Exploring structural and computational contrasts in Myoglobins: Implications for thermal treatment-induced Sulfmyoglobin formation.

Greening of tuna metmyoglobin (MetMb) by thermal treatment (TT) and free cysteine is associated with sulfmyoglobin (SulfMb) production. This greening reaction (GR) was once thought to occur only in tuna species. However, recent research has revealed that not all tuna species exhibit this behavior, and it can also occur in horse MetMb. Thus, the present study aimed to compare the GR-reactive (Katsuwonus pelamis and Equus caballus) and GR-unreactive (Sarda chiliensis and Euthynnus lineatus) MetMb using UV-vis spectrometry during TT (60 °C/30 min and free cysteine) to monitor the GR. We used molecular dynamics (MD) simulation to assess the stability of the heme group during TT. We discovered that using GR-unreactive MetMb resulted in an incomplete GR without producing SulfMb. Additionally, our MD simulations indicated that Met85 presence in the heme cavity from GR-unreactive is responsible for the heme group instability and displacement of distal His during TT.

Do patient-reported outcome measures improve after aseptic revision total hip arthroplasty?

BACKGROUND: The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon. METHODS: A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs. RESULTS: Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS. CONCLUSIONS: Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

Comparative CT Study on Syndesmosis Mobility after Static or Dynamic Fixation for Ankle Fractures with Syndesmotic Rupture: A Pilot Study.

Background: The objective of this prospective randomized pilot study is to compare, by computed tomography (CT), the mobility of syndesmosis after static fixation (SF) or dynamic fixation (DF) in ankle fractures with syndesmotic rupture (AFSR) in adults, and to compare this mobility with that of healthy ankles. Methods: Forty-two patients with an AFSR were randomized to 2 groups: SF (N=21) or DF (N=21). Seven patients were lost to follow-up. Ultimately, 35 patients (SF, N=20; DF, N=15) were analyzed. The clinical results were assessed with the American Orthopedic Foot and Ankle Society scale. To assess syndesmosis mobility, CT in 30° of plantar flexion (PFlex) and 20° of dorsal flexion (DFlex) was performed on both ankles one year after the fracture. Four parameters were measured: anterior tibiofibular distance, posterior tibiofibular posterior distance, angle of fibular rotation (AFR), and anteroposterior fibular translation. Results: The AFR between DFlex and PFlex was more similar to the non-affected side in the DF group. The other three parameters showed no statistical differences between types of fixation. The mean loss of AFR compared with the non-affected side was 1.2° in the SF group and 0.1° in the DF group. No clinical differences between the SF group and the DF group were found. No correlation between clinical and radiological results was observed. Conclusion: The AFR was more similar to the non-affected side in the DF group. However, this finding did not correlate with a better clinical result.

Digital Fluoroscopic Navigation for Limb Length Restoration During Anterior Total Hip Arthroplasty.

Background: Restoration of limb length is important in total hip arthroplasty. Clinical evaluation and preoperative templating establish the intended lengthening. The purpose of this study was to assess whether digital fluoroscopic navigation (DF) improved the accuracy of planned lengthening in direct anterior approach total hip arthroplasty (DAA-THA). Methods: Planned lengthening measurements on 100 consecutive unilateral DAA-THA patients, along with patient characteristics, were prospectively collected by 2 surgeons. One surgeon utilized DF to achieve intended length (n = 50), while the other utilized unaided standard fluoroscopy (SF; n = 50). A third surgeon blinded to the procedures assessed actual limb length using an ipsilateral overlay technique on the 6-week postoperative radiograph. The difference between the mean planned and actual limb lengthening stratified by DF and SF was assessed using bivariate and multivariate statistics. Results: The mean (standard deviation) planned lengthening in DF and SF groups was 3.96 (2.1) and 3.47 (2.2) mm, respectively. The mean (standard deviation) actual lengthening in DF and SF groups was 3.11 (4.0) and 0.68 (4.6) mm, respectively. After accounting for age, sex, body mass index, laterality, and the Bone Index, multivariate regression results showed that the average difference between planned and actual limb lengthening in the DF group was significantly lower than that in the SF group (ß = -1.92; 95% confidence interval: -3.51, -0.33; P < .02). A greater percentage of patients in the DF group (66% vs 40%) were within 3 mm of the intended plan (P < .01). Conclusions: Fluoroscopy helps achieve the intended surgical lengthening in DAA-THA. The use of DF resulted in more accurate execution of lengthening.

Unicompartmental Knee Arthroplasty vs Total Knee Arthroplasty: A Risk-adjusted Comparison of 30-day Outcomes Using National Data From 2014 to 2018.

Background: When clinically indicated, the choice of performing a total knee arthroplasty (TKA) vs a unicompartmental knee arthroplasty (UKA) is dictated by patient and surgeon preferences. Increased understanding of surgical morbidity may enhance this shared decision-making process. This study compared 30-day risk-adjusted outcomes in TKA vs UKA using a national database. Methods: We analyzed data from the National Safety and Quality Improvement Program database, for patients who received TKA or UKA between 2014-2018. The main outcomes were blood transfusion, operation time, length of stay, major complication, minor complication, unplanned reoperation, and readmission. Comparisons of odds of the outcomes of interest between TKA and UKA patients were analyzed using multivariate regression models accounting for confounders. Results: We identified 274,411 eligible patients, of whom 265,519 (96.7%) underwent TKA, while 8892 (3.3%) underwent UKA. Risk-adjusted models that compared perioperative and postoperative outcomes of TKA and UKA showed that the odds of complications such as blood transfusion (adjusted odds ratio [aOR], 19.74; 95% confidence interval [CI]: 8.19-47.60), major (aOR, 1.87; 95% CI: 1.27-2.77) and minor complications (aOR, 1.43; 95% CI: 1.14-1.79), and readmission (aOR, 1.41; 95% CI: 1.16-1.72) were significantly higher among patients who received TKA than among those who received UKA. In addition, operation time (aOR, 7.72; 95% CI: 6.72-8.72) and hospital length of stay (aOR, 1.11; 95% CI: 1.05-1.17) were also higher among the TKA recipients compared to those who received UKA. Conclusions: UKA is associated with lower rates of adverse perioperative outcomes compared to TKA. Clinical indications and surgical morbidity should be considered in the shared-decision process.

The greening reaction of skipjack tuna (Katsuwonus pelamis) metmyoglobin promoted by free cysteine during thermal treatment.

Background: Tuna muscle greening is a problem that occurs after heating. A hypothesis has been postulated to address this problem, involving a conserved Cys residue at position 10 (Cys-10) present on tuna myoglobin (Mb) that is exposed during the thermic treatment, forming a disulfide bond with free cysteine (Cys) in the presence of trimethylamine oxide (TMAO), resulting in the greening of the tuna Mb. Methods: We present a study using skipjack tuna (Katsuwonus pelamis) metmyoglobin (MbFe(III)-H2O) where the effect of free Cys (1-6 mM), TMAO (1.33 mM), and catalase on the greening reaction (GR) was monitored by UV-vis spectrometry during thermal treatment at 60 °C for 30 min. Moreover, the participation of Cys-10 on the GR was evaluated after its blocking with N-ethymaleimide. Results: The GR occurred in tuna MbFe(III)-H2O after heat treatment with free Cys, forming sulfmyoglobin (MbFe(II)-S) as the responsible pigment for the tuna greening. However, the rate constants of MbFe(II)-S production depended on Cys concentration (up to 4 mM) and occurred regardless of the TMAO presence. We postulate that two consecutive reactions involve an intermediate ferrylmyoglobin (promoted by H2O2) species with a subsequent MbFe(II)-S formation since the presence of catalase fosters the reduction of the rate reaction. Moreover, GR occurred even with blocked Cys-10 residues in tuna Mb and horse Mb (without Cys in its sequence). Discussion: We found that GR is not exclusive to tuna Mb´s, and it can be promoted in other muscle systems. Moreover, Cys and thermal treatment are indispensable for promoting this pigmentation anomaly.

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty.

BACKGROUND: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches. METHODS: A prospective consecutive series of primary THA for osteoarthritis (n = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA (n = 913; 38%), AL/DL (n = 505; 21%), or PL (n = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed. RESULTS: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain (p = 0.002). Approach was not a significant factor for 1-year HOOS-PS (p = 0.16) or 1-year UCLA activity (p = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (p > 0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (p < 0.05). CONCLUSIONS: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

SARS-CoV-2 outbreak impact on a trauma unit.

BACKGROUND: From February 2020 onwards, our country has been hit by the coronavirus severe acute respiratory syndrome-2 (SARS-CoV-2) infection. At a glance, hospitals became overrun and had to reformulate all the assistance guidelines, focusing on the coronavirus disease 2019. One year after the start of the pandemic, we present the results of a morbimortality study. AIM: To analyze how our department was affected by the outbreak in terms of morbimortality, and to analyze demographic data, admission to hospital-related data, and subgroups analyses for patients with hip fractures and polytrauma. METHODS: We designed a study comparing data from patients who were admitted to our unit due to a lower limb fracture or a high energy trauma during the pandemic (from March to April 2020) to those admitted during the same period in 2019 before the pandemic. during the pandemic situation. Both cohorts completed a minimum of 6 mo of follow-up. RESULTS: The number of patients admitted to hospital in 2020 was nearly half of those in 2019. Hip fractures in the elderly represented 52 out of 73 of the admitted patients. Twenty patients had a positive test result for SARS-CoV-2 infection. Patients with SARS-CoV-2 infection were admitted to the hospital for a longer time than the non-infected (P < 0.001), and had a higher mortality rate during hospitalization and follow-up (P = 0.02). Patients with a hip fracture associated with a severe respiratory syndrome were mostly selected for conservative treatment (P = 0.03). CONCLUSION: Mortality and readmission rates were higher in the 2020 cohort and during follow-up, in comparison with the cohort in 2019.

Factors that Influence Soft-tissue Injury in Fractures of the Distal Tibia.

BACKGROUND: Soft tissue injury associated with fractures of the distal tibia is a predictive factor for a poor prognosis. The purpose of this study was to investigate factors associated with the need for a flap coverage after distal tibial fracture, and whether there was a difference in functional outcomes between patients with flap coverage or no flap coverage for a distal tibial fracture. METHODS: All fractures of the distal tibia treated in our department between 2010 and 2017 were reviewed. The functional result was assessed using the SF-36 Quality of Life Questionnaire, the Visual Analog Scale (VAS) when walking and the AOFAS scale (American Orthopedic Foot and Ankle Society). RESULTS: 132 distal tibia fractures were reviewed, of which 51 required soft tissue flap reconstruction, which was associated with open fractures (P<0.001, OR 5.25), high energy trauma (P<0.001, OR 1.7)), the use of external fixation (p <0.001, OR 12.5) and the presence of vascular alterations on the Angio-CT scan (P<0.001). No significant differences were found in any of the scales that assessed the functional results between the group of patients who required soft tissue flap reconstruction and the group of patients who did not. CONCLUSION: We found that the need for a soft tissue flap was associated with the following parameters: open fracture, high energy of trauma, presence of skin necrosis, the use of external fixation and the existence of vascular injury. In relation to functional results, differences were not found between the group that needed coverage with a flap and the one that did not.

Open reduction and navigated Iliosacral screws for vertically unstable pelvic fractures.

AIMS: To evaluate clinical and radiological results of vertically unstable pelvic fractures managed by open reduction and navigated iliosacral screws. PATIENTS AND METHODS: The study included eleven patients with complex posterior ring fractures with vertical instability admitted to our hospital and managed with CT navigated iliosacral screws. There were 7 type C1, 2 C2 and 2 C3, according to Tile classification. Three patients presented a spino-pelvic dissociation and four a vertical sacral fracture affecting the foramina (Denis 2). Vertical displacement, pelvic deformity and asymmetry were measured. Tornetta and Matta criteria were used to assess the quality of pelvic reduction. RESULTS: An excellent reduction was achieved in 9 fractures and a good reduction in two. Asymmetry index improved from 13.18 to 2.72. Deformity index improved from 0.049 to 0.010. Only two patients with a Denis 2 fracture showed secondary displacement during follow-up. Four patients presented neurological complications due to their initial injuries. Seven patients were able to resume their previous activities. CONCLUSION: CT navigated IS screws provide enough stability after an anatomic reduction of the fracture. There was no complication related to screw insertion and adequate screw positioning was achieved in all the cases.

Exploring the Milk-Clotting and Proteolytic Activities in Different Tissues of Vallesia glabra: a New Source of Plant Proteolytic Enzymes.

Proteolytic enzymes are widely distributed in nature, playing essential roles in important biological functions. Recently, the use of plant proteases at the industrial level has mainly increased in the food industry (e.g., cheesemaking, meat tenderizing, and protein hydrolysate production). Current technological and scientific advances in the detection and characterization of proteolytic enzymes have encouraged the search for new natural sources. Thus, this work aimed to explore the milk-clotting and proteolytic properties of different tissues of Vallesia glabra. Aqueous extracts from the leaves, fruits, and seeds of V. glabra presented different protein profiles, proteolytic activity, and milk-clotting activity. The milk-clotting activity increased with temperature (30-65 °C), but this activity was higher in leaf (0.20 MCU/mL) compared with that in fruit and seed extracts (0.12 and 0.11 MCU/mL, respectively) at 50 °C. Proteolytic activity in the extracts assayed at different pH (2.5-12.0) suggested the presence of different types of active proteases, with maximum activity at acidic conditions (4.0-4.5). Inhibitory studies indicated that major activity in V. glabra extracts is related to cysteine proteases; however, the presence of serine, aspartic, and metalloproteases was also evident. The hydrolytic profile of caseins indicated that V. glabra leaves could be used as a rennet substitute in cheesemaking, representing a new and promising source of proteolytic enzymes.

Limiting spread of COVID-19 in an orthopaedic department-a perspective from Spain.

Besides national and international recommendations, orthopaedic departments face significant changes in daily activity and serious issues to maintain their standards in musculoskeletal care during the pandemic Covid-19 crisis that we are facing. This report retrospectively addresses measures that were progressively put in place to modify in a week time the activity of a busy orthopaedic department in a large tertiary university hospital in face of the pandemic. Surgical priorities and surgical outcomes are key aspects to consider. The experience may offer some insight to areas where the spread of the disease may be slower or delayed. Abrupt stop of scheduled surgery and clinics is useful to adapt an orthopaedic department to the overall hospital resource reorganization. Orthopaedic surgeons need to be aware of the risks to patients and personnel in view of underdiagnosed cases, which make pre-operative Covid-19 evaluation mandatory for all surgical cases.

Hemiarthroplasty vs Total Hip Arthroplasty for Femoral Neck Fractures: 2010-2017 Trends in Complication Rates.

BACKGROUND: Optimal treatment of femoral neck fractures (FNFs) remains debated. Recent data suggest that total hip arthroplasty (THA) confers improved functional outcomes compared to hemiarthroplasty (HA) in active patients. However, temporal trends in complication rates between these treatments lack study. METHODS: The National Surgical Quality Improvement Program database was retrospectively queried to compare differences between HA and THA over time (2010-2012, 2013-2015, and 2016-2017) in blood transfusions, operation time, major complications, minor complications, and 30-day readmission, among FNF patients aged ≥50 years. Analyses adjusted for age, gender, anesthesia type, smoking, body mass index, hypertension, bleeding disorder, steroid use, and American Society of Anesthesiologists classification. RESULTS: In total, 16,213 patients were identified. THA was associated with higher transfusion rates in 2010-2012 (mean = 0.34 vs 0.28, P = .001) and 2013-2015 (mean = 0.21 vs 0.19, P = .002), but not in 2016-2017 (mean = 0.13 vs 0.14, P = .146). Operation time was significantly higher for THA across all periods (P's < .001), but declined over time. In recent years, THA was associated with less major (2016-2017: 5.4% vs 10.2%, P = .02; 2013-2015: 5.3% vs 10.3%, P < .001) and minor (2016-2017: 6.2% vs 9.8%, P = .02; 2013-2015: 7.2% vs 12.4%, P < .001) complications compared to 2010-2012 (major: 7.2% vs 10.6%, P = .87; minor: 12.6% vs 10.1%, P = .89). No differences in 30-day readmission were noted. CONCLUSION: THA was associated with less major and minor complications in recent time periods compared to HA for the treatment of FNF, controlling for comorbidities. THA trends in transfusions and operation duration have improved over time compared to HA.

Does the Timing of the Second Surgery of a Staged Bilateral Total Joint Arthroplasty Affect the Rate of Hospital Adverse Events and Perioperative Outcomes?

BACKGROUND: The optimal timing of the second surgery in primary staged bilateral total hip/knee arthroplasty remains uncertain. Perioperative hospital adverse events represent a significant issue, even "minor events" lead to substantial costs in workup tests, interconsultations, and/or increased hospital length-of-stay (LOS). Therefore, we sought to ascertain whether the timing of the second arthroplasty affects perioperative outcomes and/or rates of adverse events. METHODS: We retrospectively reviewed a consecutive series of 670 primary staged bilateral total hip/knee arthroplasty performed by 2 surgeons (2010-2016) at a single institution. The days between both arthroplasties were calculated for each pair of hips or knees. We evaluated demographics and LOS, discharge disposition, adverse events (ie, nausea, pulmonary embolism), and transfusion rates. The second arthroplasties (n = 335) were set apart in 2 groups based on the time they were done with respect to their corresponding contralateral first arthroplasty using 3 different thresholds: (1) ≤90 vs >90 days, (2) ≤180 vs >180 days, and (3) ≤365 vs >365 days. RESULTS: No significant differences in outcome comparisons were observed using either 90 or 180 days thresholds. However, using the 365 days thresholds, the mean LOS (2.21 vs 1.92 days, P = .015), adverse event (26% vs 15.3%, P = .021), total transfusion (7.4% vs 1.5%, P = .020), and allogeneic transfusion (6.9% vs 1.5%, P = .033) rates were significantly higher in second arthroplasties performed at or less than 1 year apart from the first, respectively. CONCLUSION: Staging the second arthroplasty more than a year apart from the first one seems to offer better LOS and rates of hospital adverse events, transfusions. However, unless patients are willing to wait a year between surgeries, our data also suggest no increased risk in regards to adverse events when proceeding before or after 90/180 days. LEVEL OF EVIDENCE: Level III.

Validation of a long bone fracture non-union healing score after treatment with mesenchymal stromal cells combined to biomaterials.

The available scores to clinically evaluate fracture consolidation encounter difficulties to interpret progression towards consolidation in long-bone non-union, particularly when incorporating biomaterials in the surgical treatment. The aims of this study were to validate the REBORNE bone healing scale in tibia, humerus and femur non-unions treated by a combination of mesenchymal stromal cells (MSCs) and biomaterials, through the interclass correlation (ICC) among raters, and to define reliability and concordance in anteroposterior and lateral radiographs, compared to computed tomography (CT). METHODS: Twenty-six cases from the EudraCT 2011-005441-13 clinical trial underwent bone healing evaluation, if at least 3 out of 4 cortical views clearly identified. Three senior orthopaedic surgeons evaluated radiographs and CTs at 3 and 6 months FU. All cases included preoperative imaging and radiographs at 12 months. The 4-stage scale score was obtained from each cortical view in orthogonal radiographs or CTs. A score of 0.6875 (11/16) was set as a threshold for bone healing. Statistically, ICC evaluated agreement among raters. Cronbach's alpha coefficient tested reliability. Lin's concordance correlation coefficients (CCC) were estimated between mean CT scores and mean radiographic scores. Bland and Altman graphs provided the limits of agreement between both imaging techniques. Sensitivity and specificity were assessed in radiographs (against CT), and the Area Under the Receiver Operating Characteristics (ROC) Curve was estimated. The probability to predict bone consolidation with REBORNE scores obtained from radiographs was modelled. RESULTS: An ICC of 0.88 and 0.91 (CT and radiographs) confirmed agreement in the REBORNE score for non-union bone healing, with an inter-rater reliability of 0.92 and 0.95. Scores through the radiographic evaluation were found equivalent to the CTs at 6 months FU. A CCC of 0.79 was detected against CT. The radiographic scores in the REBORNE bone healing scale correctly classified bone consolidation in 77%, with an accuracy of 83% based on ROC curves. CONCLUSIONS: The REBORNE score measured with CT or radiographic images was reliable among raters at a follow-up time above 6 months for long bone non-union fractures. The REBORNE scale measured with radiographs proved valid to assess consolidation against CT measurements.

Hospital Adverse Events and Perioperative Outcomes in Bilateral Direct Anterior Approach Total Hip Arthroplasty.

BACKGROUND: Perioperative hospital adverse events represent a significant outcome that is often overlooked. Even "minor events" such as fever or tachycardia may lead to significant costs due to workup tests, interconsultations, and/or increased length of stay (LOS). The optimal timing of bilateral direct anterior approach total hip arthroplasty (DAA-THA) remains unsettled. Consequently, we wanted to compare hospital LOS, discharge disposition, hospital adverse events (major and minor), and transfusion rates between simultaneous and staged bilateral DAA-THA. METHODS: A retrospective chart review was conducted on a consecutive series of 347 primary bilateral DAA-THAs (204 patients) performed by 2 surgeons in a single institution (2010-2016). The hips finally included were categorized as simultaneous (Sim-n = 61), staged 1 (Stg1-n = 143), or staged 2 (Stg2-n = 143). We also compared simultaneous with staged surgeries performed ≤1 and >1 year apart. Baseline demographics, LOS, discharge disposition, hospital adverse events, and transfusions were assessed. RESULTS: The simultaneous group had significantly younger patients and a higher proportion of males when compared with the staged groups and showed significant longer LOS [2.61 (Sim) vs 2.06 (Stg1) vs 1.63 (Stg2) days, P < .001], lower proportion of home discharge [77% (Sim) vs 91.6% (Stg1) vs 96.5% (Stg2), P < .001], as well as higher (overall) rate of adverse events [31.1% (Sim) vs 28.7% (Stg1) vs 14.0% (Stg2), P = .003] and transfusions [45.9% (Sim) vs 6.3% (Stg1) vs 7.0% (Stg2), P < .001]. However, most transfusions were autologous [37.7% (Sim) vs 3.5% (Stg1) vs 0% (Stg2), P < .001]. CONCLUSION: Our data show that bilateral DAA-THAs performed in a staged fashion, rather than simultaneously, have a shorter hospital LOS and decreased rates of adverse events and overall transfusions. Notwithstanding, simultaneous surgery should still be considered an option in selected patients. LEVEL OF EVIDENCE: Level III.

Histoplasma capsulatum periprosthetic knee infection complicated by autoimmune-mediated systemic inflammatory response syndrome.

Histoplasma capsulatum periprosthetic knee infection has rarely been reported in the literature due to its low frequency. Notwithstanding, it is important to keep it among the differential diagnoses to avoid delays in treatment. The current report presents the case of infectious knee monoarthritis in an immunocompetent patient after unicompartmental knee arthroplasty. The joint infection was accompanied by disseminated histoplasmosis, which initiated an autoimmune reaction, ensuing a systemic inflammatory response syndrome. The management protocol used in this case was successful and included staged arthroplasty reconstruction combined with chronic antifungal and steroid pharmacotherapy. Approximately 4 years after total knee arthroplasty revision, there were no clinical signs of localized or systemic infection.

Are Patients More Satisfied With a Balanced Total Knee Arthroplasty?

BACKGROUND: Patient-reported outcome measures are increasingly recognized as an important tool in quantifying the clinical success of arthroplasty surgery. The aim of this study is to measure post-operative joint awareness and satisfaction in patients with and without a quantitatively balanced knee following primary total knee arthroplasty (TKA). METHODS: In this multi-center study, a total of 318 eligible patients were assigned to one of the 2 patient groups: sensor-guided TKA or surgeon-guided TKA. In the sensor-guided group, quantitative balancing was performed according to intercompartmental tibiofemoral load measurements measured by an instrumented tibial trial component. In contrast, for the surgeon-guided group, the knees were balanced according to the surgeons' standard manual techniques while blinding the surgeon to the sensor measurements. Patients were blinded to their allocation and filled out the validated Forgotten Joint Score and 2011 Knee Society Satisfaction questionnaires at 6 weeks and 6 months. For the purposes of this study, the subjects were pooled and stratified by their state of soft tissue balance, based on the mediolateral load differential through the range of motion. RESULTS: In the surgeon-guided group, approximately 50% of the cases yielded a quantitatively balanced knee. Significantly more balanced knees were observed in the sensor-guided group (84.0%). More importantly, for both outcome measures, the balanced group of patients reported significantly better outcomes scores. CONCLUSION: This demonstrates that using sensor feedback during knee arthroplasty surgery results in a more reproducible procedure, resulting in a higher percentage of balanced patients who in turn demonstrate superior clinical outcomes compared to unbalanced patients.

The Practice of Overlapping Surgery Is Safe in Total Knee and Hip Arthroplasty.

BACKGROUND: Overlapping surgery occurs when a surgeon performs 2 procedures in an overlapping time frame. This practice is commonplace in the setting of total joint arthroplasty and is intended to increase patient access to experienced surgeons, improve efficiency, and advance the surgical competence of surgeons and trainees. The practice of overlapping surgery has been questioned because of safety and ethical concerns. As the literature is scarce on this issue, we evaluated the unplanned hospital readmission and reoperation rates associated with overlapping and non-overlapping total joint arthroplasty procedures. METHODS: We reviewed 3,290 consecutive primary total knee and hip arthroplasty procedures that had been performed between November 2010 and July 2016 by 2 fellowship-trained senior surgeons at a single institution. Overlapping surgery was defined as the practice in which the attending surgeon performed a separate procedure in another room with an overlapping room time of at least 30 minutes. Patient baseline characteristics and 90-day rates of complications, readmissions, and reoperations were compared between overlapping and non-overlapping procedures. Subanalyses also were done on patients with a body mass index (BMI) of ≥30 kg/m2 and those with an American Society of Anesthesiologists (ASA) score of 3 or 4. The level of significance was set at 0.05. RESULTS: Of the 2,833 procedures that met the inclusion criteria, 57% (1,610) were overlapping and 43% (1,223) were non-overlapping. Baseline demographics, BMI, and ASA scores were similar between the groups. No significant differences were found between the overlapping and non-overlapping procedures in terms of the 90-day rates of complications (5.2% vs. 6.6%, respectively; p = 0.104), unplanned readmissions (3.4% vs. 4.3%; p = 0.235), or reoperations (3.1 vs. 3.1; p = 1.0) in the analysis of the entire cohort or in subgroup analyses of obese patients and patients with an ASA score of 3 or 4. The total mean operating room time was 5.8 minutes higher for overlapping procedures. CONCLUSIONS: Overlapping procedures showed no increase in terms of the 90-day rates of complications, readmissions, or reoperations when compared with non-overlapping procedures. There was just over a 5-minute increase in mean operating room time for overlapping procedures. Our data suggest that overlapping surgery does not lead to detrimental outcomes following total knee arthroplasty or total hip arthroplasty. Future investigations evaluating patient-oriented outcomes and satisfaction are warranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Antibiotic cement spacer for isolated medial wall acetabular deficiency in the setting of infected hip arthroplasty.

Periprosthetic joint infections remain challenging for orthopaedic surgeons. These are typically treated with 2-stage revision with an antibiotic spacer and arthroplasty reimplantation after infection eradication. We report a novel technique to create an antibiotic cement spacer construct in the setting of significant acetabular medial wall destruction due to osteolysis and infection. The medial wall of the acetabulum was reconstructed using antibiotic cement with 2 screws acting as a rebar. An acetabular liner was then cemented into place forming a cement construct similar to a reconstruction cage in function. This technique created a firm acetabular construct that allowed for the placement of a stable articulating spacer. The spacer allowed for infection eradication and was successfully converted into a revision total hip arthroplasty.