avascular necrosis of the hip have been developed to assist physicians in the diagnosis and treatment of this potentially debilitating disorder. However, this lack of consistency makes clinical decision making difficult when comparing publications. The purpose of this study was to quantify the classification systems reported since 1985 (post-MRI) and identify consistent factors which would allow cross-publication comparisons to be made. Materials and Methods: The authors performed a PubMed search for reports of outcome studies concerning treatment methods of hip avascular necrosis that were the initial basis for analysis. All studies reported since 1985 were included in the analysis if outcomes of greater than 10 patients treated for this disease were reported. Classification systems utilizing at least one factor were also identified. Tabulation of how frequently these classification systems were used in terms of the number of studies reporting results was performed. Results: Fifteen major classification systems utilizing more than one radiographic factor were identified with 9 having one to three modifications reported throughout the literature. Additionally, 14 systems utilized either MRI or anatomic factors. Cross-publication analysis revealed five major classification systems which were utilized in greater than 80% of the reported studies. Discussion: This analysis of the reported classification systems for avascular necrosis of the femoral head revealed several similarities between systems. A cross system analysis can be made if data is collected according to patient symptoms, magnetic resonance imaging findings, and x-ray findings which would allow for the use of any staging system

Objectives

The aim of this study was to assess the clinical application of, and optimize the variables used in, the BACH classification of long-bone osteomyelitis.

Aims

To evaluate interobserver reliability of the Orthopaedic Trauma Association’s open fracture classification system (OTA-OFC).