Cortical Thickness Index and Canal Calcar Ratio: A Comparison of Proximal Femoral Fractures and Non-Fractured Femora in Octogenarians to Centenarians.

Background: The cortical thickness index (CTI) is a measure of bone quality and it correlates with the risk of proximal femoral fractures. The purpose of this study was to investigate the CTI in femoral neck, trochanteric fractures and non-fractured femora in geriatric patients and to determine whether there is a correlation between the CTI and the presence of a fracture. Methods: One hundred and fifty patients (fifty femoral neck- (FNFx), fifty trochanteric fractures (TFx) and fifty non-fractured (NFx)) with a mean age of 91 (range 80-104) years were included. Hip radiographs (antero-posterior (ap), lateral) were evaluated retrospectively. Measurements on the proximal femoral inner and outer cortices, including CTI and Dorr's canal calcar ratio (CCR), were assessed for inter-observer reliability (ICC), differences of each fracture and correlation of parameters. Results: The mean ap CTI on the affected side was 0.43, 0.45 and 0.55 for FNFx, TFx and NFx, respectively. There was a significant difference of the ap CTI and CCR comparing the injured and healthy side for both fracture cohorts (p < 0.001). Patients with FNFx or TFx had significantly lower CTI on both sides compared to the NFx group (p < 0.05). There was no difference for CTI (p = 0.527) or CCR (p = 0.291) when comparing both sides in the NFx group. The mean inter-observer reliability was good to excellent (ICC 0.88). Conclusions: In proximal femoral fractures, the CTI and CCR are reduced compared with those in non-fractured femora. Both parameters are reliable and show a good correlation in geriatric patients. Therefore, especially for geriatric patients, the CTI and CCR may help to predict fracture risk and consult patients in daily practice.

Operative treatment of periprosthetic fractures of the proximal femur with a contralateral, upside-down LISS plate in elderly patients.

BACKGROUND: Increasing expectancy of life and levels of activity in the growing geriatric population lead to a rising number of prosthetic implants of the hip and consequently the incidence of periprosthetic fractures of the femur increase. The fracture pattern and the possible instability of the stem are a challenge to the orthopaedic surgeon. Treatment options are complete replacement of the implant or a solitary osteosynthesis. The goal of this study was to analyse the feasibility of the operative intervention using a contralateral reversed anatomic distal femoral LISS® locking plate and the radiological and functional outcome in a geriatric cohort. METHODS: We included all patients older than 75 years of age with a Vancouver type B fracture, which have been treated by osteosynthesis using a LISS® (contralateral reversed) plate in our institution in an interdisciplinary ortho-geriatric setting between 7/2013 and 12/2021. Perioperative morbidities, clinical and radiological outcome during follow-up were retrospectively analysed. RESULTS: During the observed time period, 83 patients (mean age: 88 years (range: 76-103), male/female: 26/57) were treated. Most fractures were Vancouver type B2 (n = 45, 54%) followed by B1 (n = 20, 24%) and B3 (n = 18, 22%). The most prevalent postoperative surgical complication was anaemia (n = 73, 88%) followed by infections (n = 12, 14%, urinary infections, pneumonia) and cardiovascular decompensation (n = 8, 10%). Clinical and radiological follow up 6-8 weeks postoperative was possible for 59 patients (70%). The majority of them did not describe pain (n = 50, 85%) and had a good or excellent radiological outcome. Three cases needed revision surgery due to infection and another three due to non-union, loosening of the stem or an additional fracture. 1-year mortality was 30%. CONCLUSION: We are convinced that the reversed contralateral LISS-plate is an easy-to-use implant with a small complication rate but a very successful and high healing rate in a geriatric, polymorbid cohort.

Quantification of Malalignment and Corrective Osteotomies in Patients With Malunion After Elastic Stable Intramedullary Nailing of Pediatric Forearm Fractures.

Purpose: This study looked at postoperative malunion with restricted function after elastic stable intramedullary nailing (ESIN) in pediatric patients in their childhood or adolescence. The primary objective was to compare the magnitude of the osseous malposition to the healthy opposite side. Second, these individuals were treated with patient-specific surgical instrumentation, and functional outcomes were documented. Methods: Patients under the age of 18 at the time of a corrective osteotomy due to a forearm malunion after initial ESIN treatment were included in this study. The healthy contralateral side was used as a reference for preoperative analysis and planning of the osteotomy. Osteotomies were performed using patient-specific guides and the direction and extent of the malunion were compared to the change in range of motion (ROM) after the operation. Results: Fifteen patients met the inclusion criteria at three years after initial ESIN placement, with the most pronounced malposition in the rotational axis. The postoperative function significantly improved by 12° (pre-op: 60° ± 17; post-op: 72° ± 10) of pronation and 33° (pre-op: 43° ± 26; post-op: 76° ± 13) of supination. There was no correlation between the amount and direction of malformation and the change in ROM. Conclusions: The most noticeable malunion after forearm fractures treated with the ESIN technique is in the rotational direction. Patient-specific corrective osteotomy of pediatric forearm malunion following forearm fracture fixation with ESIN achieves significant improvement in forearm range of motion. Clinical relevance: The findings are clinically relevant since forearm fractures are the most common pediatric fracture, affecting a large number of patients who can benefit from the findings of this study. It has the potential to raise awareness of the significance of the accurate rotational component of intraoperative bone alignment in the ESIN procedure.

Two-staged management of ankle fracture-dislocations with a posterior fragment: computer-tomography-based classification, treatment and its outcome.

INTRODUCTION: Trimalleolar fractures are difficult to treat and malreduction can lead to functional impairment. Involvement of the posterior malleolus has a poor predictive value. Current computed-tomography (CT)-based fracture classifications led to an increase in fixation of the posterior malleolus. The aim of this study was to describe the functional outcome after a two-stage stabilisation with direct fixation of the posterior fragment in trimalleolar dislocation fractures. MATERIALS AND METHODS: In a retrospective study, all patients presenting with a trimalleolar dislocation fracture, an available CT scan, and a two-stage operative stabilisation including the posterior malleolus by a posterior approach were included. All fractures were treated with initial external fixator and delayed definitive stabilisation including fixation of the posterior malleolus. Next to clinical and radiological follow-up, outcome measures (Foot and Ankle Outcome Score (FAOS), Numeric Rating Scale (NRS), Activity of Daily Living (ADL), Hulsmans implant removal score) and complications were analysed. RESULTS: Between 2008 and 2019, of 320 trimalleolar dislocation fractures, 39 patients were included. Mean follow-up was 49 months (standard deviation (SD) 29.7, range 16-148). Mean age was 60 years (SD 15.3, 17-84) with 69% female patients. The mean FAOS was 93/100 (SD 9.7, 57-100), NRS 2 (interquartile range (IQR) 0-3) and ADL 2 (IQR 1-2). Four patients showed a postoperative infection, three re-operations had to be performed and implants were removed in 24 individuals. CONCLUSION: A two-stage procedure of trimalleolar dislocation fractures with in-direct reduction and fixation of the posterior tibial fragment through a posterior approach leads to good functional outcome scores with a low rate of complications.

Salami-Tactics: when is it time for a major cut after multiple minor amputations?

INTRODUCTION: Repetitive minor amputations carry the concomitant risks of multiple surgical procedures, major amputations have physical and economical major drawbacks. The aim of this study was to evaluate whether there is a distinct number of minor amputations predicting a major amputation in the same leg and to determine risk factors for major amputation in multiple minor amputations. MATERIALS AND METHODS: A retrospective chart review including 429 patients with 534 index minor amputations between 07/1984 and 06/2019 was conducted. Patient demographics and clinical data including number and level of re-amputations were extracted from medical records and statistically analyzed. RESULTS: 290 legs (54.3%) had one or multiple re-amputations after index minor amputation. 89 (16.7%) legs needed major amputation during follow up. Major amputation was performed at a mean of 32.5 (range 0 - 275.2) months after index minor amputation. No particular re-amputation demonstrated statistically significant elevated odds ratio (a.) to be a major amputation compared to the preceding amputation and (b.) to lead to a major amputation at any point during follow up. Stepwise multivariate Cox regression analysis revealed minor re-amputation within 90 days (HR 3.8, 95% CI 2.0-7.3, p <0.001) as the only risk factor for major amputation if at least one re-amputation had to be performed. CONCLUSIONS: There is no distinct number of prior minor amputations in one leg that would justify a major amputation on its own. If a re-amputation has to be done, the timepoint needs to be considered as re-amputations within 90 days carry a fourfold risk for major amputation. LEVEL OF EVIDENCE: Retrospective comparative study (Level III).

3D planning and patient specific instrumentation for intraarticular corrective osteotomy of trapeziometacarpal-, metacarpal and finger joints.

BACKGROUND: Intra-articular malunions of the finger can lead to deformity and loss of function and can be treated with intra-articular corrective osteotomies. The aim of this study was to evaluate radiographic joint congruency, feasibility and functional outcome of three-dimensional (3D) printed patient-specific instrumentation (PSI) for corrective osteotomies at the trapeziometacarpal and finger joints. METHODS: Computer-tomography (CT) scans were acquired preoperatively for standard 3D planning, which was followed by calculation of cutting planes and the design of individualized bone surface contact drilling, sawing and reposition guides. Follow-up CT scans and clinical examinations (range of motion, grip strength) were performed. Postoperative complications were documented and patient-reported outcome measurements were assessed (Single Assessment Numeric Evaluation (SANE) score, brief Michigan Hand Questionnaire (MHQ)). RESULTS: Ten patients (mean age 28.4 ± 12.8,range 13.8-51.3) years) were included with a mean follow-up of 21 ± 18 (3-59) months including seven osteotomies at the trapeziometacarpal or metacarpophalangeal joints and three at the proximal interphalangeal joint (PIP). All radiographic follow-up examinations showed the planned correction with good joint congruency and regular osseous consolidation. At the latest follow-up, the range of motion (ROM) increased and the average grip strength recovered to the level of the contralateral side. No postoperative complication was detected. The mean SANE score improved from 44 ± 23 (0-70) to 82 ± 12 (60-90) after a mean of 72 ± 20 (44-114) months. The mean postoperative brief MHQ was 92 ± 8 (71-98). CONCLUSION: The use of 3D PSI in treating intra-articular malunions at the trapeziometacarpal and finger joints restored articular congruency accurately. ROM and grip strength improved postoperatively comparable to the healthy contralateral side and patient-reported outcome measures improved after medium-term follow-up.

Long-term outcome of patients with adolescent idiopathic scoliosis seeking nonoperative treatment after a mean follow-up of 42 years.

PURPOSE: Adolescent idiopathic scoliosis (AIS) affects up to 3% of otherwise healthy adolescents. The extreme long-term outcomes of nonoperative treatment are underreported. This study aimed to investigate the long-term outcome of nonoperative-treated AIS patients. Comparison between a bracing and an observation approach were performed. METHODS: In a retrospective cohort study, 20 nonoperatively treated AIS patients were observed concerning patient-related outcome measures (PROM) (visual analog scale (VAS), Short Form Health Survey 36 item (SF 36), Scoliosis Research Society (SRS 24), Oswestry Low Back Pain Disability Index (ODI), Psychological General Well-Being Index (PGWBI)), radiological curve progression and health-related quality of life (HRQoL). Baseline characteristics and radiological imaging were collected. At follow-up, anteroposterior and lateral X-rays as well as questionnaires were analyzed. RESULTS: Twenty patients (16 females, mean age: 14.6 ± 3.2 years) with a follow-up time of 42 ± 9 years were included. Nine patients (initial Cobb 35° ± 19°) were treated with bracing for a mean time of 26 ± 9 months, while the other 11 patients (initial Cobb 29° ± 11°) were observed. The primary curve progressed from 32° ± 15° to 52° ± 25° in average with no significant difference between the cohorts (p = 0.371). At final follow-up, a mean ODI score of 7 ± 7.9 points with no difference depending on the treatment (p = 0.668) was seen. No significant differences were observed for PROMs. Curve magnitude correlated neither at diagnosis (p = 0.617) nor at follow-up (p = 0.535) with the ODI score at final follow-up. CONCLUSION: After a mean of 42 years, patients with nonoperative treatment of moderate AIS demonstrated a good clinical outcome despite progression of the deformity. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Nonoperative Treatment of Finger Flexor Tenosynovitis in Sport Climbers-A Retrospective Descriptive Study Based on a Clinical 10-Year Database.

The aim of this study was to describe the nonoperative treatment outcomes of finger flexor tenosynovitis in sport climbers and to evaluate the association with baseline measures and therapy contents. Sixty-five sport climbers (49 males, mean age 34.1 years) diagnosed with tenosynovitis of the finger flexors were retrospectively asked about injury triggers, therapy contents and outcomes. Pulley thickness was measured by ultrasound. All patients were initially treated conservatively, and only one of the patients needed further therapy (single injection with hyaluronic acid); none of them underwent surgical treatment. The most frequently applied therapy was climbing-related load reduction (91%). The treatment resulted in a statistically significant reduction in pain intensity during climbing (before/after therapy ratio [Visual Analog Scale (VAS)/VAS] = 0.62, 95% CI = 0.55, 0.68). The average duration of the symptoms was 30.5 weeks (range 1-120 weeks). In a multiple linear regression analysis, initial daily life pain intensity and a climbing level higher than 7b according to the French/sport grading scale were the only predictive parameters for the relative change in pain intensity and symptom duration, respectively. All patients were able to resume climbing, with 75% regaining or even exceeding their initial climbing level. The good to excellent outcomes and no correlation between particular therapy contents and therapy outcome may suggest that finger flexor tenosynovitis in sport climbers has a favorable natural course without requiring invasive therapy. However, further cohort studies and, ultimately, randomized controlled trials are needed to conclusively confirm our promising observations.

Osteosynthesis of scapular fractures: a retrospective cohort study.

PURPOSE: In recent years a trend from conservative to operative treatment of displaced scapula fractures has evolved. The aim of this study was to assess surgical and patient-based radiological and functional outcome after open reduction and internal fixation (ORIF) of displaced scapula fractures following predefined operative indications. METHODS: We retrospectively analyzed data of a consecutive series of patients with displaced scapula fractures following operative fixation at our institution between 06/2010 and 02/2020. The primary endpoint was a functional outcome using the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), numeric rating scale (NRS) for pain, Activities of Daily Living score (ADL) and complications. RESULTS: Twenty-six male patients were treated operatively. Twenty-three of whom were available for follow-up after a median follow-up time of 33 months (interquartile range [IQR] 8-70 months). In 18 (69%) cases a standard open approach and in 8 (31%) cases a minimal invasive (MI) approach was used. The median QuickDASH was 0 (IQR 0-0) with a median SSV of 95 (IQR 90-98). Patients reported a median NRS of 0 (IQR 0-1) and a median ADL score of 1 (IQR 1-1). Radiological fracture union was 100% without the occurrence of implant failure or mal-union. Two patients (7.7%) required early correction osteosynthesis, one patient (3.8%) developed a frozen shoulder 3 months postoperatively, and one patient (3.8%) presented with a superficial wound infection. CONCLUSION: Following previously published indications for ORIF of displaced scapula body and neck fractures a good functional outcome and a low rate of complications could be achieved.

Lateral approach for intramedullary nailing of displaced midshaft clavicle fractures; a retrospective cohort study.

PURPOSE: Midshaft clavicle fractures represent about 4% of all fractures in the emergency department. Non-operative treatment of displaced midshaft clavicle fractures (DMCF) can result in a relatively high non-union rate. Several operative techniques, including intramedullary fixation (IMF) using elastic stable intramedullary nailing (ESIN), have therefore been established. IMF through the medial approach is less suitable for fractures of the lateral diaphysis. IMF of DMCF of the lateral diaphysis through a lateral approach can be an alternative approach for these fractures. The aim of this study is to describe the technique of IMF from the lateral side and to present the functional outcome and complications. METHODS: A retrospective cohort study was performed. All patients with a traumatic DMCF treated with IMF using ESIN through a lateral approach between 2014 and 2019 were included. Endpoints were the functional outcome (QuickDASH, Subjective Shoulder Value (SSV)), pain (numeric rating scale (NRS)), daily impairment (activities of daily living (ADL)), complications and implant removal. RESULTS: Forty out of 43 patients were available for follow-up. Mean follow-up was 37 months. Mean age was 24 years (range 13-70). The median QuickDASH score was 0 (IQR 0.0-0.0) and the median SSV was 100 (95-100). The median ADL score was 1 (1-4) and the median NRS was 0 (0-0). No non-union occurred. Implant related irritation occurred in 11 patients (27.5%). Implants were removed in a total of 38 (95%) patients; in 10 cases due to irritation, in 28 cases routinely or on patient's request. CONCLUSION: IMF of DMCF of the lateral diaphysis through a lateral approach leads to excellent functional results and seems to be a suitable option for internal fixation. However, as with IMF from the medial side, it is not without complications and implant-related irritation.

Vascular Response Toward an Absorbable Sirolimus-eluting Polymeric Scaffold for Vascular Application in a Model of Normal Porcine Carotid Arteries.

BACKGROUND: Fully absorbable polymeric scaffolds, as a potential alternative to permanent metallic stents, are entering the clinical field. The aim of this study is to assess the in vivo biocompatibility of a novel Sirolimus-eluting (SIR) absorbable scaffold based on poly(L-lactide) (PLLA) and poly(4-hydroxybutyrate) (P4HB) for interventional application. METHODS: Absorbable PLLA/P4HB scaffolds either loaded with SIR coating or unloaded scaffolds were implanted interventionally into common carotid arteries of 14 female. Bare metal stents (BMS) served as control. Peroral dual anti-platelet therapy was administered throughout the study. Stented common carotid arteries segments were explanted after 4 weeks, and assessed histomorphometrically. RESULTS: The absorbable scaffolds showed a decreased residual lumen area and higher stenosis after 4 weeks (PLLA/P4HB: 6.56 ± 0.41 mm² and 37.56 ± 4.67%; SIR-PLLA/P4HB: 6.90 ± 0.58 mm² and 35.60 ± 3.15%) as compared to BMS (15.29 ± 1.86 mm² and 7.65 ± 2.27%). Incorporation of SIR reduced the significantly higher inflammation of unloaded scaffolds however not to a level compared to bare metal stent (PLLA/P4HB: 1.20 ± 0.19; SIR-PLLA/P4HB: 0.96 ± 0.24; BMS: 0.54 ± 0.12). In contrast, the BMS showed a slightly elevated vascular injury score (0.74 ± 0.15), as compared to the PLLA/P4HB (0.54 ± 0.20) and the SIR-PLLA/P4HB (0.48 ± 0.15) groups. CONCLUSION: In this preclinical model, the new absorbable polymeric (SIR-) scaffolds showed similar technical feasability and safety for vascular application as the permanent metal stents. The higher inflammatory propensity of the polymeric scaffolds was slightly reduced by SIR-coating. A smaller strut thickness of the polymeric scaffolds might have been a positive effect on tissue ingrowth between the struts and needs to be addressed in future work on the stent design.

Haemophilus haemolyticus: an atypical pathogen of septic arthritis of the knee joint.

Septic knee arthritis is a common disease, mostly due to bacterial infections. We describe a rare case of Haemophilus haemolyticus causing unilateral septic arthritis of a native knee. The affected patient presented with persistent severe knee pain after repeated intra-articular injections. Patient history included knee arthroscopy and a known rheumatoid arthritis treated by steroids. Since conservative treatment was ineffective and infection could not be excluded, diagnostic arthroscopy was performed. Synovial fluid and biopsies verified the uncommon microorganism and antibiotic therapy was initiated. Clinical findings and blood results showed rapid improvement. The patient was discharged in a good condition after 6 weeks. A review of the current literature describes only one joint infection with H. haemolyticus as underlying cause. In immunocompromised patients with septic knee arthritis also atypical pathogens must be considered. Nevertheless, the established treatment algorithm with arthroscopy and anti-infective therapy seems to be effective leading to satisfactory results.

Extreme long-term outcome of operatively versus conservatively treated patients with adolescent idiopathic scoliosis.

PURPOSE: We report on outcomes of surgically versus (vs) non-surgically treated patients with moderate adolescent idiopathic scoliosis (AIS) after minimum of 29 years. METHODS: AIS patients with a follow-up of ≥ 41 years in the surgical group and ≥ 29 years in the non-surgical group were included. Patients were treated surgically for primary curves ≥ 45° vs non-surgically for curves < 45° or refusal of surgery. Groups were matched for age, gender, comorbidities and primary curve severity. Oswestry Disability Index (ODI) was used to measure clinical outcomes and standard radiography to quantify curve severity at final follow-up. RESULTS: In total, 16 patients (8 within each group, 75% females) with a median age of 14 (interquartile range (IQR) 2) years could be included and were followed up after 46 (IQR 12) years. All matched variables were similar for both groups, including the primary curve Cobb angles of 48° (IQR 17°) (surgical) vs 40° (IQR 19°) (non-surgical); p = 0.17). At final follow-up after a median of 47 (IQR 5) years for the surgical and 39 (IQR 19) years for the non-surgical group (p = 0.43), the ODI was similar for both groups (15 (IQR 13) points (surgical) vs 7 (IQR 15) points (non-surgical); p = 0.17) with, however, a primary curve magnitude lower in the surgical compared to the non-surgical group (38° (IQR 3°) vs 61° (IQR 33°); p = 0.01), respectively. CONCLUSION: After around 47 and 39 years, respectively, surgical and non-surgical treatment of moderate AIS showed similar subjective outcomes, but with a relevant smaller curve magnitude with surgical treatment. LEVEL OF EVIDENCE: III.

Introducing the Lateral Femoral Condyle Index as a Risk Factor for Anterior Cruciate Ligament Injury.

BACKGROUND: The asymmetry of the medial and lateral knee compartments contributes significantly to femorotibial biomechanics and pivoting, and it is reported to be a relevant risk factor for an anterior cruciate ligament (ACL) injury. PURPOSE: (1) To assess the role of femoral condyle sphericity as a risk factor for an ACL rupture and rerupture. (2) To compare the new risk factor with existing bony morphological risk factors via magnetic resonance imaging (MRI) and to assess the most predictive risk factor for an ACL rupture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective case-control study of 60 patients was conducted. Three age- and sex-matched cohorts (each n = 20) were analyzed: ACL reruptures, primary ACL ruptures, and a control group consisting of isolated meniscal tears or patients with anterior knee pain without signs of trochlear dysplasia. The lateral femoral condyle index (LFCI) as a novel MRI measurement was developed to quantify femoral sphericity. In addition, previously known MRI risk factors associated with ACL injury were analyzed (notch width index, medial tibial slope, lateral tibial slope, medial tibial depth, and lateral tibial height). Differences among groups were compared; cutoff values were defined; and diagnostic performance of the risk factors was assessed. The risk factors were subsequently analyzed with multiple logistic regression. RESULTS: The LFCI was significantly smaller in knees with ACL reruptures (median, 0.67; range, 0.59-0.75) and primary ACL ruptures (0.67; range, 0.60-0.75) than in the control group (0.76; range, 0.6-0.81; P < .01). The LFCI yielded the highest area under the curve among the analyzed risk factors: 0.82 (95% CI, 0.7-0.9). A cutoff of 0.70 yielded a sensitivity of 78% and a specificity of 80% to predict an ACL rupture or rerupture (odds ratio, 13.79; 95% CI, 3.67-51.75). In combination with lateral tibial height (cutoff, 3.8 mm) and lateral tibial slope (cutoff, 2.9°), the diagnostic performance was improved. The area under the curve was 0.86 (95% CI, 0.75-0.94), with a sensitivity of 90% and a specificity of 70% (odds ratio, 21.00; 95% CI, 5.10-85.80). CONCLUSION: A decreased LFCI is associated with an ACL injury. The LFCI, lateral tibial height, and lateral tibial slope are the most predictive risk factors for an ACL injury. These findings might aid clinicians in identifying patients at risk for an ACL injury and inform the patient after reconstruction for a higher risk of rerupture.

Predictors for reoperation after lower limb amputation in patients with peripheral arterial disease.

Background: Major amputations in patients with peripheral arterial disease (PAD) carry a high risk for complications, including revision of the amputation, sometimes to a higher level. Determining a safe level for amputation with good wound healing potential depends largely on vascular measurements. This study evaluated potential predictive factors for revision of major lower extremity amputations in patients with PAD. Patients and methods: A retrospective chart review of all major lower extremity amputations at our institution was conducted. Amputations due to trauma or tumor and below-ankle amputations were excluded. Patient demographics, level/type of amputation, level/time of revision, comorbidities and risk factors were extracted. Results: 180 patients with PAD, mean age 66.48 (range: 31-93) years, 125 (69.4%) male were included. Most (154/180, 86.6%) underwent below-knee amputation. 71 (39.4%) patients had coronary arterial disease, 104 (57.8%) had diabetes. More than half of patients, (93/138; 51.7%) had undergone previous balloon angioplasty. 44 (30%) patients required revision surgery: 42/180 (23.3%) were revised at the same level, and in 12/180 (6.7%) a more proximal amputation was necessary. PAD stage was not associated with the level of reamputation (p = 0.4369). Significantly more patients who had previous balloon angioplasty required revision surgery (66.7% versus 45.2%, p = 0.009). 67 (37.2%) patients underwent preoperative TcPO2 measurement: 40/67 (59.7%) had TcPO2 ≥ 40 mmHg; 4/67 (6%) had TcPO2 < 10 mmHG. Three patients with TcPO2 ≥ 40 mmHg, one with 30 mmHg ≤ TcPO2 ≤ 40 mmHg and one with 10 mmHg ≤ TcPO2 ≤ 20 mmHg required re-amputation to a more proximal level. Conclusions: TcPO2 measurements are useful for determining level of lower limb amputation and predicting wound healing problems when an amputation level with TcPO2 < 40 mmHg is chosen. In transtibial amputations, TcPO2 ≥ 40 mmHg does not safely predict wound healing.

Cementless Stem for Femoral Neck Fractures in a Patient's 10th Decade of Life: High Rate of Periprosthetic Fractures.

BACKGROUND: Subsidence of cementless femoral stems in hemiarthroplasty (HA) and increased fracture rates are ongoing concerns of orthopedic surgeons when treating fractures in very old patients. Additionally, bone cement implantation syndrome may result in perioperative cardiac or pulmonary complications, especially in older patients, leading to morbidity and mortality. This study was performed to analyze possible subsidence and intraoperative fractures in a cohort of very old patients treated with cementless stems. METHODS: We retrospectively analyzed a consecutive cohort of patients aged ≥90 years with femoral neck fractures treated by uncemented HA and an anterior minimally invasive approach. Immediate full-weight bearing was allowed postoperatively. Pelvic radiographs were examined for subsidence immediately postoperatively and 6 weeks later. RESULTS: We treated 109 patients (74% women; mean age, 93 years; range, 90-102 years) by HA from January 2010 to March 2016. The 30-day mortality rate was 16%, and the morbidity rate was 47%. There were 11 (12%) intraoperative fractures: 8 (Vancouver B2) had to be addressed immediately during the primary operation, while 3 (1 Vancouver B1 and 2 Vancouver AG) were treated conservatively. One periprosthetic femoral fracture (Vancouver B1) was documented during follow-up. In 17 patients, subsidence of >2.0 mm (median, 3.9 mm; range, 2.5-9.0 mm) was documented. CONCLUSION: Early subsidence was low in this very old cohort treated with an uncemented stem and not showing a periprosthetic fracture. The risk of intraoperative periprosthetic fractures was high. The use of uncemented implants in osteoporotic bone continues to be an intervention with high risk and should only be performed by experienced surgeons. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Perioperative Fractures in Cementless Total Hip Arthroplasty Using the Direct Anterior Minimally Invasive Approach: Reduced Risk With Short Stems.

BACKGROUND: The direct minimally invasive anterior approach (DMIAA) and the use of uncemented stems demonstrated an increase in intraoperative fractures in recent literature. Whether the different design of the stems additionally influences the incidence of perioperative local complications, was the goal of this study. METHODS: From January 2008 until June 2010, all patients undergoing primary cementless total hip arthroplasty, using a DMIAA, were consecutively included. The choice of the implant was defined by the day of operation. Age, gender, body mass index, type of prosthesis, and the practical experience of the performing surgeon were retrospectively analyzed. Of main interest were intraoperative fractures, postoperative hematoma, and wound healing. RESULTS: Six hundred forty consecutive patients (64 years [18-94], 339 female, 53%, body mass index 26) have been included. A Quadra-H stem (Medacta) was used in 457 patients (71%). In 183 (29%) patients, a short stem designed for the DMIAA (130 Fitmore, Zimmer and 53 AMIStem, Medacta) was used. We counted 34 (5.3%) intraoperative fractures (16 at the greater trochanter, 18 proximal shaft fractures), 20 (4%) hematomas, and 8 (2%) wound healing problems. The standard length stem showed more local complications (11.8% vs 4.4%) (P = .014, odds ratio 1.63, confidence interval 1.1-2.4) and significantly more (6.8% vs 1.6%) intraoperative fractures (P = .027, odds ratio 1.98, confidence interval 1.1-3.6). CONCLUSION: The standard length stem showed more perioperative complications, especially periprosthetic fractures. It seems that these implants not only put more stress to proximal osseous structures, but there might also be more traction and irritation to the soft tissue while preparing, resulting in more hematomas and wound healing problems.