Arvind von Keudell

Rates of Radiolucency and Loosening After Total Shoulder Arthroplasty with Pegged or Keeled Glenoid Components

BACKGROUND The objective of this study was to conduct a meta-analysis and cost-effectiveness analysis of the effect of glenoid design on radiolucency, loosening, and revision after total shoulder arthroplasty. METHODS We conducted a systematic review of PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and CINAHL with use of a search for the terms arthroplasty AND shoulder AND (peg OR keel). Data on study design and on the end points of radiolucency, loosening, and revision were extracted independently and in duplicate. Random-effect models were used to calculate the pooled risk ratio and risk difference. The risk difference was used to estimate the number needed to treat (the number of individuals who would have to receive a pegged component to avoid one loosening or revision). RESULTS Eight studies with a total of 1460 patients (mean age, sixty-seven years) were included. The mean study quality was 1.75 points (95% confidence interval [CI], 1.26 to 2.24) on the 3-point modified Jadad scale. There was no significant difference in the risk of any radiolucency (risk ratio, 0.42; 95% CI, 0.12 to 1.42) or in the risk of severe radiolucency (risk ratio, 0.65; 95% CI, 0.23 to 1.82) between pegged and keeled components. The pooled risk ratio for revision was 0.27 (95% CI, 0.08 to 0.88) in favor of pegged components (p = 0.028). At a cost-effectiveness threshold of

Influence of Sex on the Outcome of Autologous Chondrocyte Implantation in Chondral Defects of the Knee

50,000 per quality-adjusted life year, pegged components can be between

Complications of pelvic radiation in patients treated for gynecologic malignancies.

2325 and

Diagnosis and treatment of acute extremity compartment syndrome

40,920 more expensive than keeled components and still be cost-effective. CONCLUSIONS Our study produced evidence that pegged glenoid components were associated with a lower revision risk compared with keeled components. However, the difference was rather small and will therefore be most meaningful to high-volume shoulder arthroplasty centers. Because of the similarity between primary and secondary costs, pegged glenoid designs were more cost-effective than keeled glenoid designs.

Deleterious Effects of Diluted Povidone–Iodine on Articular Cartilage

Background: Sex-specific outcomes have been reported in anterior cruciate ligament reconstruction as well as in osteoarthrosis progression, but there are currently no related published data on autologous chondrocyte implantation (ACI). The present prospective study was performed to investigate sex-dependent differences in the results after ACI. Hypothesis: The clinical and magnetic resonance imaging (MRI) results after ACI of the knee are influenced by the patient’s sex. Study Design: Cohort study; Level of evidence, 2. Methods: The midterm clinical and MRI results of a cell-based fibrin-polymer graft for the treatment of full-thickness cartilage defects were evaluated preoperatively and 6, 12, and 48 months after surgery in 52 patients (male:female ratio, 25:27; average age, 35.6 years). Depending on the sex and the location of the defects (femoral condyles, n = 32; patellofemoral compartment, n = 20), patients were assigned to 4 different groups. Baseline clinical scores were compared with follow-up data by paired Wilcoxon tests for the Lysholm score and the International Knee Documentation Committee (IKDC) scoring system. Sex-specific differences were evaluated with the Mann-Whitney U test. The MRI evaluation was performed with the Henderson score at final follow-up. Results: Clinical scores improved in all groups over the whole study period (P < .05). Compared with female patients, male patients achieved significantly better results in the Lysholm score at all time intervals and in the IKDC score at 6 and 12 months after surgery (P < .05). In a subgroup analysis, female patients with patellar defects had the worst results in both clinical scores. With the available number of patients, MRI evaluation at 48 months after surgery revealed no significant difference in defect fill between male and female patients (P > .05). The Pearson correlation coefficient between both clinical scores and the MRI parameters of defect fill and cartilage signal was significant (P < .05). Conclusion: Autologous chondrocyte implantation is a promising treatment option for full-thickness cartilage defects of male and female knee joints. Female patients with patellar defects have worse prognostic factors.

Lessons from the Boston Marathon bombing: an orthopaedic perspective on preparing for high-volume trauma in an urban academic center

Radiation therapy is a critical treatment modality in the management of patients with gynecologic tumors. New highly conformal external‐beam and brachytherapy techniques have led to important reductions in recurrence and patient morbidity and mortality. However, patients who receive pelvic radiation for gynecologic malignancies may experience a unique constellation of toxicity because of the anatomic locations, combination with concurrent chemotherapy and/or surgery, as well as potential surgical interventions. Although side effects are often categorized into acute versus late toxicities, several late toxicities represent continuation and evolution of the same pathologic process. Comorbidities and radiation dose can significantly increase the risk of morbidity. Current understanding of the incidence of various morbidities in patients treated with current radiation techniques for gynecologic malignancies, the impact of chemotherapy and surgery, treatment options for those effects, and future areas of research are highlighted. Cancer 2014;120:3870–3883.

Spontaneous Osteonecrosis of the Knee Treated with Autologous Chondrocyte Implantation, Autologous Bone-Grafting, and Osteotomy

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Intralesional Osteophyte Regrowth Following Autologous Chondrocyte Implantation after Previous Treatment with Marrow Stimulation Technique

A recent study has suggested that irrigation with povidone-iodine solution after knee arthroplasty significantly decreases rates of post-operative surgical site infection. However, there is only limited knowledge of potential chondrotoxic effects on the residual cartilage in patients with partial knee arthroplasties or unresurfaced patella in total knee arthroplasty. Macroscopically normal bovine cartilage explants (n=42) were exposed to different povidone-iodine concentrations for 1, 3 or 6 min, as well as saline control. The viability of superficial chondrocytes was measured by a Live/Dead cytotoxicity assay. Chondrotoxicity correlated positively with the length of exposure, regardless of the concentration. The extent of superficial chondrocyte death was significantly greater at higher concentrations of povidone-iodine solutions. 0.35% povidone-iodine solution was the least chondrotoxic of all concentrations, but still reduced cell viability significantly if applied for longer than 1 min. Our data suggest that povidone-iodine solution at all tested concentrations has a pronounced chondrotoxic effect on the superficial cartilage layer when used for time periods longer than 1 min.

Autologous Chondrocyte Implantation to Isolated Patella Cartilage Defects: Two- to 15-Year Follow-up

Summary: The 2013 Boston Marathon bombing resulted in a mass casualty event that tested the limits of Boston-area trauma centers. The explosions, 12 seconds apart, led to the rapid influx of 124 patients with primarily lower extremity injuries in 5 different adult level 1 trauma centers. This study aimed to examine the existing hospital systems in place for disaster scenarios at the time of the event and identify areas for improvement. Preparation before the Boston Marathon bombing included coordinating the delivery of patients to area facilities and creating a framework for response at an institutional level. These simulations, coupled with the fact that the explosions occurred at a nexus of medical facilities, helped provide impactful care preventing any fatalities in patients who arrived at a Boston hospital that day. The experience at our institution led to the implementation of a more robust communication infrastructure and reinforced the value of preparatory drills. Within the Orthopaedic Surgery Department, we developed a more robust organizational hierarchy for mass casualty events and implemented a multitrauma follow-up clinic. We believe that it is the responsibility of every hospital to have systems in place to handle the rapid arrival of patients with multiple-trauma, and we hope that others can learn from our experience.

An unusual pathogen for prosthetic joint infection

Spontaneous osteonecrosis of the knee is a disease whose primary etiology remains unknown. First described by Ahlback et al.1 in 1968, it is now categorized as either primary (spontaneous) or secondary osteonecrosis2. Primary osteonecrosis usually presents in people over the age of fifty years, with sudden onset of pain, most frequently in the medial femoral condyle. Secondary osteonecrosis is associated with certain risk factors, such as corticosteroid therapy and alcohol use, and is usually encountered in younger people. In patients with advanced disease or for whom nonoperative treatment has failed, surgery is recommended, typically partial or total joint replacement3-5. Reports of non-arthroplasty procedures are limited. Debridement, curettage, microfracture surgery, osteochondral allograft, bone-grafting, and isolated high tibial osteotomy (HTO) have been proposed6-12, but none have demonstrated proven clinical outcomes in long-term follow-up studies. The recent widespread introduction of autologous chondrocyte implantation (ACI) into clinical practice has renewed interest in biologic treatment options for osteonecrosis of the knee. Recently, Adachi et al.13 showed excellent short-term results with the use of ACI in conjunction with interconnected porous hydroxyapatite (IP-CHA) bone substitute for the treatment of steroid-induced osteonecrosis. In our patients, the abnormal subchondral bone was addressed with an autologous bone graft because of its superior osteogenic, osteoconductive, and osteoinductive properties. We describe two cases of spontaneous osteonecrosis of the knee that were treated with ACI, autologous bone-grafting, and osteotomy and followed for seven and nine years. The patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case 1. A fifty-year-old man with a history of seizures treated with Keppra (levetiracetam), Depakote (valproic acid), and Lamictal (lamotrigine) experienced spontaneous onset of sharp pain in the medial aspect of the knee in June 2000. …