Trabecular Metal Augments for Severe Acetabular Defects in Revision Hip Arthroplasty: A Long-Term Follow-Up.

BACKGROUND: Paprosky type IIIa and IIIb acetabular defects remain technically challenging during revision hip arthroplasty. Numerous surgical options exist to counter extensive acetabular bone loss with high postoperative complication and revision rates reported. Our aim was to report comprehensive long-term outcomes of our experience with Trabecular Metal (TM) augments for these difficult cases. METHODS: 38 patients underwent revision total hip arthroplasty at our institution from 2009 to 2014 where a TM augment was used for acetabular deficiency. Prospective radiographic and Patient-Reported Outcome Measures were recorded and analyzed to a mean of 7.3 years (range: 5.4 to 10.8). RESULTS: No patient was excluded or lost to follow-up. Complications included 3 intraoperative fractures, 1 early infection requiring washout with implant retention, 1 early revision due to allograft resorption, and 6 patients who required late repeat revision surgery: 3 for late infection, 2 for aseptic loosening with augment fracture or dislocation, and 1 for recurrent dislocation. The estimated mean implant survivorship was 8.99 years. 93.5% of augments remaining were well osseointegrated while 97% of the acetabular shells were osseointegrated. Hip center of rotation was restored by a mean of 14 mm inferiorly without significant medialization. Short Form-12 (SF-12) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were significantly reduced postoperatively to a level comparable to the average individual. CONCLUSION: This long-term study details our experience of TM augments for the most severe acetabular defects. For such cases, no excellent surgical solution exists; in comparison to alternative methods, we advocate that this technique is reasonably safe and effective.

Arthroplasty and global research output: A bibliometric analysis.

INTRODUCTION: Peer-reviewed research helps to advance many aspects of medical and surgical practice. This paper determines the main contributors tos joint arthroplasty research in terms of quantity and quality. METHODS: A search of the Web of Science™ platform was conducted to identify arthroplasty articles published between 2001 and 2016. The number of articles and citations per article were analysed to assess the quantity and quality of research from individual countries. Results were standardised according to the country's populations and Gross Domestic Product (GDP). RESULTS: In total, 43,470 arthroplasty articles were published worldwide from January 2001 through December 2016. There was a 4.5-fold increase in global output during this time period. Twenty-two countries contributed at least 1% to the total number of publications. The United States of America published the most articles (35.40%), followed by England (10.31%) and Germany (10.03%). The USA had the highest absolute number of citations (50,777). Denmark had the highest average citation per item (8.76). When number of articles was normalized to population, Switzerland ranked the highest. When adjusted by GDP, Scotland ranked highest. When standardised according to GDP per capita, the People's Republic of China rated highest. The Journal of Arthroplasty produced the highest number of publications related to arthroplasty with 10.9% of total volume. CONCLUSION: There has been a substantial increase in worldwide publications relating to arthroplasty. The USA has produced the largest volume whilst Denmark has produced the highest quality publications. When output was normalized according to population and GDP, Switzerland and Scotland ranked highest.

Refracture of the Pediatric Forearm with Intramedullary Nails in situ.

INTRODUCTION: There are few described cases in literature describing the management of refracture of both bone forearm fractures with elastic stable intramedullary nails (ESIN) in situ. We describe our experience and discuss it in the context of existing reports. CASE REPORT: A 6-year-old girl presented to our unit with a refracture of her forearm with ESIN in situ following a trauma, 5 months post her index injury and ESIN procedure. She was managed with closed reduction under general anesthesia with a good outcome. DISCUSSION: Treatment of this unusual injury is challenging given the paucity of evidence to inform management. Many existing case series fail to report this complication. We echo those studies that have employed similar strategies and note potential complications associated with this management including altered biomechanics of the ESIN. CONCLUSION: Closed reduction of a refracture of pediatric forearm with ESIN in situ is an acceptable approach to this unusual injury. Caution must be taken intraoperatively and postoperatively to account for any biomechanical deficiencies in the ESIN resulting from the forces applied to cause the refracture and forces applied to the in situ nails to achieve correction intraoperatively.

Standardized traction versus side-bending radiographs in adolescent idiopathic scoliosis: a preliminary study.

The aim of this study was to develop a new type of preoperative flexibility test for adolescent idiopathic scoliosis. The objective was to develop a test that was standardized and allow for the measurement of in-vivo forces required for curve correction. It was undertaken to compare the results of this new test with side-bending radiographs. Various preoperative radiographic techniques have been used to assess flexibility in patients awaiting scoliosis correction surgery. The major limitation of these investigations is a lack of standardization. The side-bending radiograph is the current gold standard, against which this new test was compared. A prospective clinical study was conducted. An axial traction force of 1.5 times body weight was applied through the spine of patients using a traction jig. Posteroanterior, side-bending and traction radiographs were taken. Cobb angle and apical vertebra axial rotation measurements were obtained. Flexibility indices in the coronal and axial planes were calculated. Cobb angle reduction and axial derotation were compared between the two methods. A total of 15 (12 female and three male) patients, with a mean age of 15.1 years, were assessed. The mean force imparted on traction films was 800 N. The major curve Cobb angle measurements were 60.4° on standing posteroanterior radiograph, 52.7° on side-bend film and 44.5° on traction at 1.5 times body weight. The corresponding apical vertebrae axial rotations were 23.9°, 22.2° and 16.5°, respectively. The mean Cobb angle reduction was 15.9 for traction and 7.7 for side-bend radiographs (P<0.0001). The mean apical vertebra derotation was 7.4 for traction and 1.7° for side-bend radiographs (P=0.0083). The mean flexibility index in the coronal plane was 0.479. The mean flexibility index in the axial plane was 0.240. Our novel method of traction radiographs at 1.5 times body weight is a safe and reproducible method of assessing curve flexibility in patients with scoliosis. This method achieves a larger Cobb angle and axial derotation when compared with side-bending radiographs.

Acetabular Revision Using Trabecular Metal Augments for Paprosky Type 3 Defects.

BACKGROUND: Trabecular Metal (TM) augments are one option when reconstructing bone loss during acetabular side revision surgery. METHODS: We studied 38 consecutive patients with Paprosky type 3 defects that were revised using a TM shell and one or more augments over a 6-year period. There were 29 Paprosky type 3A defects and 9 Paprosky type 3B defects. The mean age of the patients at the time of surgery was 68.2 years (range 48-84). The mean length of follow-up was 36 months (range 18-74). RESULTS: The mean preoperative short form 12 health survey improved from 27.7 before operation to 30.1 at the time of final follow-up (P = .001). The mean Western Ontario and McMaster Universities Osteoarthritis Index score improved from 53 preoperatively to a mean of 78.8 at final follow-up (P < .0001). There was evidence of radiographic loosening in 7 of the cup-augment constructs. One patient developed a deep infection requiring re-revision. Two patients required revision for aseptic loosening. CONCLUSION: The use of TM in complex acetabular reconstruction is associated with good outcome in the short to medium term.

The impact of day of surgery on the length of stay for major urological procedures.

INTRODUCTION: Surgery performed later in the week has been associated with longer length of stay (LOS). The aim of this study was to assess if the day of the surgery impacted the LOS for two major urological procedures in a tertiary referral university teaching hospital. METHODS: A retrospective review was performed of two major urological procedures consecutively performed by a single surgeon in our unit from March 2012 to December 2015. Patient demographics, histopathological characteristics, operative details, and LOS were obtained from the patients' medical records. Procedures performed on Monday or Tuesday were defined as early in the week and procedures performed on Wednesday, Thursday, or Friday were defined as late in the week. RESULTS: During the study period, 140 open radical prostatectomy (ORP) and 42 open partial nephrectomy (OPN) procedures were performed. There was a significant difference in median LOS for major urological procedures performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0001). There was a significant difference in median LOS for ORP performed early in the week compared to late in the week (3 [3-4] days vs. 4 [4-5] days; p= 0.0004). There was a similar significant difference in OPN performed early in the week compared to late in the week (4 [3-5.5] days vs. 5 [4-5] days; p= 0.029). CONCLUSIONS: The day of surgery impacts LOS for major urological procedures. Major procedures should be performed early in the week, when it is feasible to facilitate prompt safe discharge and better use of hospital resources.

Periprosthetic fractures in the resurfaced hip--a case report and review of the literature.

Traumatic periprosthetic fractures adjacent a hip resurfacing prosthesis are rare. When proximal fractures are encountered the obvious surgical solution is to revise to a large head stemmed femoral component. A previously well functioning implant may however be retained as various non-operative and operative treatment options exist. This paper reports the case history of a traumatic periprosthetic fracture successfully treated with cannulated screw fixation and reviews the current literature.