Showing papers in "Acta Orthopaedica in 2008"
TL;DR: Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.
Abstract: Background We have developed a multimodal technique for the control of pain following knee and hip surgery, called "local infiltration analgesia" (LIA). It is based on systematic infiltration of a mixture of ropiva-caine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control with little physiological disturbance. The technique allows virtually immediate mobilization and earlier discharge from hospital. Patients and methods In this open, nonrandomized case series, we used LIA to manage postoperative pain in all 325 patients presenting to our service from Jan 1, 2005 to Dec 31,2006 for elective hip resurfacing (HRA), primary total hip replacement (THR), or primary total knee replacement arthroplasty (TKR). We recorded pain scores, mobilization times, and morphine usage for the entire group. Results Pain control was generally satisfactory (numerical rating scale pain score range 0-3). No morphine was required for postoperative pain control in two-thirds of the patients. Most patients were able to walk with assistance between 5 and 6 h after surgery and independent mobility was achieved 13-22 h after surgery. Orthostatic hypotension, nausea, and vomiting were occasionally associated with standing for the first time, but other side effects were unremarkable. 230 (71%) of the 325 patients were discharged directly home after a single overnight stay in hospital. Interpretation Local infiltration analgesia is simple, practical, safe, and effective for pain management after knee and hip surgery.
563 citations
TL;DR: Age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization, were all found to influence postoperative outcome in general and LOS in particular.
Abstract: Background and purpose Very few studies have focused on patient characteristics that influence length of stay (LOS) in fast-track total hip (THR) and knee arthroplasty (TKR). The aim of this prospe...
489 citations
TL;DR: Antibiotic-impregnated cement is used as a spacer or during re-implantation surgery for the treatment of infected total hip arthroplasties as mentioned in this paper, and the routine use of antibiotic-impr...
Abstract: Background and purpose Antibiotic‐impregnated cement is used as a spacer or during re‐implantation surgery for the treatment of infected total hip arthroplasties. The routine use of antibiotic‐impr...
224 citations
TL;DR: Modern-day treatment methods are superior to conventional treatment options in the management of distal femur fractures above TKAs and should be interpreted with caution, due to the lack of randomized controlled trials and the possible selection bias in case series.
Abstract: Background There is no consensus on the best treatment for periprosthetic supracondylar fracture.Material and methods We systematically summarized and compared results of different fixation techniq...
219 citations
TL;DR: Intralesional surgery should be the first choice in most giant cell tumors, even in the presence of a pathological fracture, after thorough evacuation, the cavity should be filled with cement.
Abstract: BACKGROUND: Giant cell tumors of bone rarely metastasize but often recur locally after surgery. There is limited knowledge about the risk of recurrence related to different types of treatment. PATIENTS AND METHODS: We analyzed factors affecting the local recurrence rate in 294 patients with giant cell tumors of the extremities using prospectively collected material from 13 centers. The median follow-up time was 5 (0.2-18) years. RESULTS: A local recurrence was diagnosed in 57 of 294 patients (19%). The overall 5-year local recurrence rate was 0.22. Univariate analysis identified young age and intralesional surgery to be associated with a higher risk of recurrence. Based on multivariate analysis, the relative risk was 2.4-fold for intralesional surgery compared to more extensive operative methods. There was no correlation between tumor size, tumor extension, sex of the patient, tumor location, or fracture at diagnosis and outcome. In the subgroup of 200 patients treated with intralesional surgery, the method of filling (cement or bone) was known for 194 patients and was statistically highly significant in favor of the use of cement. INTERPRETATION: Intralesional surgery should be the first choice in most giant cell tumors, even in the presence of a pathological fracture. After thorough evacuation, the cavity should be filled with cement.
211 citations
TL;DR: After the hand, the foot was the most frequently symptomatic joint complex at the start of the disease, but also during active medical treatment, and was the only joint to subjectively impair gait.
Abstract: Background and purpose Our knowledge of frequency of foot involvement in rheumatoid arthritis (RA) is still often based on a study from Finland in 1956. Great changes in the treatment of RA may have led to a different situation. We investigated the distribution of joint involvement in RA patients today, with special attention given to the feet and subjective walking ability.Methods 1,000 RA patients answered a questionnaire concerning joints affected, joint surgery, foot problems, and subjectively experienced reasons for walking incapacity.Results In 45% of the patients, the forefoot was involved at the start of the disease. In 17%, the hindfoot/ankle was involved at the start. Only hand symptoms were commoner. 80% of patients reported current foot problems, 86% in the forefoot and 52% in the hindfoot/ankle. Difficulty in walking due to the feet was reported by 71%. For 41% of patients, the foot was the most important part of the lower extremity causing reduced walking capacity, and for 32% it was the onl...
191 citations
TL;DR: In this article, the authors compared the long-term survivorship and cost effectiveness of unicondylar arthroplasty and total knee arthrochastic surgery (TKA) in patients with primary OA.
Abstract: Background and purpose Both unicondylar arthroplasty (UKA) and total knee arthroplasty (TKA) are commonly used for the treatment of unicompartmental osteoarthritis (OA) of the knee. The long‐term survivorship and cost‐effectiveness of these two treatments have seldom been compared on a nationwide level, however. We therefore compared the survival of UKA with that of TKA and conducted a cost‐benefit analysis comparing UKA with TKA in patients with primary OA.Patients and methods We analyzed 1,886 primary UKAs (3 designs) and 48,607 primary TKAs that had been performed for primary OA and entered in the Finnish Arthroplasty Register between 1980 and 2003 inclusive.Results UKAs had a 60% (95% CI: 54–66) survival rate and TKAs an 80% (95% CI: 79–81) survival rate at 15 years with any revision taken as the endpoint. Overall survival of UKAs was worse than that of TKAs (p < 0.001). All 3 UKA designs had poorer overall survival than the corresponding TKA designs. In the theoretical cost‐benefit analysis, the cost...
176 citations
TL;DR: An accelerated perioperative care and rehabilitation intervention in patients undergoing primary total hip replacement, and total or unicompartmental knee replacement is indeed effective—and of advantage to both the hospital and the patient.
Abstract: Background Approximately 12,000 hip and knee replacements were performed in Denmark in 2005. Accelerated perioperative interventions are currently implemented, but there is conflicting evidence regarding the effect. We therefore performed an efficacy study of an accelerated perioperative care and rehabilitation intervention in patients receiving primary total hip replacement, and both total and unicompartmental knee replacement.Methods A randomized clinical trial was undertaken in which 87 patients were randomized to either a control group receiving the current perioperative procedure, or an intervention group receiving a new accelerated perioperative care and rehabilitation procedure. Outcome measures were length of stay (LOS) in hospital, and gain in quality of life (QOL) using EQ-5D from baseline to 3-month follow-up.Results Mean LOS was reduced (p < 0.001) from 8 days (95% CI: 7.1–8.4) in the control group to 5 days (95% CI: 4.2–5.6) in the intervention group. This was accompanied by a greater gain in...
162 citations
TL;DR: After only 2 years, the nationwide system for surveillance of demographics, treatment, and outcome of hip fractures is functioning well, and the completeness of registration was 64% in 2005 and 79% in 2006.
Abstract: Background and purpose The Norwegian Hip Fracture Register was established in January 2005 to collect nationwide information as a basis for improved management of patients with hip fractures. We now report our experience after the first 2 years.Methods After both primary operations and reoperations, the surgeons fill in a standardized 1-page form with information about the patient, the fracture, and the operation. Fractures treated with a total hip arthroplasty are reported to the national arthroplasty register, but are added to the hip fracture register before analyses are performed. 4, 12, and 36 months postoperatively, a standardized questionnaire including health-related quality of life (EQ-5D), visual analog scales concerning pain and patient satisfaction, and Charnley class for functional assessment is sent directly from the register to the patients. To evaluate the completeness of registration, our data were compared with data from the Norwegian Patient Registry (NPR).Results During the first year ...
148 citations
TL;DR: The purpose of this review is to provide an overview of the current literature on the adverse periprosthetic biological reactions associated with metal-on-metal hip resurfacing arthroplasty.
Abstract: Metal-on-metal hip resurfacing arthroplasty has undergone a recent resurgence as an alternative treatment option for young and active patients with significant osteoarthritis. The claimed advantages of metal-on-metal hip resurfacing arthroplasty include lower wear rate, preservation of bone stock for subsequent revision procedures, restoration of anatomic hip mechanics, and enhanced stability due to the larger diameter of articulation. A disadvantage, however, is that the metal-on-metal resurfacing releases large amounts of very small wear particles and metal ions. The long-term biological consequences of the exposure to these Co-Cr particles and ions remain largely unknown. The purpose of this review is to provide an overview of the current literature on the adverse periprosthetic biological reactions associated with metal-on-metal hip resurfacing arthroplasty.
144 citations
TL;DR: Extracorporal shock-wave therapy appears to be a supplement for the treatment of chronic Achilles tendinopathy.
Abstract: Background and purpose Chronic Achilles tendinopathy is a painful condition and there are often unsatisfactory results with conservative treatment. Extracorporal shock-wave therapy (ESWT) has been ...
TL;DR: The posterolateral approach was associated with a significantly increased risk of dislocated in patients with femoral neck fractures treated with HA, and a posterior repair appears to reduce the rate of dislocation, although not to the same low level as in patients operated using the anterolateral approaches.
Abstract: Background and purpose Hip replacement using a hemiarthroplasty is a common surgical procedure in elderly patients with fractures of the femoral neck. The optimal surgical approach regarding the risk of dislocation is controversial. We analyzed factors influencing the stability of the hemiarthroplasty, with special regard to the surgical approach.Patients and methods We studied 720 consecutive patients on whom 739 hemiarthroplasties were performed between 1996 and 2003, either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Logistic regression analyses were performed in order to evaluate factors associated with prosthetic dislocation.Results The multivariate regression analysis showed that the posterolateral approach was the only factor associated with a significantly increased risk of dislocation: OR 3.9 (CI: 1.6–10) for the posterolateral approach with posterior repair and OR 6.9 (CI: 2.6–19...
TL;DR: Overweight and obesity are found to be associated with increased risk of implant dislocation following primary total hip replacement and greater attention should be given to high BMI as a risk factor for implant dislocated following THR.
Abstract: Background and purpose Implant dislocation is one of the commonest complications following primary total hip replacement (THR). We investigated the effect of body mass index (BMI) and tobacco use on the risk of this complication.Subjects and methods Through linkage between the Swedish Construction Workers’ cohort and the Swedish Inpatient Register, 2,106 male patients who had undergone primary THR between 1997 and 2004 were identified. We used Cox multivariable regression analysis to study the association between BMI and tobacco use and the risk of implant dislocation.Results 53 patients (2.5%) developed implant dislocation during a mean of 2 (0–3) years of follow-up. We found overweight and obesity to be associated with increased risk of implant dislocation (HR = 2.5,95% CI: 1.1–5.5 and HR = 3.7, 95% CI: 1.5–9.3, respectively as compared to those of normal weight). There was no statistically significant association between tobacco use and the risk of dislocation.Interpretation Greater attention should be...
TL;DR: Decompression alone had high a reoperation rate compared to decompression and internal stabilization, and nonoperative treatment was effective in nine-tenths of the patients.
Abstract: Background and purpose Spondylodiscitis may be a serious disease due to diagnostic delay and inadequate treatment. There is no consensus on when and how to operate. We therefore retrospectively analyzed the outcome of a large series of patients treated either nonoperatively or surgically.Patients and methods Between 1992 and 2000, 163 patients (101 males) were hospitalized due to spondylodiscitis. The mean age was 56 (1–83) years. The infection was located in the cervical spine in 13 patients (8%), in the thoracic spine in 62 patients (38%), at the thoracolumbar junction in 10 patients (6%), and in the lumbo-sacral spine in 78 patients (48%). In 67 patients (41%), no microorganisms were detected. Most of the other patients had Staphylococcus aureus infection (53 patients) and/or Mycobacterium tuberculosis (22 patients). The patients were divided into 3 groups: (A) 70 patients who had nonoperative treatment, (B) 56 patients who underwent posterior decompression alone, and (C) 37 patients who underwent deco...
TL;DR: Persistence of bacterial growth on bone cement remains a hazardous problem in orthopedic surgery and adherence of bacteria to cement can lead to emergence of bacterial resistance to antibiotics and might result in clinical recurrence of infection.
Abstract: Background and purpose Implantation of antibiotic-loaded beads is used for orthopedic infections. However, recent in vitro reports have emphasized that bacteria can persist on—or even colonize—antibiotic-impregnated bone cement. We therefore assessed whether bacterial adherence and growth could be determined on gentami-cin- and gentamicin-vancomycin-loaded beads that had been removed after eradication of infection.Material and methods We bacteriologically examined 18 chains of antibiotic-loaded beads (11 gentami-cin-loaded, 7 gentamicin-vancomycin-loaded) that had been implanted because of orthopedic infections. Among the causative agents, Staphylococcus epidermidis, Staph-ylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent organisms identified.Results In 4 cases (3 with S. epidermidis and one with MRSA), we found that there was persistence of bacterial growth on the beads. S. epidermidis strains persisted only on gentamicin-loaded beads, while MRSA could grow on...
TL;DR: It is concluded that embalmed or frozen bones can safely be used for mechanical testing, at least for storage periods of up to one year, and there appears to be a tendency to increasing hardness.
Abstract: Background and purpose Bones used in mechanical studies are frequently harvested from human cadavers that have been embalmed in a buffered formaldehyde solution. It has been reported that formaldehyde fixation or freezing hardly affects the mechanical properties of bone after a storage period of several weeks. However, human cadaver bones are usually stored for longer periods of time before use. We therefore investigated the effects of long-term embalming or freezing on the mechanical properties of cortical bone.Methods After 5 different storage periods (ranging from 0 to 12 months), goat femora and humeri were used to evaluate the effect of embalming and freezing on torsion, and on bending stiffness and strength. The effect on hardness and bone mineral density (BMD) was also evaluated.Results Even after 1 year, no statistically significant differences could be found in stiffness, strength, and energy absorption when we compared embalmed or frozen bones to a fresh reference group. In addition, although we...
TL;DR: Current practice regarding orthopedic management of tibial shaft fractures in Canada strongly favors operative treatment with intramedullary nailing, although respondents were divided in their preference for reamed and unreamed nailing.
Abstract: Background and purpose Strategies to manage tibial fractures include nonoperative and operative approaches. Strategies to enhance healing include a variety of bone stimulators. It is not known what forms of management for tibial fractures predominate among Canadian orthopedic surgeons. We therefore asked a representative sample of orthopedic trauma surgeons about their management of tibial fracture patients.Methods This was a cross-sectional survey of 450 Canadian orthopedic trauma surgeons. We inquired about demographic variables and current tibial shaft fracture management strategies.Results 268 surgeons completed the survey, a response rate of 60%. Most respondents (80%) managed closed tibial shaft fracture operatively; 47% preferred reamed intramedullary nailing and 40% preferred unreamed. For open tibial shaft fractures, 59% of surgeons preferred reamed intramedullary nailing. Some surgeons (16%) reported use of bone stimulators for management of uncomplicated open and closed tibial shaft fractures, ...
TL;DR: Comparisons of the study population and the underlying general populations of interest indicate that this population can be used to predict the incidences and outcomes of TKA in the general population of California and of the United States as a whole.
Abstract: Background and purpose There are limited popula-tion-based data on utilization, outcomes, and trends in total knee arthroplasty (TKA). The purpose of this study was to examine TKA utilization and s...
TL;DR: This nationwide study of tibial shaft fractures shows a falling off of fracture incidence, a finding that can be used to advantage by healthcare providers.
Abstract: Background and purpose There is a lack of national epidemiological data on the characteristics of patients with tibial shaft fractures. We therefore analyzed data on Swedish patients with tibial sh...
TL;DR: The sample of vertebral fracture patients was fairly small and included a high proportion of fractures leading to hospitalization, but the results indicate higher long-term costs and greater loss in quality of life related to vertebral fractures than previously believed.
Abstract: Background and purpose Few economic or quality-of-life studies have investigated the long-term consequences of fragility fractures. This prospective observational data collection study assessed the cost and quality of life related to hip, vertebral, and wrist fracture 13–18 months after the fracture, based on 684 patients surviving 18 months after fracture.Patients and methods Data regarding resource use and quality of life related to fractures was collected using questionnaires at 7 research centers in Sweden. Information was collected using patient records, register sources, and by asking the patient. Quality of life was estimated using the EQ-5D questionnaire. Direct and indirect costs were estimated from a societal standpoint.Results The mean fracture-related cost 13–18 months after a hip, vertebral, or wrist fracture were estimated to be €2,422, €3,628, and €316, respectively. Between 12 and 18 months after hip, vertebral, and wrist fracture, utility increased by 0.03, 0.05, and 0.02, respectively. C...
TL;DR: An experimental model on plastic pelvises was designed to simulate tumor resection and reconstruction and the attempt to evaluate geometry of the pelvic reconstruction using simple parameters was not satisfactory, and there is a need to define new standards of evaluation.
Abstract: BACKGROUND AND PURPOSE: Osseous pelvic tumors can be resected and reconstructed using massive bone allografts. Geometric accuracy of the conventional surgical procedure has not yet been documented. The aim of this experimental study was mainly to assess accuracy of tumoral resection with a 10-mm surgical margin, and also to evaluate the geometry of the host-graft reconstruction. METHODS: An experimental model on plastic pelvises was designed to simulate tumor resection and reconstruction. 4 experienced surgeons were asked to resect 3 different tumors and to reconstruct pelvises. 24 resections and host-graft junctions were available for evaluation. Resection margins were measured. Several methods were created to evaluate geometric properties of the host-graft junction. RESULTS: The probability of a surgeon obtaining a 10-mm surgical margin with a 5-mm tolerance above or below, was 52% (95% CI: 37-67). Maximal gap, gap volume, and mean gap between host and graft was 3.3 (SD 1.9) mm, 2.7 (SD 2.1) cm3 and 3.2 (SD 2.1) mm, respectively. Correlation between these 3 reconstruction measures and the degree of contact at the host-graft junction was poor. INTERPRETATION: 4 experienced surgeons did not manage to consistently respect a fixed surgical margin under ideal working conditions. The complex 3-dimensional architecture of the pelvis would mainly explain this inaccuracy. Solutions to this might be to increase the surgical margin or to use computer- and robotic-assisted technologies in pelvic tumor resection. Furthermore, our attempt to evaluate geometry of the pelvic reconstruction using simple parameters was not satisfactory. We believe that there is a need to define new standards of evaluation.
TL;DR: The aim with high tibial valgus osteotomy (HTO) is to correct the mechanical axis in medial compartmental osteoarthritis of the knee, and disruption of the opposite cortex in the medial opening‐wedge technique leads more often to varus malalignment.
Abstract: Background and purpose The aim with high tibial valgus osteotomy (HTO) is to correct the mechanical axis in medial compartmental osteoarthritis of the knee. Loss of operative correction may threaten the long‐term outcome. In both a lateral closing‐wedge procedure and a medial opening‐wedge procedure, the opposite cortex of the tibia is usually not osteotomized, leaving 1 cm of bone intact as fulcrum. A fracture of this cortex may, however, lead to loss of correction; this was examined in the present study.Patients and methods We used a prospective cohort of 92 consecutive patients previously reported by Brouwer et al. (). The goal in that randomized controlled trial, was to achieve a correction of 4 degrees in excess of physiological valgus. In retrospect, we evaluated the 1‐year radiographic effect of opposite cortical fracture. Opposite cortical fracture was identified on the postero‐anterior radiographs in supine position on the first day after surgery.Results 44 patients with a closing‐wedge HTO (stap...
TL;DR: Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone.
Abstract: Background High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated.Me...
TL;DR: An encouraging rate of long-term implant survival for patients with childhood hip disorders is found and the advent of alternative bearings and the use of large-diameter femoral heads may improve the outcome after primary THA in these patients.
Abstract: Background Childhood hip disorders including acetabular dysplasia, congenital hip dislocation, epiphysiolysis, and morbus Calve-Legg-Perthes are well-established risk factors for the development of...
TL;DR: The findings suggest that elderly patients with displaced femoral neck fracture should be treated with arthroplasty, based on data from the Norwegian Hip Fracture Register.
Abstract: Background Primary arthroplasty and internal fixation are the two main options for treatment of displaced femoral neck fractures. Despite the fact that there have been several randomized studies, the optimal treatment in the elderly is still controversial. In the present study, based on data from the Norwegian Hip Fracture Register, we compared satisfaction, pain, and quality of life 4 months after surgery in patients over 70 years of age with a displaced femoral neck fracture operated with internal fixation or with a bipolar hemiarthroplasty.Patients and methods Data on 1,569 fractures in patients over 70 years of age operated with internal fixation (n = 663) or hemiarthroplasty (n = 906) were registered in the hip fracture register. The register also included data on patient satisfaction, pain, and quality of life (EQ-5D) assessed 4 months after surgery using VAS scales and EQ-5D health questionnaires.Results Patients operated with hemiarthroplasty had less pain (VAS 27 vs. 41), were more satisfied with...
TL;DR: Clinical testing for NHI is insufficient as a screening method for dysplastic hips that require total hip replacement in young adulthood, and only 8% of those who underwent THR due to dysplasia were reported to have unstable hips at birth.
Abstract: Background and purpose Dysplasia is probably the most common underlying condition in osteoarthritis of the hip, leading to total hip replacement (THR) in young adulthood. We investigated whether hip instability at birth predisposes to THR in young adulthood.Methods Since 1967, all newborns in Norway have been screened for neonatal hip instability (NHI) and the results have been reported to the Medical Birth Registry of Norway (MBRN). In the period 1967-2004,2,218,596 newborns were registered. From 1987 to 2004, 442 of these individuals had been reported to the Norwegian Arthroplasty Register (NAR) after undergoing total hip replacement (mean age 25 (12-36) years).Results Neonatal hip instability was reported in 19,432 newborns (0.88%) in the MBRN; according to the NAR, they had a 2.6 (CI 1.4-4.8) times increased risk of THR in young adulthood compared to those without NHI. The absolute risk was low, however; only 57 (95% CI: 30-105) in 105 for patients with NHI compared to 20 (95% CI: 18-22) in 105 for th...
TL;DR: Findings suggest that ideal candidates for corrective osteotomy are men with symptomatic medial compartmental osteoarthritis of Ahlbäck grade 1, who, 10 years after surgery, have an almost tenfold lower probability of failure of HTO than women with more advanced osteearthritis.
Abstract: Background and purpose High tibial valgus osteotomy (HTO) is a well-accepted treatment for medial unicompartmental osteoarthritis of the knee with varus alignment in relatively young and active pat...
TL;DR: Today's state-of-the-art material is no longer conventional UHMWPE, but HXLPE, and the latest advancements are described in detail to help the orthopedic surgeon make scientifically sound decisions when selecting material for total-joint implants.
Abstract: Ultra-high molecular weight polyethylene (UHMWPE) is the key material for achieving excellent long-term results in total joint arthroplasties. Despite the fact that there has been a substantial amo...
TL;DR: The design and position of the implant should be considered before using hip resurfacing arthroplasty as a standard treatment for younger patients, since impingement of the femoral neck on the acetabular component increases the risk of neck fractures, of dislocation and of subsequent implant loosening.
Abstract: Background and purpose Hip resurfacing arthroplasty is being used more and more frequently. The small ratio in size between the resurfaced femoral head and the relatively thick femoral neck raises ...
TL;DR: There are statistically significant differences between the sexes in lumbar disc herniation surgery regarding basic demographic status and postoperative status, whereas the surgical effect is similar.
Abstract: BACKGROUND AND PURPOSE: Although there have been numerous publications on lumbar disc herniation (LDH) treated surgically, there has been little interest in sex differences. It has been shown in ma ...