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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 134 - 134
1 Feb 2012
Hassouna H Bendall S
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Arthroscopy of ankle is becoming a common procedure for the diagnosis and treatment of ankle pain. Little information exists regarding the long term prognosis following ankle arthroscopy, particularly in avoiding further major surgery. The purpose of this study is to evaluate the prognosis of arthroscopic ankle treatment, based on survival analysis. Also we will formalise the relationship between the arthroscopic treatment and time for a further major ankle surgery. Type of study. Consecutive Case Series study using prospectively gathered data. Methods. Eighty consecutive patients (80 ankles) having ankle arthroscopy (between 1998 and 2000) with the finding of OA or impingement were identified and their outcome at five years ascertained. Results. Fifty-five (69%) patients had soft tissue impingement, and 25 (31%) patients had osteoarthritic degenerative changes. Seven (9%) patients had further major surgery (arthrodesis or arthroplasty) and 6 (8%) had repeat arthroscopy. The surgery was required for 7 arthritic ankles within five years of arthroscopic procedure. Survival analysis showed no statistical significance between those under 50 and those over 50 years in the OA group. Seven (28%) of osteoarthritic patients progress to major ankle surgery, within 5 years of arthroscopic treatment. None of the patients with impingement symptoms required further major surgery. Conclusion. Arthroscopically treated impingement ankles have an excellent prognosis, while osteoarthritic ankles have a less favoured prognosis, with a high proportion requiring further major surgery. Age does not affect prognosis in the OA group


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 44 - 44
1 Mar 2013
Colman M Choi L Chen A Siska P Goodman M Crossett LS Tarkin I McGough R
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Objectives. To examine patient mortality, implant survivorship, and complication profiles of proximal femoral replacement (PFR) as compared to revision total hip arthroplasty (REV) or open reduction internal fixation (ORIF) in the treatment of acute periprosthetic fractures of the proximal femur. Methods. We performed a retrospective controlled chart review at our tertiary center from from 2000–2010, identifying 97 consecutive acute periprosthetic proximal femoral fractures. Patients were stratified into three treatment groups: PFR (n=21), REV (n=19), and ORIF (n=57). Primary outcome measures included death, implant failure, and reoperation. We also recorded patient demographics, medical comorbidities, fracture type, treatment duration, time to treatment, and complication profiles. Statistical analyis included competing risks survival, which allows independent survival analysis of competing failure mechanisms such as death and implant failure. Results. Competing Risks survival analysis of overall mortality during the mean 35-month follow-up showed no difference between the three groups (p=0.65; 12 and 60 month mortality for PFR: 37%, 45%; REV: 16%, 46%; ORIF: 14%, 100%). Implant survival was worse for the PFR group (p=0.03, 12 and 60-month implant failure rate for PFR: 5%, 39%; REV: 93%, 93%; ORIF 98%, 98%). Comparing PFR to REV and ORIF, PFR had a trend towards higher dislocation (19% vs. 5% vs. 4%, p=0.06). There was no difference between groups with regard to summary non-death complications including DVT, infection, dislocation, and other measures (30% vs. 40% vs. 34%, p=0.80). Operative times were not different between groups (172 min. vs. 162 min. vs. 168 min, p=0.92). Conclusions. In treating difficult periprosthetic fractures, PFR as compared with REV or ORIF has worse medium-term implant survival, primarily due to instability and dislocation. The groups had similar perioperative complication rates, similar short and long term mortality, and similar operative times


Bone & Joint 360
Vol. 6, Issue 2 | Pages 37 - 39
1 Apr 2017
Khan T


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IV | Pages 109 - 109
1 Mar 2012
Baker P Khaw M Kirk L Gregg P
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Introduction. We have carried out a 15 year survival analysis of a prospective, randomised trial comparing cemented with cementless fixation of press-fit condylar primary total knee replacements. Methods. A consecutive series of 501 PFC knee replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. No patients were lost to follow up. Revision was defined as further surgery, irrespective of indication, that involved replacement of any of the three originally inserted components (Femur, Tibia, Patella). Results. Altogether 44 patients underwent revision surgery (24 cemented group Vs 20 cementless group). 11 cases were revised secondary to infection (7 cemented, 4 cementless, mean time to revision=5.1 years) and 26 were revised due to aseptic loosening (14 cemented, 12 cementless, mean time to revision=9.2 years). 7 cases were revised for other reasons (Instability, Anterior knee pain, polyethylene wear, patellar malallignment). For cemented knees 15-year survival=80.7% (95%CI, 71.5-87.4), 10-year survival=91.7 (95%CI, 87.1-94.8). For cemented knees 15-year survival=75.3% (95% CI, 63.5-84.3), 10-year survival=93.3% (95%CI, 88.4-96.2). When comparing the covariates (operation, sex, age, diagnosis, side), there was no significant difference between operation type (Hazard ratio=0.83 (95%CI, 0.45-1.52) p=0.545), side of operation (HR=0.58 (95%CI, 0.32-1.05) p=0.072), age (HR=0.97 (95%CI, 0.93-1.01) p=0.097), diagnosis (OA vs non OA, (HR=1.25 (95%CI, 0.38-4.12) p=0.718). However, there was a significant gender difference (Males vs Females, HR=2.48 (95%CI, 1.34-4.61) p=0.004). Conclusion. This single surgeon series, with no loss to follow up, provides reliable data of the revision rates of the most commonly used total knee replacement. The survival of the press-fit condylar total knee replacement remains good at 15 years irrespective of the method of fixation. This information is useful for strategic health authorities when establishing future requirements for revision knee surgery


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 145 - 145
1 Feb 2012
Pradhan C Daniel J Ziaee H Pynsent P McMinn D
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Introduction

Secondary osteoarthritis in a dysplastic hip is a surgical challenge. Severe leg length discrepancies and torsional deformities add to the problem of inadequate bony support available for the socket. Furthermore, many of these patients are young and wish to remain active, thereby jeopardising the long-term survival of any arthroplasty device.

For such severely dysplastic hips, the Birmingham Hip Resurfacing (BHR) device provides the option of a dysplasia component, a hydroxyapatite-coated porous uncemented socket with two lugs to engage neutralisation screws for supplementary fixation into the solid bone of the ilium more medially. The gap between the superolateral surface of the socket component and the false acetabulum is filled with impacted bone graft.

Methods and results

One hundred and thirteen consecutive dysplasia BHRs performed by the senior author (DJWM) for the treatment of severely arthritic hips with Crowe grade II and III dysplasia between 1997 and 2000 have been reviewed at a minimum five year follow-up. There were 106 patients (59M and 47F). Eighty of the 113 hips were old CDH or DDH, 29 were destructive primary or secondary arthritis with wandering acetabulae and four were old fracture dislocations of the hip. Mean age at operation was 47.5 years (range 21 to 68 years – thirty-six men and forty-four women were below the age of 55 years).

There were two failures (1.8%) out of the 113 hips at a mean follow-up of 6.5 years (range 5 to 8.3 years). One hip failed with a femoral neck fracture nine days after the operation and another failed due to deep infection at 3.3 years.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 12 - 12
24 Nov 2023
Wong J Lee A Fang C Yung C Leung H Liu A So R Leung F
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Aim. To determine mortality and outcomes of patients diagnosed with fracture-related infections (FRIs). Method. FRI patients treated at a trauma centre between 2001 and 2020 were analysed. The primary outcome was 1-year mortality; mortality associations with FRI organism, depth of involvement, and temporality were investigated with multivariable survival analysis. Healthcare-associated and serological outcomes were reported as secondary outcomes. Results. 311 FRIs with mean age of 67.0 and median Charlson comorbidity index of 0 were analysed. Methicillin-sensitive Staphylococcus aureus (MSSA) (29.9%) was the most frequently implicated organism. The majority of FRIs were deep infections (62.7%). FRIs were diagnosed at a median of 40 (IQR 15–200) days post index surgery. The mean follow-up was 5.9 years. One-year mortality amounted to 17.7%. MSSA FRIs were associated with better survival (adj HR 0.34, 95%CI 0.15–0.76, p=0.008). There was no difference in survivorship between deep or superficial FRI (adj HR 0.86, 95%CI 0.62–1.19, p=0.353) or in relation to onset time (adj HR 1.0, 95%CI 0.99–1.00, p=0.943). Implant removal or debridement alone was performed in 61.7% and 17% respectively. Antibiotics was prescribed for 53 (IQR 23–110) days, and patients were hospitalised for 39 (IQR 19–78) days. CRP and ESR normalised in 70.3% (median 46 days) and 53.8% (median 86 days) patients respectively. Conclusions. Fracture-related infections are associated with significant mortality and morbidity regardless of depth and temporality. Non-MSSA FRIs are associated with inferior survival


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_3 | Pages 33 - 33
23 Feb 2023
Paltoglou N Page R Gill S
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In Australia nearly two-thirds of arthroplasty procedures are performed in the private setting, which is disproportionate to the dimensioning 43.5% of the population with private health cover. The rapid growth of shoulder arthroplasty surgery will be absorbed by both private and public sectors. This study aimed to assess the influence of healthcare setting on elective shoulder arthroplasty outcomes, defined by revision rate, and functional measures. Data was collected on all primary procedures performed from 2004 – 2019 within a regional area of Victoria, Australia. Patients were categorised into private or public settings. Trauma cases for acute proximal humerus fractures were excluded. The primary outcome of revision surgery was recorded as a cumulative percentage, and survival analysis conducted to calculate a hazard ratio (HR). Functional outcomes were measured through range-of-motion (ROM) and multiple validated patient-reported-outcome-measures (PROMs). 458 patients were identified in the study: 290 private and 168 public. There was no difference in the revision rate (3.8% private, 4.8% public), with an adjusted HR of 1.25 (p=0.66) for public compared to private. Baseline and post-operative functional measures were significantly greater in the private setting for ROMs and PROMs analysis, in particular post-operative QuickDASH (15.9±14.7 to 32.7±23.5; p<0.001) and Oxford Shoulder Score (42.6±6.3 to 35.7±11.2; p<0.001). However, there was no significant difference for any of the functional measures in the amount of change from baseline to 12-months between settings. Although healthcare setting does not appear to influence revision rate for shoulder arthroplasty, clear differences were demonstrated for functional measures both pre and post operatively. This may be attributed to factors such as access to perioperative rehabilitation and should be an area to target future investigations


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_8 | Pages 31 - 31
10 May 2024
Clatworthy M Rahardja R Young S Love H
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Background. Anterior cruciate ligament (ACL) reconstruction with concomitant meniscal injury occurs frequently. Meniscal repair is associated with improved long-term outcomes compared to resection but is also associated with a higher reoperation rate. Knowledge of the risk factors for repair failure may be important in optimizing patient outcomes. Purpose. This study aimed to identify the patient and surgical risk factors for meniscal repair failure, defined as a subsequent meniscectomy, following concurrent primary ACL reconstruction. Methods. Data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation, the New Zealand Government's sole funder of ACL reconstructions and any subsequent surgery, was reviewed. Meniscal repairs performed with concurrent primary ACL reconstruction was included. Root repairs were excluded. Univariate and multivariate survival analysis was performed to identify the patient and surgical risk factors for meniscal repair failure. Results. Between 2014 and 2020, a total of 3,024 meniscal repairs were performed during concurrent primary ACL reconstruction (medial repair = 1,814 and lateral repair = 1,210). The overall failure rate was 6.6% (n = 201) at a mean follow-up of 2.9 years, with a failure occurring in 7.8% of medial meniscal repairs (142 out of 1,814) and 4.9% of lateral meniscal repairs (59 out of 1,210). The risk of medial failure was higher in patients with a hamstring tendon autograft (adjusted HR = 2.20, p = 0.001), patients aged 21–30 years (adjusted HR = 1.60, p = 0.037) and in those with cartilage injury in the medial compartment (adjusted HR = 1.75, p = 0.002). The risk of lateral failure was higher in patients aged ≤ 20 years (adjusted HR = 2.79, p = 0.021) and when the procedure was performed by a surgeon with an annual ACL reconstruction case volume of less than 30 (adjusted HR = 1.84, p = 0.026). Conclusion. When performing meniscal repair during a primary ACL reconstruction, the use of a hamstring tendon autograft, younger age and the presence of concomitant cartilage injury in the medial compartment increases the risk of medial meniscal repair failure, whereas younger age and low surgeon volume increases the risk of lateral meniscal repair failure


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 40 - 40
1 Oct 2022
Ottink K Dorleijn D Wouthuyzen-Bakker M
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Background. A few patients undergoing a total hip replacement need a subsequent revision of the cup. In some of these cases, the treating surgeon may be confronted with Unexpected Positive Intraoperative Cultures (UPIC). The exact incidence of this finding is unclear. Moreover, it is unknown what the clinical outcome of these patients is when the stem is left in situ. The aim of our study was to describe the incidence of UPIC in patients undergoing cup revision and to determine the need for total revision in this patient group during follow-up. Methods/design. In this retrospective multicenter cohort study, we included all consecutive patients that underwent a cup revision between 2015–2017 and had a minimal follow-up of 2 years. Patients were divided in 3 cohorts: i) no positive intra operative cultures; ii) one UPIC; iii) two or more UPIC. Cases in whom 2 or fewer cultures were obtained during cup revision were excluded from the analysis. Results. From the 334 evaluated cases, 77 were excluded because an inadequate number of cultures were obtained. From the total of 257 included cases, the incidence of UPIC was 16% (n=39). 21 cases had one (8%), and 18 cases had two or more UPIC (7%). After two years of follow up, implant survival in the no UPIC group was 88% (95% CI 0.83 – 0.93), in the one UPIC group 95% (95% CI 0.86 – 1.0), and in the two or more UPIC group 77% (95% CI 0.57 – 0.97). Survival analysis showed no statistically significant differences between the cohorts as determined by cox regressive analysis and log rank test (P = 0.19). Conclusion. The incidence of UPIC in patients who undergo cup revision is relatively high but does not seem to have a major influence on the need for total revision of the hip during a follow-up of 2 years


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 51 - 51
1 Oct 2022
Azamgarhi T Scobie A Karunaharan N Mepham SO Mack D Vekaria K Crick K Chin SH Warren S
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Aim. There is a lack of data supporting the use of doxycycline as a single agent after removing infected orthopaedic metalwork. We evaluated the efficacy and safety of doxycycline compared with other single antibiotic regimens used at our specialist orthopaedic hospital. Methods. A retrospective observational study including all adult patients diagnosed with an orthopaedic metalwork infection due to staphylococci. All patients were managed with the removal of metalwork, and multiple intraoperative samples were sent for culture, followed by the administration of at least four weeks of oral antibiotics. Antibiotic selection was on the recommendation of an infection consultant. Infection outcome was assessed as the proportion of patients meeting the OVIVA Trial definition of definite failure at follow-up. The probability of definite failure for doxycycline and the alternatives group was estimated using the Kaplan-Meier survival method. All adverse drug reactions (ADR) during treatment were analysed. Results. Seventy-nine orthopaedic metalwork infections were identified between July 2017 and July 2021. Forty-four were prosthetic joints, and 35 were fracture-related metalwork. In 54 cases, the infecting organism was Staphylococcus aureus, and 25 were due to coagulase-negative staphylococci. Forty-four were treated with doxycycline 100mg 12 hourly, and 35 were treated with alternatives (flucloxacillin 1g 6-hourly n=21 and clindamycin 450mg 6-hourly n=14). Overall, 70 patients (88.6%) were infection-free after a median follow-up of 23 months (IQR, 19 – 44). 38 (82.3%) were infection-free in the doxycycline group compared with 32 (91.4%) patients treated with alternatives. Of the failures in the alternatives group, all 3 received flucloxacillin. Survival analysis showed no significant difference in time to treatment failure between doxycycline and alternative antibiotics. Eighteen patients experienced an ADR: 2 nausea, one rash and one vaginal candidiasis due to doxycycline. Four diarrhoea, one reflux, two rashes and one headache due to clindamycin; 1 nausea and five diarrhoea due to flucloxacillin. Four patients required discontinuation therapy, two due to clindamycin and two due to flucloxacillin. Conclusions. In our cohort of patients, doxycycline monotherapy was an effective and well-tolerated oral option for treating staphylococcal infection following debridement and removal of orthopaedic metalwork


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_10 | Pages 85 - 85
1 Oct 2022
Mannala G Rupp M Alt V
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Aim. Fungal periprosthetic joint infections are difficult to treat and often associated with a limited outcome for patients. Candida species account for approximately 90% of all fungal infections. In vivo biofilm models play major role to study biofilm development, morphology, and regulatory molecules for bacteria. However, in vivo modeling of biofilm-associated fungi models are very rare. Furthermore, due to ethical restrictions, mammalian models are replaced with other alternative models in basic research. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections with bacteria. This model organism was not used for fungi biofilm infection yet. Thus, we aimed to establish G. mellonella as in vivo model to study fungal implant infections using Candida albicans as model organism and to test anti-fungal medication. Method. Titanium and Stainless steel K-wires were cut into small pieces with size of 4mm. For the infection process, implants were pre-incubated in specified fungal growth culture Candida albicans at 1×10. 7. CFU/ml for 30 min at 150 rpm shaking conditions. Later, these implants were washed with 10ml PBS and implanted in the larvae as mentioned. To analyze the susceptibility of the implant-associated fungal infections towards anti fungal compounds, the larvae were treated with amphotericin B, fluconazole and voriconazole after 24h of implantation. The effect of anti-fungal compounds was measured in terms of survival observation for 5 days and fungal load in larvae on 2. nd. day. To reveal the fungal biofilm formation on implant, the implants were removed on day 3 and processed for SEM analysis. Results. Pre-incubated K-wire caused the Candida infection and observed the death of the larvae. The treatment with antifungal compounds recovered the larvae from the implant-infection, except in case of Voriconazole. However, the recovery with treatment of anti fungal compounds was not effective as the larvae with planktonic infection, which highlights typical biofilm phenotype. Further, the treatment with anti-fungal compounds with Amphotericin B and Fluconazole reduced the fungal load in larvae tissue. The SEM analysis revealed the formation fungal biofilm with hyphae and spores associated with larvae tissue on implant surface. Conclusions. The results from survival analysis, antifungal treatment and SEM analysis are very promising to use of G. mellonella as in vivo model to study fungal infections on implanted materials. Our study highlights the use of G. mellonella larvae as alternative in vivo model to study implant-associated fungal infections that reduces the use of the higher mammals


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_13 | Pages 91 - 91
1 Dec 2022
Rizkallah M Aoude A Turcotte R
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Resection of the proximal femur raises several challenges to the orthopedic oncology surgeon. Among these is the re-establishment of the abductor mechanism that might impacts on hip function. Extent of tumor resection and surgeons’ preferences dictate the reconstruction method of the abductors. While some surgeons advocate the necessity of greater trochanter (GT) preservation whenever possible, others attempt direct soft tissues reattachment to the prosthesis. Sparse data in the literature evaluated the outcomes of greater trochanter fixation to the proximal femur megaprosthesis. This is a retrospective monocentric study. All patients who received a proximal femoral replacement after tumor resection between 2005 and 2021 with a minimum follow-up of three months were included. Patients were divided into two groups: (1) those with preserved GT reattached to the megaprosthesis and (2) those with direct or indirect (tenodesis to fascia lata) abductor muscles reattachment. Both groups were compared for surgical outcomes (dislocation and revision rates) and functional outcomes (Trendelenburg gait, use of walking-assistive device and abductor muscle strength). Additionally patients in group 1 were subdivided into patients who received GT reinsertion using a grip and cables and those who got direct GT reinsertion using suture materials and studied for GT displacement at three, six and 12 months. Time to cable rupture was recorded and analyzed through a survival analysis. Fifty-six patients were included in this study with a mean follow-up of 45 months (3-180). There were 23 patients with reinserted GT (group 1) and 33 patients with soft tissue repair (group 2). Revision rate was comparable between both groups(p=0.23); however, there were more dislocations in group 2 (0/23 vs 6/33; p=0.037). Functional outcomes were comparable, with 78% of patients in group 1 (18/23) and 73% of patients in group 2 (24/33) that displayed a Trendelenburg gait (p=0.76). In group 1, 70% (16/23) used walking aids compared to 79% of group 2 (27/33) (p=0.34). Mean abductor strength reached 2.7 in group 1 compared to 2.3 in group 2 (p=0.06). In group 1, 16 of the 23 patients had GT reinsertion with grip and cables. Median survival of cables for these 16 patients reached 13 months in our series. GT displacement reached a mean of two mm, three mm, and 11 mm respectively at three, six and 12 months of follow-up in patients with grip and cables compared to 12 mm, 24 mm and 26 mm respectively at the same follow-up intervals in patients with GT stand-alone suture reinsertion(p<0.05). Although GT preservation and reinsertion did not improve functional outcomes after proximal femur resection and reconstruction with a megaprosthesis, it was significantly associated with lower dislocation rate despite frequent cable failure and secondary GT migration. No cable or grip revision or removal was recorded. Significantly less displacement was observed in patients for whom GT reattachment used plate and cables rather than sutures only. Therefore we suggest that GT should be preserved and reattached whenever possible and that GT reinsertion benefits from strong materials such as grip and cables


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_13 | Pages 100 - 100
1 Dec 2022
Wajda B Abbott A Kendal J Moorman S Schneider P Puloski S Monument M
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Metastatic bone disease (MBD) is a significant contributor to diminished quality of life in cancer patients, often leading to pathologic fractures, hypercalcaemia, intractable bone pain, and reduced functional independence. Standard of care management for MBD patients undergoing orthopaedic surgery is multi-disciplinary, includes regular surgical follow-up, case by case assessment for use of bone protective medications, and post-operative radiation therapy to the operative site. The number of patients in southern Alberta receiving standard of care post-operative management is currently unclear. Our aim is to develop a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD and to assess for deficiencies and opportunities to ensure standard of care for this complex patient population. Patients were identified for database inclusion by a search query of the Alberta Cancer Registry of all patients with a diagnosis of metastatic cancer who underwent surgery for an impending or pathologic fracture in the Calgary, South and Central Alberta Zones. Demographic information, primary cancer history, previous local and systemic treatments, anatomical location of MBD event(s), surgical fixation techniques, and post-operative care details were collected. The rate of standard of care post-operative treatment was evaluated. A comparison of outcomes between tertiary urban centres and rural centres was also completed. Survival was calculated from time of first operation to date of death. Univariate and multivariate analyses were performed to identify the impact of post-operative care variables on survival amongst patients surviving longer than one month. We identified 402 patients who have undergone surgical treatment for MBD in southern Alberta from 2006-2018. Median age at time of surgery was 66.3 years and 52.7% of patients were female. Breast, lung, prostate, renal cell and multiple myeloma were the most common primary malignancies (n=328, 81.6%). Median post-operative survival was 6.8 months (95%CI: 5.7-8.3). 203 patients (52.5%) were treated with post-operative radiotherapy and 159 patients (50.8%) had post-operative surgical follow-up. Only 39 patients (11.3%) received bone protective agents in the peri-operative period. On multivariate survival analysis, post-operative surgical follow-up was associated with improved survival (p<0.001). Patients were treated at nine hospitals across southern Alberta with most patients treated in an urban center (65.9%). Post-operative survival was significantly longer amongst patients treated in an urban center (9.0 months, 95%CI: 6.9-12.3 versus 4.3 months, 95%CI: 3.4-5.6, p<0.001). The burden of MBD is significant and increasing. With treatment occurring at multiple provincial sites, there is a need for standardized, primary disease-specific peri- and post-operative protocols to ensure quality and efficacious patient care. To provide evidence informed treatment recommendations, we have developed a database of all patients in southern Alberta undergoing orthopaedic surgery for MBD. Our results demonstrate that many patients were not treated according to post-operative standard of care recommendations. Notably, half of the included patients did not have documented surgical follow-up, post-operative radiation treatment was low and only 11% were actively treated with bone protective agents. This data justifies the need for established surgical MBD care pathways and provides reference data to benchmark prospective QA and QI outcomes in this patient population


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_15 | Pages 76 - 76
1 Dec 2021
Mannala G Rupp M Alagboso F Docheva D Alt V
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Aim. In vivo biofilm models play major role to study biofilm development, morphology, and regulatory molecules involve in biofilm. Due to ethical restrictions, the use mammalian models are replaced with other alternative models in basic research. Recently, we have developed insect infection model G. mellonella larvae to study implant associated biofilm infections. This model organism is easy to handle, cheap and ethical restriction free and could be used for the high through put screening of antimicrobial compounds to treat biofilm. To promote the use of this model in basic research we aimed to validate this based on the typical biofilm features such as less susceptible to the antibiotics, complexity of the biofilm structure and gene expression profile of biofilms. Method. G. mellonella larvae are maintained at 30oC on artificial diet in an incubator. Titanium and Stainless steel K-wires were cut into small pieces with size of 4mm. After sterilization with 100% alcohol, these K-wires were pre-incubated in S. aureus bacterial suspension (5×10. 6. CFU/ml) for 30 min, washed in PBS and implanted inside the larva after with help of scalpel. The larvae were incubated at 37. o. C for two day for the survival analysis. To analyze the less susceptibility of the biofilms towards antibiotics, the larvae were treated with gentamicin and compared survival with planktonic infection in G. mellonella. To reveal the complex structure of biofilm, the implants were removed and processed for the MALDI analysis. Whole genome-based transcriptome of biofilm was performed to explore the changes in transcriptional landscapes. Results. The results are very promising to validate the use of G. mellonella as in vivo model to study the biofilm formation on implanted materials. The gentamicin treatment could rescue the larvae from the planktonic infection, but not from the biofilm infection on the implants. Further, the MALDI analysis could reveal the complex structure and components of S. aureus biofilm formed on the implant inside the larvae. Finally, the transcriptomic analysis revealed the gene expression changes that can be compared to normal biofilm expression profile. Conclusions. Further, comparison of these results with other in vivo models such as rat and mouse as well as acute and chronic clinical samples from patients with implant-associated bone infections could validate and relevant use of this model to study S. aureus biofilm infections


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_3 | Pages 62 - 62
1 Mar 2021
Lee J Perera J Trottier ER Tsoi K Hopyan S
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Paediatric bone sarcomas around the knee are often amenable to either endoprosthetic reconstruction or rotationplasty. Cosmesis and durability dramatically distinguish these two options, although patient-reported functional satisfaction has been similar among survivors. However, the impact on oncological and surgical outcomes for these approaches has not been directly compared. We retrospectively reviewed all wide resections for bone sarcoma of the distal femur or proximal tibia that were reconstructed either with an endoprosthesis or by rotationplasty at our institution between June 2004 and December 2014 with a minimum two year follow-up. Pertinent demographic information, surgical and oncological outcomes were reviewed. Survival analysis was performed using the Kaplan-Meier method with statistical significance set at p<0.05. Thirty eight patients with primary sarcomas around the knee underwent wide resection and either endoprosthetic reconstruction (n=19) or rotationplasty (n=19). Groups were comparable in terms of demographic parameters and systemic tumour burden at presentation. We found that selection of endoprosthetic reconstruction versus rotationplasty did not impact overall survival for the entire patient cohort but was significant in subgroup analysis. Two-year overall survival was 86.7% and 85.6% in the endoprosthesis and rotationplasty groups, respectively (p=0.33). When only patients with greater than 90% chemotherapy-induced necrosis were considered, overall survival was significantly better in the rotationplasty versus endoprosthesis groups (100% vs. 72.9% at two years, p=0.013). Similarly, while event-free survival was not affected by reconstruction method (60.2% vs. 73.3% at two years for endoprosthesis vs rotationplasty, p=0.27), there was a trend towards lower local recurrence in rotationplasty patients (p=0.07). When surgical outcomes were considered, a higher complication rate was seen in patients that received an endoprosthesis compared to those who underwent rotationplasty. Including all reasons for re-operation, 78.9% (n=15) of the endoprosthesis patients required a minimum of one additional surgery compared with only 26.3% (n=5) among rotationplasty patients (p=0.003). The most common reasons for re-operation in endoprosthesis patients were wound breakdown/infection (n=6), limb length discrepancy (n=6) and periprosthetic fracture (n=2). Excluding limb length equalisation procedures, the average time to re-operation in this patient population was 5.6 months (range 1 week to 23 months). Similarly, the most common reason for a secondary procedure in rotationplasty patients was wound breakdown/infection, although only two patients experienced this complication. Average time to re-operation in this group was 23.8 months (range 5 to 49 months). Endoprosthetic reconstruction and rotationplasty are both viable limb-salvage options following wide resection of high-grade bony sarcomas located around the knee in the paediatric population. Endoprosthetic reconstruction is associated with a higher complication rate and may negatively impact local recurrence. Study of a larger number of patients is needed to determine whether the reconstructive choice affects survival


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_1 | Pages 38 - 38
1 Feb 2021
Hickey M Anglin C Masri B Hodgson A
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Introduction. Innovations in surgical robotics and navigation have significantly improved implant placement accuracy in total knee arthroplasty (TKA). However, many comparative studies have not been shown to substantially improve revision rates or other clinical outcome scores. We conducted a simulation study based on the reported distribution of patient-specific characteristics and estimated potential effect of coronal plane alignment (CPA) on risk of revision to evaluate the hypothesis that most published study designs in this area have been too underpowered to detect improvements in revision rates. Methods. To model previously reported studies, we generated a series of simulated TKA patient populations, assigning each patient a set of patient-specific factors (age at index surgery, BMI, and sex (Fig.1a)), as well as one surgeon-controlled factor (CPA) (Fig.1b) based on registry data and published literature. We modelled the survival probability for an individual patient at time t as a Gaussian function (exp[-(t/(k∗τ. max. )). 2. ]), where τ. max. (99.5 years) is selected to ensure the mean survival probability of the patient population matched 92% at 15 years. The value of k was adjusted for simulated patients within a range of 0 to 1 as a function of their patient and surgeon-specific factors (Fig.2). To evaluate power associated with a study design, we ran a Monte Carlo simulation generating 10,000 simulated populations of ten different cohort sizes. We divided the patient population into two groups: one group was assigned CPAs governed by the precision of a navigated/robotic approach (σ=1.5°), and the other CPAs governed by the precision of a conventional approach (σ=3°). We then simulated the time to failure for each patient, computed the corresponding Kaplan-Meier survival curves, and applied a Log-Rank test to each study to test for statistical difference. From the 10,000 simulations associated with each cohort size, we determined the percentage of simulated studies that found a statistically significant difference at each time point. Results. Figure 3 shows a contour plot illustrating the probability that a survival analysis with a specific study design would find statistical significance between the conventional and navigated/robotic patient groups. Entries from recently published literature are overlaid for context. No studies achieved statistical significance (p<0.05). Discussion. The effectiveness of navigated/robotic surgery is one of the most controversial debates in orthopedic surgery. The results from this simulation suggest that most revision studies aiming to settle this debate are likely significantly underpowered, falling below the normal 80% threshold. Limitations of this analysis include using only a single surgeon-controlled variable in the survival simulation, and only a single precision for the navigated/robotic approaches. Further studies will include more implant-related risk factors and a wider range of precisions for navigated/robotic procedures. Based on this simulation, it appears the effect size afforded by navigated/robotic surgeries on revision rates in TKA surgery is too small to recommend broad application, especially since adoption could involve added costs and unforeseen risks associated with novelty. Clinically, it may be beneficial to examine the use of robotics/navigation on high-risk patients, where studies are likely to have higher power due to larger effect sizes. For any figures or tables, please contact the authors directly


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_7 | Pages 39 - 39
1 Jul 2020
Le V Escudero M Wing K Younger ASE Penner M Veljkovic A
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Restoration of ankle alignment is thought to be critical in total ankle arthroplasty (TAA) outcomes, but previous research is primarily focused on coronal alignment. The purpose of this study was to investigate the sagittal alignment of the talar component. The talar component inclination, measured by the previously-described gamma angle, was hypothesized to be predictive of TAA outcomes. A retrospective review of the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was performed on all TAA cases at a single center over a 11-year period utilizing one of two modern implant designs. Cases without postoperative x-rays taken between 6 and 12 weeks were excluded. The gamma angle was measured by two independent orthopaedic surgeons twice each and standard descriptive statistics was done in addition to a survival analysis. The postoperative gamma angles were analyzed against several definitions of TAA failure and patient-reported outcome measures from the COFAS database by an expert biostatistician. 109 TAA cases satisfied inclusion and exclusion criteria. An elevated postoperative gamma angle higher than 22 degrees was associated with talar component subsidence, defined as a change in gamma angle of 5 degrees or more between postoperative and last available followup radiographs. This finding was true when adjusting for age, gender, body mass index (BMI), and inflammatory arthritis status. All measured angles were found to have good inter- and intraobserver reliability. Surgeons should take care to not excessively dorsiflex the talar cuts during TAA surgery. The gamma angle is a simple and reliable radiographic measurement to predict long-term outcomes of TAA and can help surgeons counsel their patients postoperatively


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_1 | Pages 15 - 15
1 Feb 2020
Song S Kang S Park C
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Purpose. Long-term clinical and radiographic results and survival rates were compared between closed-wedge high tibial osteotomy (HTOs) and fixed-bearing unicompartmental knee arthroplasty (UKA) in patients with similar demographics. Methods. Sixty HTOs and 50 UKAs completed between 1992 and 1998 were retrospectively reviewed. There were no significant differences in preoperative demographics. The mean follow-up period was 10.7 ±5.7 years for HTO and 12.0 ±7.1 years for UKA (n.s.). The Knee Society knee and function scores, WOMAC, and range of motion (ROM) were investigated. The mechanical axis and femorotibial angle were evaluated. Kaplan–Meier survival analysis was performed (failure: revision to TKA), and the failure modes were investigated. Results. Most of the clinical and radiographic results were not different at the last follow-up, except ROM; ROM was 135.3 ±12.3° in HTO and 126.8 ±13.3° in UKA (p=0.005). The 5-, 10-, 15-, and 20-year survival rates were 100%, 91.0%, 63.4%, and 48.3% for closed-wedge HTO, respectively, and 90.5%, 87.1%, 70.8%, and 66.4% for UKA (n.s.). The survival rate was higher than that for UKA until 12 years postoperatively but was higher in UKAs thereafter, following a remarkable decrease in HTO. The most common failure mode was degenerative osteoarthritic progression of medial compartment in HTO and femoral component loosening in UKA. Conclusions. Long-term survival did not differ significantly between closed-wedge HTO and fixed-bearing UKA in patients with similar preoperative demographics and knee conditions. The difference in postoperative ROM and failure mode should be considered when selecting a procedure


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_1 | Pages 63 - 63
1 Feb 2020
Garcia-Rey E Cimbrelo EG
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Introduction. Total hip arthroplasty (THA) dislocation has been associated with different risk factors. The main difficulty in analysing dislocation is its low rate of incidence, necessitating large series for study. We assessed factors related with patients, implant characteristics, and quality of the hip reconstruction to better identify their influence on the THA dislocation rate. Material and Methods. Dislocations in 2,732 THAs performed between 2001 and 2016 were assessed with regard to factors related with the patient (gender, age, preoperative diagnosis, lumbar pathology); the implant (femoral head size, bearing surface, stem offset, femoral head/neck ratio); and the surgical technique (approach, cup and stem position, and abductor mechanism reconstruction). Regression analysis was used for different risk factors and Kaplan-Meier for survival analysis. Results. After ERAS implementation, opioid consumption decreased for hospital day one (49.5MME to 35.4MME; p=0.000) and overall hospitalization (79.5MME to 59.5MME; p=0.000). Average LOS decreased (57.84hrs to 51.87hrs; p=0.011), blood transfusion rate was unchanged (4.25% to 3.81%; p=0.725), and disposition to home over skilled nursing facility increased (80.4% to 82.5%; p= 0.022). Unplanned return-to-hospital encounters were unchanged (8.51% to 8.88%; p=0.8486). Readmission trended up during postoperative days 0–30 and trended down during postoperative days 31–90. (1.42% to 2.96%; p=0.1074) and (1.21% to 0.85%; p=0.5748), respectively. There were 92 dislocations (3.4%), of these, 62 were treated conservatively (2.3%) and 30 surgically (1.1%). Survivorship analysis for dislocation was 96.0% (95% CI:95.0–97.0) at 17 years. Among patient-related factors, greater age (p=0.001), lower activity level (p=0.001) and lumbar fusion (p<0.001) were associated with a higher dislocation rate. Among implant-related factors, a ceramic-on-ceramic THA (p<0.001) and a femoral size of 32 or 36 mm in diameter had lower dislocation rates. With regards to surgical technique, a greater acetabular abduction angle (p=0.001) and a greater distance to the hip anatomic center (p=0.006) had higher dislocation rates. A cup position outside Lewinnek´s safe zone (p<0.001) and the abductor mechanism window (p<0.001) also had a higher dislocation rate. Multivariate analysis revealed that only significant lumbar pathology (p=0.001) and lumbar fusion (p<0.001) were significant dislocation-related factors among patient-related factors. Poor reconstruction of the hip rotation (p=0.035), a cup position outside of Lewinnek's safe zone (p<0.001) and the abductor mechanism window (p<0.001) were significantly associated with a higher dislocation risk among surgical technique-associated factors. Conclusions. Significant lumbar spine pathology increases the rate of dislocation. A proper reconstruction of the hip, including appropriate cup position and rotation centre reconstruction of the hip are essential to decrease the risk of dislocation after primary THA. The weakness of the abductor muscles is also an important cause for dislocation


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 7 - 7
1 Sep 2012
Gandhi J Sidaginamale R Mereddy P Langton D Joyce T Lord J Natu S Nargol A
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Background. The failure and subsequent withdrawal of the ASR device in both its resurfacing and THR form has been well documented. The National Joint Registry report of 2010 quoted figures of 12–13% failure at five years. Adverse reaction to metal debris (ARMD) is a poorly understood condition and patients developing severe metal reactions may go unrecognised for sometime. Patients and Methods. In 2004 a single surgeons prospective study of the ASR bearing surface was undertaken. We present the ARMD failure rates of the ASR resurfacing and ASR THR systems. The diagnosis of ARMD was made by the senior author and was based on clinical history, examination, ultrasound findings, metal ion analysis of blood and joint fluid, operative findings and histopathological analysis of tissues retrieved at revision. Mean follow up was 52 months (24–81) and 70 patients were beyond 6 years of the procedure at the time of writing. Kaplan Meier survival analysis was carried out firstly with joints designated “failure” if the patient had undergone revision surgery or if the patient had been listed. A second survival analysis was carried out with a failure defined as a serum cobalt > 7µg/L. Full explant analysis was carried out for retrieved prostheses. Results. There were 505 ASR patients in total. 657 metal ion samples were available at the time of writing (152 repeats). Survival analysis using revision/listed as end point (at 6 years):. ASR resurfacing: 26.1% failure. ASR THR: 55.5% failure. Survival using ion analysis (at 5 years):. ASR resurfacing: 50.1% failure. ASR THR: 66.5% failure. The median (range) volumetric wear rate of failed prosthesis was 8.23mm. 3. /year (0.51–95.5). Conclusion. A number of design flaws in the ASR has led to excessive wear of the bearing & taper leading to catastrophic failure secondary to ARMD