Total hip arthroplasty for sickle cell osteonecrosis: guidelines for perioperative management.

The prognosis of sickle cell disease (SCD) has greatly improved in recent years, resulting in an increased number of patients reporting musculoskeletal complications such as osteonecrosis of the femoral head. Total hip arthroplasty (THA) can be utilized to alleviate the pain associated with this disease.Although it is well known that hip arthroplasty for avascular necrosis (AVN) in SCD may represent a challenge for the surgeon, complications are frequent, and no guidelines exist to prevent these complications. Because patients with SCD will frequently undergo THA, we thought it necessary to fulfil the need for guidance recommendations based on experience, evidence and agreement from the literature.For all these reasons this review proposes guidelines that provide clinicians with a document regarding management of patients with SCD in the period of time leading up to primary THA. The recommendations provide guidance that has been informed by the clinical expertise and experience of the authors and available literature.Although this is not a systematic review since some papers may have been published in languages other than English, our study population consisted of 5,868 patients, including 2,126 patients with SCD operated on for THA by the senior author in the same hospital during 40 years and 3,742 patients reported in the literature. Cite this article: EFORT Open Rev 2020;5:641-651. DOI: 10.1302/2058-5241.5.190073.

Hip osteonecrosis and pregnancy in healthy women.

PURPOSE: Osteonecrosis has been reported to be associated with pregnancy in the absence of other known risk factors for the disease. Few population-based data exist to support an association since the association is rare. We investigated the association of the femoral head and pregnancy to define if pregnancy was a risk factor and to define the risk period. METHODS: Using a case-crossover method design among 652 patients who were healthy (without any known cause of osteonecrosis) during or after pregnancy, we defined the periods of risk based on the timing of reported osteonecrosis and pregnancy. We compared each patient's likelihood of osteonecrosis during a ten years period including five years antepartum, pregnancy and five years postpartum with nine month intervals for the ten year and three month intervals for the two years after gestation. RESULTS: For the 436 women who had only one child and one hip osteonecrosis, the incidence of osteonecrosis was 71.8% during pregnancy and the postpartum period, compared with 28.2% during the equivalent antepartum period for this population. Nine months after delivery, the risk of osteonecrosis declined progressively over time, from an odds ratio of 14.5 (95% confidence interval, 8.2-18.3) in last trimester of pregnancy. After the 27th month following onset of pregnancy, the relative risk was no more significantly different from the baseline risk observed in the antepartum period of women who had osteonecrosis before gestation. For women with several children, a subsequent pregnancy was not associated with osteonecrosis. CONCLUSIONS: A risk of hip osteonecrosis is present during the end of pregnancy and after delivery, and appears to decrease quickly.

Comparison of fixed-bearing and mobile-bearing total knee arthroplasty after high tibial osteotomy.

PURPOSE: There is no information comparing the results of fixed-bearing total knee replacement and mobile-bearing total knee replacement in the same patients previously treated by high tibial osteotomy. The purpose was therefore to compare fixed-bearing and mobile-bearing total knee replacements in patients treated with previous high tibial osteotomy. METHODS: We compared the results of 57 patients with osteoarthritis who had received a fixed-bearing prosthesis after high tibial osteotomy with the results of 41 matched patients who had received a rotating platform after high tibial osteotomy. The match was made for length of follow-up period. The mean follow-up was 17 years (range, 15-20 years). The patients were assessed clinically and radiographically. RESULTS: The pre-operative knee scores had no statistically significant differences between the two groups. So was the case with the intra-operative releases, blood loss, thromboembolic complications and infection rates in either group. There was significant improvement in both groups of knees, and no significant difference was observed between the groups (i.e., fixed-bearing and mobile-bearing knees) for the mean Knee Society knee clinical score (95 and 92 points, respectively), or the Knee Society knee functional score (82 and 83 points, respectively) at the latest follow-up. However, the mean post-operative knee motion was higher for the fixed-bearing group (117° versus 110°). In the fixed-bearing group, one knee was revised because of periprosthetic fracture. In the rotating platform mobile-bearing group, one knee was revised because of aseptic loosening of the tibial component. The Kaplan-Meier survivorship for revision at ten years of follow-up was 95.2% for the fixed bearing prosthesis and 91.1% for the rotating platform mobile-bearing prosthesis. CONCLUSIONS: Although we did manage to detect significant differences mainly in clinical and radiographic results between the two groups, we found no superiority or inferiority of the mobile-bearing total knee prosthesis over the fixed-bearing total knee prosthesis for patients previously operated by high tibial osteotomy.

History of clubfoot treatment, part I: From manipulation in antiquity to splint and plaster in Renaissance before tenotomy.

Idiopathic clubfoot is one of the most common problems in paediatric orthopaedics. The treatment is controversial and continues to be one of the challenges in paediatric orthopaedics. The aim of this review is to assess the different methods of clubfoot treatment used over the years in light of the documentation present in the literature and art paintings from the antiquity to the end of the 19th century. The aim of this paper is to review all treatment methods of the clubfoot over the years that were proposed to provide patients a functional, pain-free, normal-looking foot, with good mobility, without calluses, and requiring no special shoes. Hippocrates was the first to write references about treatment methods of clubfoot. After the Middle Ages and the Renaissance where patients were treated by barber-surgeons, quacks and charlatans, bonesetters, and trussmakers, there were more detailed studies on the disease, with the help of famous names in medicine such as Venel and Scarpa.

History of internal fixation with plates (part 2): new developments after World War II; compressing plates and locked plates.

The first techniques of operative fracture with plates were developed in the 19th century. In fact, at the beginning these methods consisted of an open reduction of the fracture usually followed by a very unstable fixation. As a consequence, the fracture had to be opened with a real risk of (sometimes lethal) infection, and due to unstable fixation, protection with a cast was often necessary. During the period between World Wars I and II, plates for fracture fixation developed with great variety. It became increasingly recognised that, because a fracture of a long bone normally heals with minimal resorption at the bone ends, this may result in slight shortening and collapse, so a very rigid plate might prevent such collapse. However, as a consequence, delayed healing was observed unless the patient was lucky enough to have the plate break. One way of dealing with this was to use a slotted plate in which the screws could move axially, but the really important advance was recognition of the role of compression. After the first description of compression by Danis with a "coapteur", Bagby and Müller with the AO improved the technique of compression. The classic dynamic compression plates from the 1970s were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates resulted in delayed union and the osteoporosis, cancellous bone, comminution, and/or pathological bone resulted in some failures due to insufficient stability. Finally, new devices represented by locking plates increased the stability, contributing to the principles of a more biological osteosynthesis while giving enough stability to allow immediate full weight bearing in some patients.

History of internal fixation (part 1): early developments with wires and plates before World War II.

Though the date at which an orthopaedic implant was first used cannot be ascertained with any certainty, the fixation of bone fracture using an iron wire was reported for the first time in a French manuscript in 1775. The first techniques of operative fracture treatment were developed at the end of the 18th and in the beginning of the 19th centuries. The use of cerclage wires to fix fractures was the most frequent fixation at this time. The French Berenger-Feraud (1832-1900) had written the first book on internal fixation. However internal fixation of fractures could not become a practical method before Lister had ensured the safety of open reduction and internal fixation in the treatment of fractures. Lister is not only the father of asepsis; he also used metal wires to fix even closed fractures. The first internal fixation by means of a plate and screws was described by Carl Hansmann in 1858 in Hamburg. Nevertheless, Arbuthnot Lane (1892) and Albin Lambotte (1905) are considered to be the founders of this method, which was further developed by Sherman in the first part of the 20th century.

Supercharging irradiated allografts with mesenchymal stem cells improves acetabular bone grafting in revision arthroplasty.

PURPOSE: The procedure of bone allografting associated with a reinforcement device is widely used for acetabulum revision. However in absence of biologic fixation of the allograft, failure of the reconstruction may occur. We made the hypothesis that it would be possible to load these grafts with bone marrow derived mesenchymal stem cells (MSC) to rescue the osteogenic capacity of an allogenic dead bone and therefore enhance incorporation of allografts with the host bone and decrease the number of failures related to the allograft. METHOD: We identified 60 patients who had undergone acetabular component revision for aseptic failure of cemented implants associated with massive periacetabular osteolysis and Paprosky type 3A or 3B classification (without pelvic discontinuity) between 1996 and 2001. The study group of 30 patients received MSCs in the allograft and at the host graft junction. The average total number of MSCs received by each patient was 195,000 cells (range 86,000-254,000 cells). The control group of 30 patients had no MSCs in the allograft. Patients were matched for the size of periacetabular osteolysis (Paprosky type 3A or 3B). We compared the evolution of the allografts and evaluated cup migration and revision of the hips as end points at a minimum of 12 years or until failure. RESULT: Better radiographic graft union rates and less allograft resorption were observed with allografts loaded with stem cells. Allograft resorption was significantly decreased in the group with allograft loaded with MSCs (1.2 cm(2) -range 0-2.3 cm(2)-of resorption on radiographs in the group with MSCs; versus 6 cm(2), range 2.1-8.5 cm(2) in the group without MSCs). The rate of mechanical failure was highest (p = 0.01) among the 30 patients with allograft without stem cells (9/30; 30 %) compared with no failures for patients with allograft loaded with stem cells. Revision of the cup was necessary in nine patients in the control group. No revision was performed in the 30 patients of the study group with MSCs. CONCLUSION: For acetabular defect reconstruction, loading the allograft with MSCs has resulted in a lower rate of failure as compared with allograft without MSCs.

The risk of dislocation after total hip arthroplasty for fractures is decreased with retentive cups.

PURPOSE: Total hip arthroplasty (THA) has been efficacious for treating hip fractures in healthy older patients. However, in those patients with fractures a widely variable prevalence of dislocation has been reported, partly because of varying durations of follow up for this specific end-point. The purpose of the present study was to determine the cumulative risk of dislocation in these patients with fractures and to investigate if retentive cups decrease the risk of dislocation. METHODS: Between 2000 and 2005, 325 patients with neck fracture underwent primary THA using a retentive (325 hips) cup. The results of these 325 acetabular cups were compared to 180 THA without retentive cups performed for neck fractures in the same hospital between 1995 and 2000 by the same surgical team. The mean age of the 505 patients was 75 years (range 65-85). All patients were followed for a minimum of five years for radiographic evidence of implant failure. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation and recurrent dislocation was calculated with use of the Kaplan-Meier method. RESULTS: For patients without retentive cups, the cumulative risk of a first-time dislocation was 5 % at one month and 12 % at one year and then rose at a constant rate of approximately 1 % every year to 16 % at five years. For patients with retentive cups, the cumulative risk of a first-time dislocation was 1 % at one month, 2 % at one year and then did not changed at five years. There were no differences in the mortality rates or in loosening rates among the treatment groups. The rate of secondary surgery was highest in the group without retentive (10 % for recurrent dislocation) compared with 1 % in the group treated with retentive cups. In absence of retentive cups, multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were 80 years old or more (as compared with those who were less than 80 years old) was 1.5. Two underlying diagnoses occurring during follow up-cognitively impaired patients or neurologic disease-were also associated with a significantly greater risk of dislocation in absence of retentive cup. For these patients the risk was also decreased with a retentive cup. CONCLUSION: With standard cups the incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are old female patients and those with a diagnosis of neurologic disease. Retentive cups in these patients are an effective technique to prevent post-operative hip dislocation.