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Non-surgical functional treatment for displaced olecranon fractures in the elderly

We retrospectively evaluated the clinical and radiological outcomes of a consecutive cohort of patients aged > 70 years with a displaced fracture of the olecranon, which was treated non-operatively with early mobilisation. We identified 28 such patients (27 women) with a mean age of 82 years (71 to 91). The elbow was initially immobilised in an above elbow cast in 90° of flexion of the elbow for a mean of five days. The cast was then replaced by a sling. Active mobilisation was encouraged as tolerated. No formal rehabilitation was undertaken. At a mean follow-up of 16 months (12 to 26), the mean ranges of flexion and extension were 140° and 15° respectively. On a visual analogue scale of 1 (no pain) to 10, the mean pain score was 1 (0 to 8). Of the original 28 patients 22 developed nonunion, but no patients required surgical treatment. We conclude that non-operative functional treatment of displaced olecranon fractures in the elderly gives good results and a high rate of satisfaction.

Hip arthroscopy in osteoarthritis: a systematic review of the literature.

Background Hip arthroscopy treatment in patients with osteoarthritis is controversial. Hypothesis/Purpose To systematically review the clinical outcome of patients with hip osteoarthritis (OA) treated with arthroscopy and what proportion of these patients subsequently underwent total hip arthroplasty (THA). Study design Systematic review. Methods PubMed, Cochrane library and LILACS were searched from January 1990 through December 2013 for eligible studies. The methodological quality of the collected data (applied to each study) was performed with a modified version of the Coleman methodology score (mCMS). Results 11 studies were included in this review. Most of the studies included reported clinical improvements. The overall conversion rate to THA ranged from 9.5% to 50%. Mean time between arthroscopy and THA was 13.5 months. Conclusions The quality of studies is low. We have found inconclusive evidence to make categorical indications for hip arthroscopy in the treatment of OA, although we have found that there is some postoperative clinical outcome improvement of pain and function in a short-term evaluation. Increasingly worse outcomes were seen as the severity of OA increased.

Is a short stem suitable for patients with hip dysplasia? A report on technical problems encountered during femoral reconstruction:

Introduction: A wide variety of stems have been used for the treatment of osteoarthritis secondary to advanced hip dysplasia. Since evidence for using short stems in dysplastic hips is limited, we planned to analyse the technical problems encountered when reconstructing the proximal femur of patients with osteoarthritis secondary to congenital dysplasia of the hip treated with total hip arthroplasty (THA) using a type 2B short stem. Methods: We prospectively analysed 17 patients (22 hips) treated with primary THA performed with a single-branded short uncemented stem with metaphyseal fixation (MiniHip™; Corin). We excluded cases in which other type of stems were used, or in which retrospective data was only available. Mean follow-up was 41.22 months (minimum 24). We analysed clinical outcome using the modified Harris Hip Score (mHHS) and pain using the visual analogue scale (VAS). Radiographs were examined in order to determine causes of complications and revision surgery. Results: All patients showed statistically significant improvement when preoperative and postoperative values for mHHS (54.19 vs. 94.57; p = 0.0001) and for pain VAS (8.71 vs. 0.71; p = 0.0003) were compared. No cases of thigh pain, instability or infection were found. 1 case of acetabular cup loosening and 1 case of periprosthetic fracture were diagnosed at 8 months and 45 days, respectively. Overall survival was 84.7% at 5 years (CI 95%, 64.4-105.3) with revision for any reason as an end point. When stem performance was separately evaluated, it showed a survival rate of 100% at 5 years with revision for aseptic loosening as an end point. Conclusions: THA with a type 2B short stem for the treatment of dysplastic osteoarthritis showed very few technical intraoperative problems, being a useful alternative for femoral reconstruction.

Transfusion rate using intravenous tranexamic acid in hip revision surgery

INTRODUCTION Hip revision surgery is associated with a high probability of the necessity for a blood transfusion. Different studies support the use of tranexamic acid (TXA) to decrease the rate of transfusions in primary hip surgery. Nevertheless, the use of this drug in hip revision surgery has not yet been widely accepted. The aim of our study was to establish the rate of blood transfusion with and without TXA in hip revision surgery. METHODS We retrospectively studied 125 hip revision surgery patients operated on between 2011 and 2014. We divided our series into 2 groups: the TXA group with 61 patients (in which a 1000 mg dose of TXA was used before the skin incision and a second identical dose after skin closure) and a control group with 64 patients. We analysed the red blood cell (RBC) transfusion rates and their odds risk as well as the presence of collateral complications. RESULTS Average RBC transfusion was 2.7 units/patient (range 0-6) in the control group compared to 1.6 units/patient (range 0-6) in the TXA group. A 90.11% (odds ratio [OR] 0.098; confidence interval [CI] 0.02-0.04; p<0.0029) odds risk reduction for transfusion of at least 1 unit of erythrocyte blood cell was observed in the TXA group. Complications associated with the TXA were similar in both groups. INTERPRETATION The benefits of TXA have been shown in elective hip replacement. In this study, TXA proved to be safe and efficacious in reducing the need for transfusions following revision total hip arthroplasty.

Metaphyseal debonding of the Corail collarless cementless stem: report of 18 cases and case-control study

Aims The Corail stem has good long‐term results. After four years of using this stem, we have detected a small group of patients who have presented with symptomatic metaphyseal debonding. The aim of this study was to quantify the incidence of this complication, to delineate the characteristics of patients presenting with this complication and to compare these patients with asymptomatic controls to determine any important predisposing factors. Patients and Methods Of 855 Corail collarless cementless stems implanted for osteoarthritis, 18 presented with symptomatic metaphyseal debonding. A control group of 74 randomly selected patients was assembled. Clinical and radiological parameters were measured and a logistic regression model was created to evaluate factors associated with metaphyseal debonding. Results The prevalence of this complication was 2.1% in our series. In the multivariable model, the presence of a Dorr B‐type proximal femur was associated with metaphyseal debonding (odds ratio (OR) 10.73, 95% confidence interval (CI) 2.31 to 49.97, p = 0.002), as was a body mass index > 25 kg/m2 (OR 6.85, 95% CI 1.06 to 44.28, p = 0.04). Smaller stems and the use of a polyethylene acetabular liner appeared to be protective when compared with metal and ceramic setting hard‐on‐hard bearings. Conclusion We have described an uncommon but important mode of failure of the Corail stem. Surgeons should be aware of this phenomenon; overweight patients with Dorr B‐type femurs and in whom hard bearings are used appear to be particularly at risk.

Periprosthetic stress fracture around a well-fixed type 2B short uncemented stem

Despite the theoretical advantages of uncemented short stems, postoperative thigh pain is still matter of concern and can be attributed to different causes. We report a peculiar case of a stress fracture around a short cementless stem with cervico-metaphyseal fixation in an otherwise healthy patient. We implanted a MiniHipTM stem in a 43 year-old male professional golf player for the treatment of primary osteoarthritis using a ceramic on ceramic bearing. Against medical advice, the patient started to play soccer at the 4th postoperative month and was completely asymptomatic to that extent; but at 8 months follow-up and without a history of trauma he started complaining about progressive hip pain. After ruling out infection and loosening, histological analysis from a bone biopsy confirmed the diagnosis of stress fracture. Although revision surgery was initially scheduled, pain started to decrease gradually with protected weight-bearing (crutches) and disappeared around the first postoperative year, remaining the patient asymptomatic at 2 and half years of follow-up, with radiographs depicting a healed fracture with a hypertrophic callus. We encourage surgeons to be aware of the existence of periprosthetic stress fractures as a source of thigh pain (sometimes intractable), and despite being infrequent, they should always be contemplated, providing that these cases can be managed conservatively with rest and limited weight-bearing. After this uncommon case, we suggest to align the stem in order to equally distribute loads onto the medial calcar and the lateral femoral cortical.

Analysis of Postoperative Complications in Spinal Surgery, Hospital Length of Stay, and Unplanned Readmission: Application of Dindo-Clavien Classification to Spine Surgery

Study Design: Retrospective study. Level of evidence III. Objective: Postoperative complications in spine surgery are associated with increased morbidity, hospital length of stay, and health care costs. Registry of complications in orthopedics and the spine surgery is heterogeneous. Methods: Between July 2016 and June 2017, 274 spinal surgeries were performed, the presence of postoperative complications was analyzed at 90 days (according to the classification of Dindo-Clavien, grades I-V), hospital length of stay, surgical complexity (low, medium, and high), unplanned readmission, and risk factors were evaluated. Results: A total of 79 patients suffered a complication (28.8%), of them 21 (26.7%) were grade I, 24 (30.3%) were grade II, 4 (5.7%) were grade IIIA, and 29 (37.3%) were grade IIIB. There were no IV and V grade cases. The most frequent complication was excessive pain followed by deep wound infection and anemia. Surgical complexity and surgical time were significantly associated with the risk of developing a complication. The average number of hospital length of stay in patients without and with complications were 2.7 and 10.6, respectively, and the unplanned readmission rate was 11%. Conclusions: Registry of postoperative complications allows the correct standardization and risk factors required to establish measures to decrease them, the application of Dindo-Clavien classification was useful for the purpose of our study.

State-of-the-art diagnosis and surgical treatment of acute peri-prosthetic joint infection following primary total hip arthroplasty

Acute peri-prosthetic joint infection (PJI) following total hip arthroplasty (THA) is a potentially devastating and undesired complication, with a prevalence of 0.3% to 2.9%. Its suspicion begins with a meticulous physical examination and anamnesis. Diagnosis should be made on the basis of the Musculoskeletal Infection Society criteria. Serum and synovial biomarkers are very useful tools when major criteria are absent. Although sometimes not possible due to medical conditions, surgery is usually the first line of treatment. Although its outcome is highly correlated with the isolated microorganism, irrigation and debridement with implant retention (DAIR) is the gold standard for treatment. Ideally, the prior approach should be proximally and distally extended to augment the field of view and remove all of the prosthetic modular components, that is, femoral head and acetabular insert. Given DAIR’s unclear control of infection, with successful outcomes in the range of 30% to 95%, one- or two-stage revision protocols may play a role in certain cases of acute infections; nonetheless, further prospective, randomized studies are necessary to compare long-term outcomes between DAIR and revision surgeries. Following surgical treatment, length of antibiotherapy is in the range of six weeks to six months, without any difference in outcomes between short and long protocols. Treatment should be adjusted to the isolated bacteria and controlled further with post-operative serum biomarker levels. Cite this article: EFORT Open Rev 2018;3:434-441. DOI: 10.1302/2058-5241.3.170032

Three cases of type-1 complex regional pain syndrome after elective total hip replacement

Complex regional pain syndrome (CRPS) constitutes an atypical cause of pain after orthopaedic procedures. To our knowledge, there is a paucity of literature reporting this syndrome after total hip arthroplasty (THR), since only two case reports have been published. We thenceforth describe the clinical outcome of three cases of type-1 CRPS developed after elective THR, two of them initially diagnosed with secondary osteoarthritis whereas the remaining one presented a sequel of a failed osteosynthesis that required conversion to THR. Remission of disease was found at an average seven months (range: 4–9). Medical treatment involved a combined therapy of pain management, bisphosphonates and intense physical therapy. One patient was additionally treated with a corticosteroid blockade of his right sympathetic lumbar ganglia. None of the patients required surgical treatment. At final follow-up, physical examinations and imaging were negative for disease.

Long-term Outcome of Unconstrained Primary Total Hip Arthroplasty in Ipsilateral Residual Poliomyelitis

Incapacitating articular sequelae in the hip joint have been described for patients with late effects of poliomyelitis. In these patients, total hip arthroplasty (THA) has been associated with a substantial rate of dislocation. This study was conducted to evaluate the long-term clinical and radiologic outcomes of unconstrained THA in this specific group of patients. The study included 6 patients with ipsilateral polio who underwent primary THA between 1985 and 2006. Patients with polio who underwent THA on the nonparalytic limb were excluded. Mean follow-up was 119.5 months (minimum, 84 months). Clinical outcomes were evaluated with the modified Harris Hip Score (mHHS) and the visual analog scale (VAS) pain score. Radiographs were examined to identify the cause of complications and determine the need for revision surgery. All patients showed significantly better functional results when preoperative and postoperative mHHS (67.58 vs 87.33, respectively; P=.002) and VAS pain score (7.66 vs 2, respectively; P=.0003) were compared. Although 2 cases of instability were diagnosed, only 1 patient needed acetabular revision as a result of component malpositioning. None of the patients had component loosening, osteolysis, or infection. Unconstrained THA in the affected limb of patients with poliomyelitis showed favorable long-term clinical results, with improved function and pain relief. Nevertheless, instability may be a more frequent complication in this group of patients compared with the general population. [Orthopedics. 2017; 40(2):e255-e261.].