C-arm fluoroscopy in orthopaedic surgical practice.

The use of C-arm fluoroscopy in intraoperative orthopaedic procedures has become an important tool in modern orthopaedic surgical practice. It enhances the technical proficiency of the surgeon in addition to reducing the morbidity and length of hospital stay of the patient. Despite the documented benefits of this device, there has been a growing concern about the increased radiation exposure to the surgical team. We therefore present the review of the literature on the usefulness of C-arm fluoroscopy, pitfalls in application of the machine as well as the harmful radiation effects and precautionary measures that need to be observed when using the C-arm fluoroscopy in orthopaedic surgical procedures.

Novel pathomorphologic classification of capsulo-articular lesions of the pubic symphysis in athletes to predict treatment and outcome.

INTRODUCTION: Radiographic abnormalities of the symphysis as well as the formation of accessory clefts, indicating injury at the rectus-adductor aponeurosis, reportedly relate to longstanding groin pain in athletes. However, yet, no systematic classification for clinical and scientific purposes exists. We aimed to (1) create a radiographic classification based on symphysography; (2) test intra- and interobserver reliability; (3) characterise clinical significance of the morphologic patterns by evaluating success of injection therapy. PATIENTS AND METHODS: We retrospectively reviewed symphysography, AP radiographs, and MRI of the pelvis from 70 consecutive competitive athletes, with chronic groin pain. Symphysographs were evaluated for intra- and interobserver variance using cohen's kappa statistics. Morphologic studies of the different contrast distribution patterns and their clinical and radiological correlation with symptom relief were investigated. All patients were followed up to evaluate immediate and long-term response to the initial therapeutic injection with steroid. RESULTS: Four reproducible symphysographic patterns were identified: type 0, no changes; type 1, symphyseal disk degeneration; types 2a with unilateral clefts, bilateral clefts (2b), suprapubic clefts (2c); and type 3, with expanded or multidirectional clefts. Analysis revealed excellent intra (0.94)-and interobserver (0.90) reliability. Our findings showed that 78.6% of our patients had significant short-term improvement enabling early resumption of physiotherapy, only in types 1 and 2 (p = 0.001), while type 0 and 3 did not respond. At follow-up, only 21.8% had permanent pain relief. Regarding the detection of pathologic clefts with symphysography, sensitivity (88%) and specifity (77%) were superior to that of MRI. CONCLUSIONS: A reproducible symphysography-based classification of distinct morphologic patterns is proposed. It serves as a predictive tool for response to injection therapy in a select group of pathologic lesions. Complete recovery after injection can only be expected in a lesser percentage, as this might indicate surgical treatment for long-term non-responders.

Patient-reported outcomes after revision surgery compared to primary total hip arthroplasty.

INTRODUCTION: Patients who undergo either primary or revision total hip arthroplasty (THA) mainly expect improvement in pain, function/activity and quality of life. The purpose of the study was to measure the degree of short-term and medium-term improvement and the differences in patient-reported outcome that can be expected in patients undergoing revision THA, compared to patients undergoing primary THA. METHODS: In this study, the results of patient-reported outcome measurements were compared in 124 matched patients, who underwent revision surgery and primary THA between 01/2007 and 12/2009. Assessment was performed at short-term and medium-term follow-up and included the WOMAC score, the UCLA activity score and EuroQol scores. RESULTS: 6 months after revision THA, the mean total WOMAC score improved by 22.1 points, the UCLA activity score by 0.6 points and the EuroQol-Index by 0.2 points. After primary THA, the improvement was 41.4 points on the WOMAC, 1.1 points on the UCLA and 0.3 points on the EuroQol-Index. At medium-term follow-up, 3.6 years after revision surgery and 2.3 years after primary THA, patients undergoing revision THA showed significantly less overall improvement, as well as lower final outcome scores, than patients undergoing primary THA. CONCLUSIONS: Patients undergoing revision arthroplasty, as well as patients undergoing primary THA, can expect major improvement in function, activity and quality of life postoperatively. However, overall level of improvement, as well as peak attainable outcome levels, are lower after revision surgery than after primary THA. Appropriate information for patients who undergo hip revision surgery is necessary in order to avoid unrealistic expectations and postoperative dissatisfaction.

Predictors of mortality for complex fractures of the pelvic ring in the elderly: a twelve-year review from a German level I trauma center.

STUDY OBJECTIVE: To document mortality rate and predictors of mortality in elderly patients with complex pelvic fractures. METHODS: We reviewed a total of 84 subjects whose ages were above 70 years with complex pelvic fractures, admitted to our hospital from January 2001 to December 2012. A multivariate linear regression model was used to determine the predictors of mortality in the study population. The median age of the patients was 80.4 years (range 70-94 years). 65 of 84 (77%) patients were females. There were 72 Tile Type B fractures (86%) and 12 Type C fractures (14%). The most common associated injuries were thoracic, extremity and head injuries, with incidence of 13 (15%), 11 (13%), and 9 (11%), respectively. RESULTS: The mortality rate was 10% in our study population. The initial haemoglobin on admission (p<0.01), the presence of blood vessel injuries (p<0.01) and the number of PRBCs transfused within the first six hours after admission (p<0.01) independently predicted mortality in elderly patients with complex pelvic fractures. CONCLUSION: Although there is a downward trend in mortality in elderly patients with complex pelvic fractures, haemodynamic instability still has a significant impact on survival of those patients.

Posterior symphyseal spurs--an unusual differential diagnosis in athletes with groin pain.

We set out to highlight the significance of posterior symphyseal spurs as an unusual diagnostic possibility in athletes with chronic groin pain and to demonstrate that operative resection was successful in quickly and safely returning the patients to sporting activities. Five competitive nonprofessional male athletes, three soccer players, and two marathon runners (median age: 30 [26/33] years), who presented to us with significant groin and central pubic pain with duration of at least 12 months, and who had failed conservative or surgical interventions (symphyseal plating), were evaluated. Physical examination as well as pelvic radiographs confirmed the diagnosis of posterior symphyseal spurs. Four out of five athletes underwent complete resection of the spur. Size of spurs was 2.2 (1.3/2.9) cm (median) with four of them posterosuperiorly and one posterocentrally located. All of them had uneventful postoperative recovery period and were still pain-free at the latest follow up after 26.6 months (24/30). Median time-to-return to competitive sports level was 10 weeks (8/13). None of the patients developed pubic instability due to symphyseal spur resection. The results of considerable postoperative improvement in our patients highlight the significance of posterior symphyseal spurs as a diagnostic possibility in athletes with chronic groin pain.

Arthroscopic debridement of the pubic symphysis: an experimental study.

PURPOSE: Open curettage of the symphysis has shown promising results in patients with recalcitrant osteitis pubis. However, this has been bedevilled with an extended intraoperative morbidity. Aim of this study was to come up with a novel arthroscopic debridement of the pubic symphysis and to bring to the fore the potential risks of soft tissue damage. METHODS: This study was conducted on six human cadavers (mean age 83 years). CT scans were obtained for measurement of the symphyseal morphology. Consequent upon these measurements, four different potential arthroscopic portals were defined with the intention to gain adequate insight and to reach the whole joint space with instruments: one suprapubic portal and three anterior portals (antero-superior, antero-central and antero-inferior). Soft tissue, except for musculotendinous attachments and neurovascular structures, was dissected. A two-portal arthroscopic debridement under image intensifier control with resection of the symphyseal disc and abrasion of the subchondral bone were performed. RESULTS: Considering the narrow joint space, small instruments/scope (4.5/2.7 mm) is recommended. Correct portal placement and debridement procedure can only be reliably performed under fluoroscopic imaging in two radiographic projections (outlet and inlet view) with a mean total fluoroscopic time of 15-20 s and a dose area product between 100 and 120 cGy cm(2). Two portals have proved beneficial: the suprapubic portal for instruments and the antero-central portal for the scope. Other portals had several limitations, e.g. potential instrumental conflict (anterior-superior) or damaging of neurovascular and other soft tissue structures (anterior-inferior). CONCLUSION: With well-defined arthroscopic portals and adherence to basic principles of arthroscopic surgery, debridement of the pubic symphysis can be performed reproducibly without compromising important anatomical structures. This less invasive arthroscopic debridement is a safely applicable procedure and therefore might be a reasonable alternative to open curettage. One may assume that this technique will lead to a shorter rehabilitation time and will provide a successful therapy especially in the treatment of professional athletes in the future.