Norbert Kastner

Venous Thrombosis After Hallux Valgus Surgery

Background: Although surgery for the treatment of hallux valgus is frequently performed, the exact rate of deep vein thrombosis following this procedure is unknown. We performed a single-center, prospective, phlebographically controlled study to quantify the rate of venous thrombosis following operative correction of hallux valgus. Methods: Consecutive patients undergoing chevron bunionectomy for correction of hallux valgus deformity were enrolled in the study. Patients with clinical or hematological risk factors for venous thrombosis were excluded. One hundred patients with a mean age of 48.9 years were operated on and did not receive medical prophylaxis against thrombosis. All patients were assessed with phlebography at a mean of twenty-nine days postoperatively. Results: Venous thrombosis was found in four patients (4%). The mean age of these patients (and standard deviation) was 61.7 ± 6.1 years compared with a mean age of 48.4 ± 13.9 years for the patients in whom thrombosis did not develop (p = 0.034). Conclusions: Patients are at a low risk for venous thrombosis following surgical treatment of hallux valgus. The need for prophylaxis against thrombosis should be calculated individually for each patient according to his or her known level of risk. Routine medical prophylaxis against thrombosis might be justified for patients over the age of sixty years. Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

Painful soft-tissue reaction to injectable Norian SRS calcium phosphate cement after curettage of enchondromas.

A prospective single-cohort study was designed to include 20 patients with enchondromas but was stopped because of poor early results. Four patients with an enchondroma, three in the proximal humerus and one in the distal femur, were treated by curettage and filling of the defect with Norian SRS cement. Clinical and radiological follow-up including CT and MRI was carried out for 18 months. All three patients with lesions in the proximal humerus had severe pain and limited movement of the shoulder. The radiological and CT appearances of the cement were unchanged at follow-up. There were characteristic appearances of synovitis and periosteitis on MRI in two patients. Since the cement induces a soft-tissue reaction the bony cavity should be sealed with the curetted and burred bone after curettage and introduction of Norian cement, especially in sites where a tourniquet cannot be applied.

Primary human bone cultures from older patients do not respond at continuum levels of in vivo strain magnitudes

Osteoporosis is characterized by excessive loss of bone mass, while exercise is believed to maintain or enhance bone mass. Since exercise marginally affects osteoporosis, we wondered whether bone cells from osteoporotic patients would fail to respond to strain. Primary human bone-like cultures were obtained from females over age 60 with hip arthroplasty procedures performed for either osteoporotic fracture (n = 8) or non-osteoporotic osteoarthrosis (n = 5). Cultures (96,000 cell/cm2) were strained in rectangular optically clear silastic wells. Three periods of uniaxial substratum strain (1000 micro-strain, 1 Hz, 10,000 cycles, sine wave) were provided every 24 h using a four-point bending, computer-controlled device. Results at a frequency of 1 Hz were compared to cultures exposed to 20 Hz with bone cells derived from one osteoarthritic subject. Alterations in protein level expression of bone-related proteins were determined using a semi-quantitative confocal approach along with enzyme (alkaline phosphatase) activity and enzyme mRNA copy number using cRNA RT-PCR. Strain did not alter levels of bone-related protein levels, enzyme activity, or steady state copy number per cell in response to strain in either group. Strained cultures from osteoporotic patients exhibited little variation from unstrained controls, while individual cultures from osteoarthritic patients exhibited increases in one protein or the other. The results suggest that bone cells from older individuals may not be responsive to continuum levels of strain anticipated with vigorous activity.

Failure modes for total ankle arthroplasty: a statistical analysis of the Norwegian Arthroplasty Register

BackgroundIt is imperative to understand the most common failure modes of total ankle arthroplasty (TAA) to appropriately allocate the resources, healthcare costs, enhancing surgical treatment methods, and improve design and longevity of the implant. The objective of this study was to investigate the primary mode or modes of failure (Loose talar component, loose tibial component, dislocation, instability, misalignment, deep infection, Fracture (near implant), Pain, defect polyethylene (PE), other, and missing information) of TAA implants, so these failure mode/modes can be targeted for future improvement.MethodsThe Norwegian Total Hip Arthroplasty Register 2008 was chosen as the primary source of data since the register have been in existence for 20 years and also gives more specific failure modes than other registries. Tukey–Kramer method was applied to Norwegian Arthroplasty Register.ResultsAfter the application of the Tukey–Kramer method, it is evident that there is no significant difference between any of the failure modes that are pertinent to the ankle. However, there is significant evidence that the number of ankle arthroplasties are increasing with time.ConclusionsSince there is no statistical evidence showing which failure mode contributes most to revision surgeries, it is concluded that more information/data is needed to further investigate failure modes in ankle arthroplasties. Since the numbers of such surgeries are increasing, sufficient data should become available in time.

Evaluating the tibial and femoral insertion site of the anterior cruciate ligament using an objective coordinate system: A cadaver study

PURPOSE The purpose of this study was to evaluate the tibial and femoral insertion site of the anterior cruciate ligament (ACL) using an objective coordinate system in a cadaver study in order to confirm radiological assumptions of previous investigators who identified the tibial footprint (T) of the ACL on T (5.3; 5.5) and the femoral footprint (F) on F (2.9; 3.5). METHODS The tibial and femoral insertion site of the ACL was analysed on 30 human cadaver knee joints preserved according to the technique by Thiel. Thirty femora and tibiae were photographed under standardised methods and measured on a coordinate system twice by two examiners with respect to the ACLs footprint. We evaluated these measurements by use of the Cohens kappa inter- and intraobserver coefficient for two observers. RESULTS The photographs and tibial and femoral measurements were achieved with an almost perfect and a substantial agreement of inter- and intraobserver coefficients. Further, we could demonstrate that assumptions of anatomic points in previous radiological investigations were correct. CONCLUSIONS Our findings confirmed the anatomic tibial and femoral ACL footprint of a previous investigation and further the reproducibility of our coordinate system as an objective method for graft placement evaluation.

Thromboseprophylaxe in der muskuloskelettalen Chirurgie

ZusammenfassungMuskuloskelettale Eingriffe sind mit einem hohen Risiko für venöse Thrombosen und Pulmonalembolien assoziiert. Die Einführung direkter oraler Antikoagulanzien (DOAK) hat die Möglichkeiten in der Prophylaxe venöser Thromboembolien bei orthopädischen und unfallchirurgischen Eingriffen erweitert. Die Fachgesellschaften für Orthopädie und Orthopädische Chirurgie (ÖGO), Unfallchirurgie (ÖGU), Hämatologie und Onkologie (OeGHO) und für Anaesthesiologie, Reanimation und Intensivmedizin (ÖGARI) tragen dieser Entwicklung Rechnung und haben die Initiative zur Erstellung österreichischer Empfehlungen für die Thromboembolieprophylaxe nach totalem Gelenksersatz von Hüfte und Knie, nach chirurgischer Versorgung von Hüftfrakturen, nach Eingriffen an der Wirbelsäule und nach kleineren orthopädischen und traumatologischen Eingriffen ergriffen. Zudem werden die Pharmakologie der DOAK und die wesentlichen Studiendaten zu jeder einzelnen der derzeit auf dem Markt befindlichen Substanzen – Apixaban, Dabigatran und Rivaroxaban – kurz dargestellt. Den Themen „Antikoagulation und neuroaxiale Blockaden“ und „Bridging“ wurden eigene Abschnitte gewidmet.SummaryMusculoskeletal surgery is associated with a high risk of venous thrombosis and pulmonary embolism. The introduction of direct oral anticoagulants (DOAK) has broadened the possibilities for prevention of venous thromboembolism in the course of orthopedic and trauma surgery. Addressing this recent development, the Austrian Societies of Orthopedics and Orthopedic Surgery (ÖGO), Trauma Surgery (ÖGU), Hematology and Oncology (OeGHO) and of Anaesthesiology, Reanimation und Intensive Care Medicine (ÖGARI) have taken the initiative to create Austrian guidelines for the prevention of thromboembolism after total hip and knee replacement, hip fracture surgery, interventions at the spine and cases of minor orthopedic and traumatic surgery. Furthermore, the pharmacology of the DOAK and the pivotal trial data for each of the three currently available substances – apixaban, dabigatran, and rivaroxaban – are briefly presented. Separate chapters are dedicated to “anticoagulation and neuroaxial anesthesia” and “bridging”.

Can we always trust in the computer? Adequate tibial alignment and flexion-gap balancing using personalised knee arthroplasty cutting blocks.

To the Editor, Patient-individualised cutting blocks have drowned the market of total knee arthroplasty (TKA), promising not only faster but even easier surgical success after adequate planning [1–4]. The authors want to discuss how to adequately achieve and improve tibial alignment and flexion gap balancing using the patient individualised TruMatch total knee arthroplasty system (Johnson & Johnson, New Brunswick, NJ, USA). In case of straightforward surgery according to the TruMatch cutting blocks, the authors achieved excellent radiological and anatomical intraoperative results but faced significant flexion gap instability. Therefore, before performing the tibial cut using the TruMatch system the authors recommend double-checking the axis with the conventional alignment tower. In addition, the authors apply the femoral TruMatch cutting block and test its position with respect to adequate flexion gap balance and rotation using the Ranawat block [5]. After adjustment with the tibial alignment tower and the Ranawat block, not only appropriate cutting to the anterior femoral cortex, as measured using the TruMatch system, but also a well-balanced flexion gap can be achieved. We believe that surgeons should always double check patient-individualised cutting blocks using their conventional guides and hope that this letter will assist other knee surgeons in doing so. When using patient individualised cutting blocks, surgeons should avoid a straightforward application of these tools without critical verification, which might on the other hand counter the claimed time reduction.

Disappearance of a cervical spine chordoma after nonoperative treatment. A case report.

C hordoma is a low-grade to intermediate-grade malignant bone tumor that arises from remnants of the embryonal notochord1. The tumor is characterized by slow growth, thus resulting in a relatively long history of symptoms related to it2. The generally accepted treatment of choice for a chordoma is en bloc excision2. However, a chordoma often may have a very late recurrence2. In this report, we present the case of a patient who had a tumor that disappeared without surgical excision or local radiation therapy. We are not aware of a report on a chordoma that has demonstrated a similar behavior. Our patient was informed that data concerning the case would be submitted for publication. A twenty-four-year-old man began having neck pain in the summer of 2002. He had no history of a fall or trauma. The symptoms progressed, and he had episodes of paresthesias in both hands and the chest. Later, urinary and bowel dysfunction occurred. A neurological examination at a local hospital revealed hyperreflexia of the upper and lower extremities. Computed tomography scans of the head showed no abnormality. Subsequently, a computed tomography scan and magnetic resonance imaging study of the cervical spine demonstrated a large tumor (2.5 × 2 × 4 cm) in the second cervical vertebra as well as bone destruction and local calcification resulting in severe spinal stenosis (Figs. 1-A and 1-B). The findings on the routine laboratory tests were normal. Because of the neurological symptoms, the patient was managed with intravenous administration of dexamethasone. A computed tomography-guided needle biopsy of the tumor was performed in November 2002, but no representative tissue was obtained. A specimen obtained from a second closed biopsy with use of a trephine needle also showed no signs of a tumor. An open biopsy from …

Sports Activity after Low-contact-stress Total Knee Arthroplasty – A long term follow-up study

The purpose of this study was to provide comprehensive long-term data about sports activity levels in patients following total knee arthroplasty (TKA) and to determine the impact of pre-operative function, pain and specific performed sports on the results. 236 patients who have undergone TKA for severe osteoarthritis of the knee were asked to provide specific information regarding exercised types of sports before surgery and after at least 10 years following TKA. Pre- and postoperative function and pain were evaluated by the use of Tegner-, WOMAC- and VAS Score. After a mean of 14.9 years, a significant improvement regarding pain and function was observed. Pre-operative Tegner- and WOMAC scores revealed significant positive correlations with the post-operative Tegner-Score. Accordingly, a high percentage of patients (70.9%) stayed actively involved in sports. Nevertheless, the number of performing patients has decreased according to the sports impact. 71.3% continued practising low-impact-, 43.7% intermediate-impact sports whereas only 16.4% kept performing high impact sports. We conclude that TKA is highly effective in long-time pain reduction as well as improvement of function. Additionally, we found considerable sports activities preserved in the investigated series. However, sports activities in particular, seem to decrease according to the impact of sports.

Impact of preoperative antithrombotic therapy on blood management after implantation of primary total knee arthroplasty

Red blood cell concentrates (RCC) substitution after total knee arthroplasty (TKA) is correlated with multifold of complications and an independent predictor for higher postoperative mortality. TKA is mainly performed in elderly patients with pre-existing polymorbidity, often requiring permanent preoperative antithrombotic therapy (PAT). The aim of this retrospective analysis was to investigate the impact of demand for PAT on inpatient blood management in patients undergoing TKA. In this study 200 patients were retrospectively evaluated after TKA for differences between PAT and non-PAT regarding demographic parameters, preoperative ASA score > 2, duration of operation, pre-, and intraoperative hemoglobin level, and postoperative parameters including amount of wound drainage, RCC requirement, and inpatient time. In a multivariate logistic regression analysis the independent influences of PAT, demographic parameters, ASA score > 2, and duration of the operation on RCC demand following TKA were analyzed. Patients with PAT were significantly older, more often had an ASA > 2 at surgery, needed a higher number of RCCs units and more frequently and had lower perioperative hemoglobin levels. Multivariate logistic regression revealed PAT was an independent predictor for RCC requirement. PAT patients are more likely to require RCC following TKA and should be accurately monitored with respect to postoperative blood loss.