How to remove a well-fixed metaphyseal sleeve in revision knee arthroplasty: A step-by-step surgical procedure.

BACKGROUND: The rising incidence and complexity of revision knee arthroplasty has led to an increase in the use of metaphyseal reconstruction systems. One of the most widely used systems are metaphyseal sleeves as they have demonstrated excellent long-term survival. However, there is concern about the possible difficulty of extracting a sleeve if it were necessary, as no known procedures have yet been validated. METHODS: We examined the outcomes of removing 23 well-integrated metaphyseal sleeves using the same systematized technique. RESULTS: All sleeves were extracted without any intraoperative complications. Four subjects required an osteotomy to complete the extraction, while 62% of the sample were found to have an AORI IIB defect. All cases were successfully reconstructed with a new metaphyseal fixation, implanting a new sleeve in 38% of subjects compared with cones in the remaining 62%. CONCLUSIONS: The technique described here produced successful, reproducible outcomes for the removal of integrated metaphyseal sleeves with minimal bone loss and no intraoperative complications.

Surgical Treatment of Saphenous Nerve Injury Assisted by Plasma Rich in Growth Factors (PRGF): Lessons from a Case Report.

The infrapatellar branch of the saphenous nerve (SN) is a widely described anatomic and functional structure; however, its relevance in daily clinical practice is underestimated. All surgical procedures performed on the anteromedial aspect of the knee are associated with a risk of iatrogenic injury to this nerve, including knee arthroscopy, knee arthroplasty, tibial nailing, etc. We present the case of a saphenous nerve neuroma after treatment with radiofrequency thermal ablation due to a knee pain problem. After conducting an anaesthetic suppression test, we decided to perform a denervation of the medial saphenous nerve in Hunter's canal. We performed surgery on the anteromedial aspect of the knee. The distal end of the medial SN was coagulated with a bipolar scalpel. The proximal end of the nerve was released proximally, and a termino-lateral suture was made at the free end of the nerve after creating an epineural window to inhibit its growth. A double crush was produced proximally to the suture site to create a grade II-III axonal injury. Autologous plasma rich in growth factors (PRGF) was used to reduce potential post-surgical adhesions and to stimulate regeneration of the surgical lesions. One year after surgery, the patient was living a completely normal life.

Office-Based Intraosseous Infiltrations of PRGF as an Effective Treatment for Knee Osteoarthritis: A Retrospective Observational Clinical Study.

The aim of this study was to explore and assess office-based ultrasound-guided intraosseous and intra-articular infiltrations of plasma rich in growth factors (PRGF) in patients with moderate and severe knee osteoarthritis (KOA). Seventy-nine patients (30 women and 49 men) with grade 3-4 KOA according to the Kellgren-Lawrence classification participated in the study. All patients were treated with a minimally invasive technique using local anesthesia WALANT (wide-awake local anesthesia no tourniquet) in the ambulatory setting. A PRGF intra-articular infiltration and two intraosseous infiltrations in the tibial plateau and femoral condyle were performed weekly for a total of three sessions. The evaluation of the results was carried out using knee injury and osteoarthritis outcome score (KOOS) at baseline and post-treatment. After a follow-up period of 11 months (median) [interquartile range, 7-14], all the KOOS domains showed statistically significant improvement (p < 0.001). Moreover, 88% of the patients showed a pain reduction of at least 10 points (minimally clinically important improvement) from pre- to post-treatment. Our retrospective study using the in-office procedure of ultrasound-guided combination of intra-articular and intraosseous infiltrations of PRGF is a safe and efficacious approach for the treatment of grade 3-4 knee osteoarthritis.

Needle-based gastrocnemius lengthening: a novel ultrasound-guided noninvasive technique.

BACKGROUND: Gastrocnemius tendon lengthening is performed to treat numerous conditions of the foot and ankle. Gastrocnemius shortening has been associated with more than 30 lower limb disorders, including plantar heel pain/plantar fasciitis, Achilles tendinosis, equinus foot, adult flat foot deformity, and metatarsalgia. Ultrasound-guided ultraminimally invasive lengthening of the gastrocnemius is a step forward in this type of surgery. It can be performed in both legs simultaneously without ischemia using only local anesthesia plus sedation and without the need for a cast or immobilization. The truly novel advantage of the procedure is that it can be performed in the office, without specific surgical instruments. The aim of our research was to prove the effectiveness and safety of a new closed needle-based ultrasound-guided surgical procedure for lengthening the gastrocnemius tendon. METHODS AND RESULTS: We performed ultrasound-guided gastrocnemius tendon lengthening using a needle in eight fresh frozen specimens (3 left and 5 right). None of the specimens had been affected by disease or undergone previous surgery that could have affected the surgical technique. We used a linear transducer with an 8- to 17-MHz linear transducer and the beveled tip of an Abbocath as a surgical blade to perform the lengthening procedure. The gastrocnemius Achilles tendon recession was entirely transected in all eight specimens, with no damage to the sural nerve or vessels. The improvement in dorsal flexion was 15°. CONCLUSION: Needle-based ultrasound-guided gastrocnemius tendon lengthening is safe, since the surgeon can see all structures clearly, thus minimizing the risk of damage. The absence of a wound obviates the need for stitches, and recovery seems to be faster. The procedure can be performed in a specialist's office, as no specific surgical instruments are required. This technique could be a valid option for gastrocnemius lengthening and may even be less traumatic than using a hook-knife, as in our previous description.

New Prognostic Factors in Operated Extracapsular Hip Fractures: Infection and GammaTScore.

There is no universal postoperative classification of extracapsular hip fractures (ECFs). We wondered if infection (according to infection after fracture fixation criteria (IAFF)), immediate partial weight bearing (PWB) and/or the new GammaTScore tool could predict early cut-out. We also examined the correlation between GammaTScore and time to consolidation and studied long-term survival. This was a retrospective cohort study of low-energy complete ECFs operated with Gamma3T nailing in 2014 and fully monitoring, in patients aged over 65. Ten not distally locked cases, one late cut-out, one cut-through, one osteonecrosis and one pseudarthrosis were discarded. Patients were classified into early cut-out (7/204; 3.55%) and no early cut-out (197/204; 96.45%). There was a lower percentage of A2 fractures according to the AO Foundation/Orthopaedic Trauma Association classification (AO/OTA, 1997) in early cut-out. IAFF and only the GammaTScore reduction parameter were different for early cut-out, in opposition to immediate PWB, tip-to-apex distance (TAD) or the Baumgaertner-Fogagnolo classification. GammaTScore inversely correlated with consolidation (p < 0.01). Long-term survival time was not statistically significantly lower in the early cut-out group. Small sample of cases may limit our results. Apart from an important role of IAFF, GammaTScore would be useful for predicting consolidation, avoiding complications and reducing costs. Further studies are needed for reliability.

Reconstruction of Chronic Proximal Hamstring Tear: A Novel Surgical Technique with Semitendinosus Tendon Allograft Assisted with Autologous Plasma Rich in Growth Factors (PRGF).

The reconstruction of a chronic proximal hamstring tear is a challenging pathology that posits difficulties to surgeons due to the distal retraction of the hamstring tendon stumps and the entrapment of the sciatic nerve within the scar formed around the torn hamstring tendon. We describe a novel surgical technique using a semitendinosus tendon allograft sutured in a "V inversion" manner, thereby avoiding an excess of tension and length of the new reconstructed hamstring tendons. In addition, and in order to speed up the healing process and avoid new sciatic entrapment, we assisted the surgery with liquid plasma rich in growth factors (PRGF) injected intraosseously, intratendinously and within the suture areas, as well as wrapping the sciatic nerve with a PRGF membrane. In conclusion, this novel approach offers mechanical and biological advantages to tackle the large retraction of hamstring stumps and the entrapment of the sciatic nerve within the scar.

Office-Based Intraosseous Infiltrations of PRGF in Knee Osteoarthritis: Description of Technique.

Knee osteoarthritis is a low-degree inflammatory condition that involves the whole synovial joint tissues as an organ. Recently, a biological approach using plasma rich in growth factors (PRGF) to tackle not only the synovial joint with intraarticular injections of PRGF, but also the subchondral bone with intraosseous infiltrations has been implemented with promising results. However, this procedure requires sedation, which limits the implementation of the procedure to operating room. We propose a modified and less cumbersome PRGF intraosseous infiltration approach for moderate and severe knee osteoarthritis, conducting the procedure in the ambulatory setting assisted with WALANT (wide-awake local anesthesia no tourniquet) technique. The proposed technique with a minimally invasive local anesthesia involves subcutaneous infiltration of lidocaine and epinephrine in a solution without sedation, and using ultrasound guidance, thereby streamlining the original procedure. This procedure is both a cost-effective and safe approach that may contribute to the widespread use of intraosseous infiltrations.

Long-term outcomes of one single-design varus valgus constrained versus one single-design rotating hinge in revision knee arthroplasty after over 10-year follow-up.

BACKGROUND: The appropriate degree of constraint in knee prosthetic revision is unknown, necessitating the use of the lowest possible constraint. This study aimed to compare the long-term clinical and survival results of revision with rotation hinge knee (RHK) VS constrained condylar constrained knee (CCK) implants. METHODS: Overall, 117 revision case were prospectively reviewed and dividing into two groups based on the degree of constraint used, using only one prosthetic model in each group (61 CCK vs 56 RHK). All implants were evaluated for a minimum of 10 years. Survival of both implants at the end of follow-up, free from revision for any cause, aseptic loosening, and septic cause was compared. RESULTS: Better results were seen with use of the RHK in joint ranges of (p = 0.023), KSCS (p = 0.015), KSFS (p = 0.043), and KOOS (p = 0.031). About 22.2% of the cases required repeat surgery (11.7% RHK vs 29.6% CCK, p = 0.023). Constrained condylar implants had a significantly lower survival rates than rotating hinge implants (p = 0.005), due to a higher aseptic loosening rate (p = 0.031). CONCLUSION: Using a specific RHK design with less rotational constraint has better clinical and survival outcomes than implants with greater rotational constraint, such as one specific CCK.

Ultrasound-Guided Proximal and Distal Tarsal Decompression: An Analysis of Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels.

Objectives. To analyze the reliability of measurements of tarsal tunnel and medial and lateral plantar tunnel pressures before and after ultrasound-guided release. Measurements taken were guided by ultrasound to improve reliability. This novel approach may help surgeons make surgical decisions. The second objective was to confirm that decompression using ultrasound-guided surgery as previously described by the authors is technically effective, reducing pressure to the tarsal and medial and lateral plantar tunnels. Methods. The study included 23 patients with symptoms compatible with idiopathic tarsal tunnel syndrome (TTS). The first step was to measure intracompartmental pressure of the tarsal tunnel, medial plantar tunnel, and lateral plantar tunnel preoperatively. The second step was ultrasound-guided decompression of the tibial nerve and its branches. Subsequently, pressure was measured again immediately after decompression in the 3 tunnels. Results. After surgery, the mean values significantly dropped to normal values. This represents a validation of effective decompression of the tibial nerve and its branches in TTS with ultra-minimally invasive surgery. Conclusions. The ultrasound-guided surgical technique to release the tibial nerve and its branches is effective, significantly reducing pressure in the tunnels and, thereby, decompressing the nerves.Level of evidence: Level IV.

A new biarticular cement spacer technique for infected total hip and knee arthroplasty with massive bone loss.

INTRODUCTION: The management of massive femoral bone defects following prosthetic infection remains a surgical challenge, particularly when the entire femur is affected. METHODS: We present the first results of a new biarticular cement spacer with antibiotic technique using a cephalomedullary nail for the treatment of infected hip arthroplasty involving complete femoral bone loss. RESULTS: 5 patients with a minimum follow-up of 1 year were included. In all cases 2-stage replacement due to hip periprosthetic infection was carried out, with the need for a biarticular complete femoral spacer in view of the magnitude of the bone defect. The infection was resolved in all patients, with no complications (spacer fracture or dislocation) associated to spacer use, and the patients were all able to maintain the sitting position with active knee movements between the 2 surgical stages. Improvement with respect to preoperative functional status was observed in all cases, as evidenced by the Harris Hip Score (HHS) (from 24.2 to 73; p < 0.001) and 12-Item Short-Form Health Survey (SF-12) (from 16.8 to 33.2; p = 0.001), with a lessened need for walking aids. DISCUSSION: The described technique offers a possible solution to a number of complications observed with the use of spacers in massive defects, affording greater patient comfort and autonomy while waiting to receive total femoral replacement.

Ultrasound-Guided Decompression of the Intermetatarsal Nerve for Morton's Neuroma: A Novel Closed Surgical Technique.

BACKGROUND: This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques. METHODS: We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery. RESULTS: Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1-2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections. CONCLUSIONS: The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.

Is Dual Antibiotic-Loaded Bone Cement More Effective and Cost-Efficient Than a Single Antibiotic-Loaded Bone Cement to Reduce the Risk of Prosthetic Joint Infection in Aseptic Revision Knee Arthroplasty?

BACKGROUND: Higher rates of prosthetic joint infections (PJIs) are related to patient risk factors and/or to special surgical procedures such as revision total knee arthroplasty (rTKA). Among the measures discussed to better protect those patients from the higher infection risks use of dual antibiotic-loaded bone cement has emerged as a further prophylactic option. METHODS: This retrospective study included 246 patients undergoing strictly aseptic revision knee arthroplasty at our institution in the time period 2015-2018. Based on the type of bone cement used for the cementation of the revision prosthesis, 2 groups were defined. In total, 143 patients received the low-dose single antibiotic-loaded bone cement (SALBC) PALACOS R+G and 103 patients received the high-dose dual antibiotic-loaded bone cement (DALBC) COPAL G+C. The number of PJI cases in each group over a follow-up time of minimum 1 year was compared and the extra costs for the DALBC use calculated against the economic savings per each avoided PJI case on basis of 3 different assumptions (treatment costs and amount of cement use). RESULTS: Use of DALBC in aseptic rTKA was associated with a significant reduction in PJI cases (relative risk = 57%, PJI rate in the SALBC group 4.1% vs 0% in the DALBC group, P = 0.035). The calculated total savings per patient was $1367. Depending on the economic assumptions the range of savings was between $1413 (less favorable calculation model) and $3661 (most favorable calculation model). CONCLUSION: The use of DALBC in rTKA has been found to be more effective in preventing PJI and proved cost-efficient in all our cost-calculation models.

Ultrasound-Guided Release of the Tibial Nerve and Its Distal Branches: A Cadaveric Study.

OBJECTIVES: The purpose of the study was to determine whether ultrasound (US)-guided surgery is a viable type of surgery for performing an effective release/decompression of the constricting structures that are responsible for focal nerve compression in tarsal tunnel syndrome. METHODS: Ultrasound guidance was used on cadaveric specimens to delineate the anatomic course of the nerves and vessels in the medial ankle that comprise the structures involved in tarsal tunnel syndrome. Ultrasound guidance was used on cadaveric specimens and assisted in delineating a safe surgical zone to adequately and effectively release these constrictive structures of the proximal and distal tarsal tunnels. The US-guided tarsal tunnel release/decompression was performed through 2 small 1- to 2-mm portals. After US-guided release, anatomic dissection was used to check the efficacy (release of the flexor retinaculum and deep abductor hallucis muscle) and safety (absence of neurovascular or tendon injury) of the procedure. RESULTS: In 12 fresh cadaveric specimens, US-guided release of the tibial nerve (proximal tarsal tunnel) and its branches (distal tarsal tunnel) at the medial ankle was effective in all 12 specimens (100% release rate), without any signs of compromise or injury into the neurovascular structures. CONCLUSIONS: Ultrasound-guided tarsal tunnel release is a feasible surgical procedure that can be safe and effective with the proper training, although further investigation is warranted. This type of surgery may promote faster recovery with less postoperative morbidity, including pain, but this will be the subject of a further investigation.

Biarticular total femur spacer for massive femoral bone loss: the mobile solution for a big problem.

Bone cement spacers loaded with antibiotic are the gold standard in septic revision. However, the management of massive bone defects constitutes a surgical challenge, requiring the use of different nails, expensive long stems, or cement-coated tumor prostheses for preparing the spacer. In most cases, the knee joint must be sacrificed. We describe a novel technique for preparing a biarticular total femur spacer with the help of a trochanteric nail coated with antibiotic loaded cement, allowing mobility of the hip and knee joints and assisted partial loading until second step surgery. This technique is helpful to maintain the length of the leg, prevent soft tissue contracture, and help eradicate the infection preserving the patient comfort and autonomy while waiting to receive total femoral replacement.

Intratissue Percutaneous Electrolysis vs Corticosteroid Infiltration for the Treatment of Plantar Fasciosis.

BACKGROUND: Corticosteroid infiltration (CI) is commonly used for treatment of plantar fasciosis. In recent years, however, interest has grown in the use of intratissue percutaneous electrolysis (EPI) for the treatment of tendinopathies. The aim of our study was to compare the effectiveness of the above techniques in the treatment of plantar fasciosis. METHODS: The results achieved over a period of 1 year following the use of these techniques to treat plantar fasciosis were examined. There were 64 patients; 32 of whom were treated with ultrasound-guided EPI and 32 with ultrasound-guided CI. A clinical examination was performed and ultrasound taken before treatment and at 3, 6, and 12 months. Clinical assessments were made using a visual analog scale (VAS) to record pain and the Foot and Ankle Disability Index (FADI) to evaluate function. Ultrasound was used to determine the thickness of the plantar fascia. RESULTS: Both the ultrasound-guided EPI and CI techniques were associated with significant clinical and echographic improvements at 12 months post-treatment ( P < .001). CONCLUSION: Both techniques were effective in the treatment of PF, providing excellent VAS pain and FADI results at 12 months. However, CI required fewer patient visits and appeared to provide somewhat better VAS and FADI results. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Trends in incidence of proximal humerus fractures, surgical procedures and outcomes among elderly hospitalized patients with and without type 2 diabetes in Spain (2001-2013).

BACKGROUND: Several studies have reported that diabetic persons have an increased risk for fractures than non-diabetes patients. The association between proximal humerus fractures and type 2 diabetes (T2DM) is unclear and some studies point to insulin treatment, hypoglycaemic episodes consequently to inadequate control of diabetes or, more recently, to an alteration of trabecular bone. We examined trends in the incidence of proximal humerus fractures, surgical procedures and outcomes among hospitalized patients aged ≥65 years, with and without T2DM in Spain, 2001-2013. METHODS: This retrospective, observational study was conducted using the Spanish National Hospital Discharge Database to select all hospital admissions with proximal humerus fracture. We calculated incidences overall and stratified by diabetes status, year and sex. We analyzed surgical procedures, comorbidities, length of stay, in-hospital complications and in-hospital mortality. RESULTS: We identified 43,872 patients with proximal humerus fracture (18.3% had a T2DM diagnosis). Age-adjusted incidence rates elevated steadily over the study period for men and women with and without T2DM, independently of diabetes status, although we found a stable trend in the later years. Patients with T2DM had lower relative risk of proximal humeral fracture incidence: 0.87 (95%IC 0.82-0.93) for men and 0.97 (95%IC 0.95-1.00) for women. In-hospital complications were 4.0% of diabetic men vs. 2.6% in non-diabetic (p < 0.001) and 2.9% among T2DM women vs. 1.7% in those without (p < 0.05). The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime and closed reduction with internal fixation is decreasing. Presence of T2DM in women was associated with higher in-hospital mortality (OR 1.67; 95%CI 1.29-2.15). Comorbidities, in-hospital complications and older age were predictors of higher in-hospital mortality in both sexes. CONCLUSIONS: The incidence of proximal humerus fractures seems to be increasing in Spain. The incidence is lower among men with than without T2DM. T2DM is associated to higher in-hospital complications in both sexes. The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime beside diabetes status. Women with T2DM have higher in-hospital mortality than those without the disease.

Metallisation of Biolox Delta® ceramic head: What's wrong?

INTRODUCTION: Since the recent failure of certain coating models, hybrid implants (coated acetabular inserts with conventional stems) and stems with modular necks, there has been growing interest in the consequences of the generation and release of metal particles at the prosthetic interfaces. The use of ceramic heads has recently been described as an option for reducing the production of metal ions and their consequences. CASE REPORT: The present case report describes the first complete metallisation of a ceramic head secondary to an excessive release of metal ions at the head-neck junction. CONCLUSIONS: We believe this to have occurred due to the use of 12/14 cones of different manufacturers.

Total femur arthroplasty for revision hip failure in osteogenesis imperfecta: limits of biology.

Osteogenesis imperfecta (OI) is a rare congenital disease characterized by alterations in bone quality, with susceptibility to fractures, instability, deformities, and osteoarthrosis. Prosthetic surgery in these patients is associated with an abnormally high rate of implant failures. On the other hand, abnormal bone fragility adds to the complexity of revision surgery in such individuals-thus representing a genuine challenge for the orthopaedic surgeon. We present a case of femoral reconstruction in a patient with OI and prosthetic loosening after reconstruction secondary to femoral septic pseudoarthrosis. Intramedullary total femoral reconstruction was carried out after exceeding the biological reconstruction limits. This is the first reported instance of the use of an intramedullary total femur arthroplasty as salvage technique in an OI patient. This technique should be considered when we have exceeded biological limits for femoral fixation.