The influence of spine-hip relations on total hip replacement: A systematic review.

Sagittal pelvic kinematics along with spino-pelvic angular parameters have recently been studied by numerous investigators for their effect on total hip replacement (THR) clinical outcomes, but many issue of spine-hip relations (SHR) are currently unexplored. Therefore, our review aims at clarifying the following questions: is there any evidence of a relationship between articular impingement/dislocation risk in primary THR and (1) certain sagittal pelvic kinematics patterns, (2) pelvic incidence, and (3) types of SHRs? A systematic review of the existing literature utilising PubMed and Google search engines was performed in January 2017. Only clinical or computational studies published in peer-reviewed journals over the last five years in either English or French were reviewed. We identified 769 reports, of which 12 met our eligibility criteria. A review of literature shows that sagittal pelvic kinematics, but not the pelvic incidence, influences the risk of prosthetic impingement/dislocation. We found no study having assessed the relationship between this risk and the types of SHRs. Sagittal pelvic kinematics is highly variable among individuals and certain kinematic patterns substantially influences the risk of prosthetic impingement/dislocation. Recommendations for cup positioning are therefore switching from a systematic to a patient-specific approach, with the standing cup orientation Lewinneck safe zone progressively giving way to a new parameter of interest: the functional orientation of the cup. Based on a recently published classification for SHRs, We propose a new concept of "kinematically aligned THR" for the purposes of THR planning. Further studies are needed to investigate the relevance of such a classification towards the assumptions and hypothesis we have made. Level of evidence,- Level IV, systematic review of level III and IV studies.

Clinical outcome in MPFL reconstruction with and without tuberositas transposition.

PURPOSE: There are several surgical options for recurrent patella dislocations. As the reconstruction of the medial patellofemoral ligament (MPFL) has been proven to restore stability, it has become more accepted. Aim of this study was to investigate the clinical outcome after MPFL reconstruction as an isolated procedure or in association with a transposition of the tibial tubercle (in case of patella alta or an excessive TT-TG) in a large prospective cohort study. Additionally, the effect on patellar height was analysed radiographically using the Caton-Deschamps index. METHODS: In a large prospective cohort study of 129 knees in 124 patients (81 females, 48 males, mean age 22.8 ± 7.7 years), 91 knees received primary MPFL reconstruction (group 1) and 38 were a combination with a transposition of the tibial tubercle (group 2). The clinical follow-up was evaluated using KOOS and Kujala scores preoperatively and 1 year postoperatively. Patient satisfaction, complications and revision surgery were recorded. RESULTS: Overall, Kujala improved significantly from 53.5 (SD 22.7) preoperatively to 74.7 (SD 20.5) postoperatively (p < 0.01). All KOOS subdomains improved significantly (p < 0.01). No significant difference for Kujala score between groups was noticed. Revision rate was (5/129) 3.9 %. Reconstruction was supplemented with a transfer of the tibial tuberosity in (38/129) 29.4 % of the cases and shows a comparable outcome. CONCLUSION: MPFL reconstruction is a viable treatment option for episodic patellar dislocation. A concomitant tuberositas transposition is useful in selected patients. LEVEL OF EVIDENCE: I.

Metal ion levels from well-functioning Birmingham Hip Resurfacings decline significantly at ten years.

A retrospective study was conducted to investigate the changes in metal ion levels in a consecutive series of Birmingham Hip Resurfacings (BHRs) at a minimum ten-year follow-up. We reviewed 250 BHRs implanted in 232 patients between 1998 and 2001. Implant survival, clinical outcome (Harris hip score), radiographs and serum chromium (Cr) and cobalt (Co) ion levels were assessed. Of 232 patients, 18 were dead (five bilateral BHRs), 15 lost to follow-up and ten had been revised. The remaining 202 BHRs in 190 patients (136 men and 54 women; mean age at surgery 50.5 years (17 to 76)) were evaluated at a minimum follow-up of ten years (mean 10.8 years (10 to 13.6)). The overall implant survival at 13.2 years was 92.4% (95% confidence interval 90.8 to 94.0). The mean Harris hip score was 97.7 (median 100; 65 to 100). Median and mean ion levels were low for unilateral resurfacings (Cr: median 1.3 µg/l, mean 1.95 µg/l (< 0.5 to 16.2); Co: median 1.0 µg/l, mean 1.62 µg/l (< 0.5 to 17.3)) and bilateral resurfacings (Cr: median 3.2 µg/l, mean 3.46 µg/l (< 0.5 to 10.0); Co: median 2.3 µg/l, mean 2.66 µg/l (< 0.5 to 9.5)). In 80 unilateral BHRs with sequential ion measurements, Cr and Co levels were found to decrease significantly (p < 0.001) from the initial assessment at a median of six years (4 to 8) to the last assessment at a median of 11 years (9 to 13), with a mean reduction of 1.24 µg/l for Cr and 0.88 µg/l for Co. Three female patients had a > 2.5 µg/l increase of Co ions, associated with head sizes ≤ 50 mm, clinical symptoms and osteolysis. Overall, there was no significant difference in change of ion levels between genders (Cr, p = 0.845; Co, p = 0.310) or component sizes (Cr, p = 0.505; Co, p = 0.370). Higher acetabular component inclination angles correlated with greater change in ion levels (Cr, p = 0.013; Co, p = 0.002). Patients with increased ion levels had lower Harris hip scores (p = 0.038). In conclusion, in well-functioning BHRs the metal ion levels decreased significantly at ten years. An increase > 2.5 µg/l was associated with poor function.

[Metal ion concentrations in patients with metal-metal bearings in prostheses]. / Metallkonzentrationen bei Patienten mit Metall-Metall-Gleitpaarungs-Prothese.

Increased wear leads to elevated systemic and local metal ion concentrations for patients treated with metal-on-metal bearings. The local metal ion content in the close environment of the joint replacement (e.g. joint aspirate or tissue) is several times higher compared to the systemic metal content (e.g. in blood or serum). As a result of increased metal ion levels, local and systemic effects, such as osteolysis, pseudotumors, sensitization or in rare cases toxicity may occur. Although the definition of a specific threshold to define clinical problems is difficult due to a lack of sensitivity, the systemic metal concentration is frequently measured clinically. Currently a threshold for cobalt and chromium between 4 µg/l and 7 µg/l is under debate. Very high levels (≥ 20 µg/l) or a steady increase over time should be a warning sign; however, metal ion levels should not be interpreted as a single diagnostic tool but rather in the entire context of the clinical, radiological and cross-sectional imaging, metal artefact reduction sequence (MARS) magnetic resonance imaging (MRI), ultrasound and computed tomography (CT) findings.

The efficacy and toxicity of a constant low dose of methotrexate as a treatment for intractable rheumatoid arthritis: an open prospective study.

Ninety-two patients with intractable rheumatoid arthritis (RA) participated in an open prospective study of the longterm efficacy and toxicity of methotrexate (MTX), administered orally at a constant dosage of 7.5 mg/week. Twenty-four patients (25%) had to be withdrawn from the study within the first 12 months because of inefficacy or adverse reactions with a fatal outcome in 2 patients. In the remaining 68 patients, the mean duration of therapy was 19 months. Sixty-three of 92 patients (68%) experienced significant clinical improvement after one year, 23 (25%) were in clinical remission. Twenty-three of these patients initially responded well but relapsed after a median of 15 months of therapy. In 5 patients (5%) the disease activity remained status quo. Toxicity was noted at some time in 51 patients (54%), consisting of clinical side effects in 37 patients (40%) and biological abnormalities in 36 patients (39%), including 9 patients (10%) with blood and bone marrow toxicity, in whom renal function at start was normal. Two of these latter 9 patients had a fatal outcome because of an unexpected renal deterioration due to intercurrent disease. Thus, MTX at this constant low dose appears to be a temporarily valuable therapy for intractable RA. Careful monitoring is necessary in view of the potentially dangerous side effects.

Onset of symptoms of rheumatoid arthritis in relation to age, sex and menopausal transition.

In a population of 564 patients with rheumatoid arthritis (RA), the onset of symptoms has been studied in relation to age, sex and last menstrual period for women. Median age of menopause was 49 years (3rd percentile: 32 years and 97th percentile: 56 years). Median age of first symptoms was 45 years in women and 50 in men. The individual interval between menopause and first symptoms has a Gaussian distribution with mean at time 0, implying that the average woman develops the first symptoms at the time of her menopause. The F:M ratio of all patients was 2.3; with increasing age the F:M ratio decreased from 3.7 before 30 years of age to 1 after the 6th decade of life, with a peak at the age of 40-44 years. A possible effect of age related changes in sex hormone levels on the pathogenesis of RA is suggested.

Destructive hip lesions in seronegative spondyloarthropathies: relation to gut inflammation.

In the seronegative spondyloarthropathies the hip lesions can be subdivided into a concentric type progressing to ankylosis and an eccentric type leading to joint destruction. Radiologic examination of the hips was performed in 177 of 211 patients suffering from seronegative spondyloarthropathies on whom ileocolonoscopy with biopsies of ileum and colon was performed; in 27 of these 177 patients, hip lesions were demonstrated. The concentric form seems to be radiologically, clinically and genetically more related to axial involvement; moreover, the frequency of subclinical gut inflammation was the same as in the group of patients with ankylosing spondylitis (AS) without peripheral arthritis, and thus significantly lower than in patients with AS with peripheral arthritis. Eccentric, destructive hip lesions seem to be unrelated to axial involvement, but they are associated with the presence of HLA-Bw62 and gut inflammation (100%), mainly of the chronic, Crohn disease-like type.

Destructive lesions of small joints in seronegative spondylarthropathies: relation to gut inflammation.

Destructive lesions of small joints were found in 40 out of 211 patients suffering from seronegative spondylarthropathies (SpA) on whom ileocolonoscopy with biopsies of the ileum and colon were performed. The destructive lesions of small joints, radiologically only distinguishable from rheumatoid arthritis lesions by the pauciarticular and asymmetrical involvement, the rare tendency to fusion and the rare occurrence of periosteal hypertrophy, were observed more frequently in patients presenting subclinical inflammatory gut lesions, predominantly of the chronic type, than in patients without gut inflammation.

Posterior subtalar joint arthrography. A useful tool in the diagnosis of hindfoot disorders.

Obscure hindfoot disorders are often classified under the heading of sinus tarsi syndrome (STS). The diagnosis of STS is based upon subjective symptoms: tenderness over the lateral aperture of the sinus tarsi and hindfoot instability. Arthrography of the posterior subtalar joint is an objective parameter, identifying peri- or intraarticular pathology as the cause of symptoms. In 27 patients with STS, the pathologic arthrographic findings include less-marked microrecesses in the sinus tarsi region, ganglions at the anterior aspect of the subtalar joint, retraction of the joint recesses, a smooth and rounded appearance of the capsule, and a frozen subtalar joint. Through analysis of these films, the appropriate therapeutic approach can be outlined; infiltrations into the sinus tarsi itself, intraarticular corticosteroid injections, or subtalar arthrodesis for resistant cases are the procedures of choice. In the authors' experience, surgical curettage of the sinus tarsi has no place in the treatment of STS.

Rapidly fatal pneumococcal septicemia in systemic lupus erythematosus.

Streptococcal pneumoniae septicemia was responsible for the deaths of 3 patients with chronic systemic lupus erythematosus. The absence of a spleen likely contributed to sepsis in 2 patients. One patient had been immunized with 14-valent pneumococcal vaccine with a doubling of serum antibody concentrations at one month to all vaccine capsular polysaccharide types except for Types 1 and 12. The patient died 74 months after immunization of pneumococcal Type 1 sepsis.