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Purpose: To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. Methods: Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. Results: In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4–18%), 25% (95% CI 19–32%) in patients from primary care, 29% (95% CI 22–36%) in patients from secondary care and 39% (95% CI 39–39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5–18%) in the asymptomatic population, 38% (95% CI − 10 to 85%) in the general population, 15% (95% CI 13–18%) in patients from primary care, 32% (95% CI 22–41%) in patients from secondary care and 21% (95% CI 16–26%) in a mixed population from primary and secondary care. Conclusions: The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]

Background Hypermobility of the first carpometacarpal joint is mostly surgically treated with a volar approached stabilization by Eaton, but recent studies indicate the importance of the dorsoradial and intermetacarpal ligaments (DRL and IML) for carpometacarpal joint stability. The aim of this study was to compare a dorsal and volar technique for primary carpometacarpal hypermobility regarding pain and functional outcome. Methods Patients with non-degenerative, painful carpometacarpal hypermobility were included and were randomly assigned to either the volar technique using the FCR, or a dorsal technique using the ECRL. After premature termination of the trial, we followed all patients treated with the volar approach. Pain, strength, and ADL function using DASH and Michigan Hand Questionnaires (MHQ) were measured at baseline and 3 and 12 months after surgery. Results After including 16 patients, the randomized trial comparing the volar and dorsal technique was terminated because of significant increased pain in the dorsal group. Although none of the other outcome measures were significant in the underpowered comparison, in line with the pain scores, all variables showed a trend towards a worse outcome in the dorsal group. Between 2009 and 2012, 57 thumbs were surgically stabilized. We found significant better pain and MHQ scores, and after 1 year improved grip and key pinch strength. Patients returned to work within 8 (±7) weeks, of which 85 % in their original job. Conclusions Surgical stabilization of the thumb is an effective method for patients suffering from hypermobility regarding pain, daily function, and strength. We recommend a volar approach. Level of Evidence: Level I, therapeutic study

Purpose: Along with the increase in primary total knee arthroplasty, there has been an increase in the number of revisions. The aim of this study was to propose a selection algorithm for the knee revision constraint according to the state of ligaments and to the bone defects Anderson Orthopaedic Research Institute Classification [AORI] classification. The hypothesis was that this algorithm would facilitate the appropriate choice of prosthesis constraint, thus providing stable components and a good long-term survivorship of the knee revisions. Methods: Sixty consecutive revision knee arthroplasties in 57 patients were prospectively evaluated. Prostheses implanted at revision included postero-stabilised, condylar constrained and rotating hinged, relative to the state of the ligaments and of the bone loss around the knee. The median follow-up was nine years (range, 4-12). Results: The median IKS knee and function scores and HSS score were 41 (15-62), 21.5 (12-43) and 34 (23-65) points, respectively, before the operation, and 81 (48-97), 79 (56-92) and 83.5 (62-98) points (p < 0.001) at the latest follow-up evaluation. The median ROM increased from 74 (29-110) preoperatively to 121 (98-132) (p < 0.01) at the final follow-up. Re-revision was necessary in five (8.3 %) patients. Conclusions: A selection algorithm for the revision implant constraint based on the state of ligaments and the bone loss AORI classification could provide stable knee reconstructions and long-term success of knee revisions. © 2013 Springer-Verlag Berlin Heidelberg.

The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.

Hip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip-apex distance (TAD), we analysed the influence of anti-rotational pin length.We compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.Hip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).In biaxial nails anti-rotational element positioning is underestimated, however, crucial.

Purpose The purpose of this study was to evaluate clinical and radiological outcomes of autologous osteochondral transfer (OATS) for femoral head osteonecrosis. Methods Twenty-one hips in 20 patients (one woman and 19 men), average patients' age at the time of surgery of 35.4 (range 20–56) years, were treated with OATS for osteonecrosis of the femoral head (ONFH). Seven patients at pre-collapse ARCO stages IIA and IIB were treated with OATS alone. Thirteen patients with large pre-collapse ARCO IIC and post-collapse ARCO III and IV were treated with OATS and morselised bone allografts (OATS/allograft). Harris hip score (HHS) was used for clinical evaluation of outcomes; X-rays were performed to examine the evolution of the disease. Kaplan-Meier survival curves were used to determine the failure of the procedures with conversion to THR defined as endpoint. Results Follow-up of patients treated with OATS alone was 46.14 (range 18–75) months with HHS improvement from a preoperative mean of 42 to 87.85 points at the latest follow-up examination. Only one patient in this group needed a revision operation with THR. The survival for this group of patients was 85.71 % at four years. Follow-up of patients treated with AOTS/allograft was 32.7 (range 7–84) months with HHS improvement from a preoperative mean of 35.2 to 65.7 points at the latest follow-up examination. One patient died six months after the surgery. There were five conversions to THR because of femoral head collapse in this group of patients with survival of 61.54 % at three years. Conclusion The use of osteochondral grafts offers the possibility of successful treatment for ONFH at small and medium pre-collapse stages. The outcomes of large pre-collapse and post-collapse stages were below our expectations. OATS is a time buying procedure for young patients as it may defer total hip replacement.

Purpose To compare the efficacy and safety of TDR to that of the fusion for the treatment of lumbar degenerative disc disease (LDDD). Methods Randomized controlled trials comparing TDR with any other intervention for LDDD were acquired by a comprehensive search in PubMedCentral, MEDLINE, EMBASE, BIOSIS, ClinicalTrials.gov, and the FDA trials register. Methodologic quality was assessed and relevant data were retrieved, and appropriate meta-analysis was performed. Two review authors independently selected studies, extracted data, and assessed risk of bias. Results and upper bounds of confidence intervals were compared with predefined clinically relevant differences. Results Six relevant randomized controlled trials (RCTs) involving 1,603 patients were identified and reported two year follow-up results. Patients in TDR group compared with lumbar fusion group demonstrated significant improvements in ODI, VAS scores and complication rates at the two year follow-up. Meanwhile, except for operating time in anterior group, intra-operative blood loss, operating time in posterior group, and reoperation rate were without clinical significance between the two groups. In addition, the range of motion (ROM) was maintained within normal ranges after TDR. Conclusions The results showed the TDR has significant safety and efficacy comparable to lumbar fusion at two year follow-up. Although superiority compared to fusion could not be proved, by comparing clinical symptoms relieved, motion preserved, and the low reoperation rate during long-term follow-up on TDR, TDR was considered safe and effective. Therefore, the authors suggest adopting TDR on a large scale; with failure of TDR, interbody fusion would be performed.

T he study findings presented by Troelsen and colleagues remind me of the book How We Know What Isn’t So: The Fallibility of Human Reason in Everyday Life, by Thomas Gilovich [1]. After reading it, I remember thinking the title was more interesting than the book. That is not the case here. The Uncemented Paradox is a catchy title, but the work by Troelsen and colleagues is truly fascinating. The paper makes me wonder how many of us think we ‘‘know’’ what the right approach is, even when the data tell us that it ‘‘isn’t so.’’ I can understand if surgeons practicing in the United States or other countries are sometimes at odds with the data from the Norwegian Hip Arthroplasty Registry. The populations may be considered too different for the results to apply. Perhaps the registry data do not fully capture important functional outcomes that guide our implant choices. But when practicing surgeons in Denmark are at odds with widely available data from their own excellent registry, questions emerge. When seven countries with quality registries do this — as Troelsen and colleagues found — it is important to stop and ask why. From 2006 to 2010, the registries of all the countries surveyed in the study by Troelsen and colleagues reported overall increases in the use of uncemented fixation, even in older patients. Yet, those same patients had more durable results with cemented implants, according to their countries’ registries. We know registry data do not provide the entire story, but we also understand that physicians occasionally make practice decisions despite the best evidence, rather than in accord with it. Surgeons still perform arthroscopic debridements for knee arthritis even after a placebo-controlled surgical trial demonstrated these to be ineffective [2, 4]. When the public discovers that patients were harmed as a result of physicians ignoring the evidence, people rightly ask probing questions [3]. The ‘‘art of medicine’’ is too often a euphemism for ‘‘doing what I feel like’’ or ‘‘doing what I have always done.’’ Where does ‘‘the art’’ stop and the science take over? How do we know what we think we know? It is a key question. Whether or not you perform hip replacements is Editor’s Spotlight/Take 5 Published online: 30 April 2013 The Association of Bone and Joint Surgeons1 2013

Three-dimensional computerised tomography (3DCT) can provide comprehensive patho-anatomy of complex bone on a single image. Though important, the key articular quadrilateral [Q] surface has not been a part of the systems developed for classifying acetabulum fractures. The purpose of the study was to simplify the complexity of classification by the direct sign of the broken Q surface which lies opposite the entire floor of the acetabulum.The study reviewed 84 acetabular fractures using 3DCT images of the interior lateral view (IL) taken between June 2002 to December 2009. Fractures were traditionally classified using the anatomical disruption, plane of the fracture line breaking through or not through the bone column described by Judet and Letournel.The 3D images clearly show the primary site of impaction acting on the acetabulum and the whole course of fracture. The image could not illustrate disruption of the lips of acetabulum and congruity of hip joints in 20 cases of wall (W) fracture. There were 30 transverse (T) fractures classified when the acetabulum was divided horizontally from front to back into upper and lower parts and 34 cases of column (C) fracture when the main vertical lines run and collide along the anterior and posterior column.This study showed that the well-known complex fractures can be satisfactorily classified with the broad flat inner plane of the Q surface.

Statistical analyses are an important part of experimental and clinical studies. These analyses must be carefully performed, and clearly described. Authors should present enough information about these analyses to allow readers to evaluate the analyses, determine their appropriateness, and, with that information in mind, assess the validity of each study’s results. It is somewhat paradoxical that many errors in this area involve basic — rather than advanced — statistics [5]. Most journals begin articles with abstracts that summarize the key elements of each study. Abstracts should present enough statistical information for the reader to determine the robustness of each study’s main findings. Readers often make their initial assessment of a study based solely on the contents of the abstract. Health professionals in some geographic regions may not have access to the full study, and therefore might need to make some healthcare decisions based upon the contents of abstracts. Statistical findings in abstracts may also aid the retrieval of relevant reports from electronic databases [3, 4, 8]. Many different kinds of studies published in Clinical Orthopaedics and Related Research® call for different statistical analyses. Even studies of the same type may be correctly analyzed with different statistical approaches. Nevertheless, some general principles apply to most study designs and analyses. Going forward, these principles will define our minimal requirements for statistical results to be reported in abstracts of papers published in CORR®. Abstracts of scientific articles in CORR® must: indicate the number of patients or samples analyzed; provide a measure of data spread for key descriptive analyses; demonstrate, using a suitable approach, the key conclusion(s) drawn was/were unlikely the result of chance; describe the confidence in the key finding(s), and when they were relevant; and present a measure of effect size for the key findings. Generally, details on how researchers performed statistical analyses are not needed in abstracts unless they are critical to the reader’s understanding or interpretation of the findings. However, the results of these analyses belong in the abstracts. The next few sections summarize our recommendations for the statistical elements that belong in the abstracts of our most common study types.

Where Are We Now? In the paper, ‘‘Role of Interleukin-6 as an Early Marker of Fat Embolism Syndrome: A Clinical Study,’’ the authors find a clear association between a spike in serum IL-6 level 12 hours after admission for extremity fractures and the development of what they define as fat embolism syndrome (FES). Il-6 has been shown to be among a group of cytokines that are expressed after trauma and can be associated with the development of lung injury and acute respiratory distress syndrome (ARDS). IL-6 has been shown to correlate with the severity of injury and the development of FES in animal models [2]. To date the exact role of IL-6 in the pathogenesis of FES in humans has not been determined. To explore the role of IL-6 in the development of FES in humans, the authors selected a small group from a very large volume of admitted patients to study only young healthy subjects with apparently only skeletal injuries. They aimed to eliminate factors that would confuse the diagnosis of FES. They diagnosed FES in 14 of 48 patients using Gurd’s criteria, and found that the mean IL-6 peak at 12 hours in these patients was approximately double that of the patients who did not have FES develop. This difference was significant.

This study evaluated the perception of veterinarians in including the emerging metastrongyloid Angiostrongylus vasorum in the differential diagnosis for dogs referred with appropriate signs. Veterinarians at teaching hospitals, private practices or kennels collected faecal samples from 606 symptomatic dogs in six different areas of Italy. The samples were examined with the Baermann technique. Fourteen dogs scored positive for A. vasorum, all showing different clinical pictures, with the most common reason for inclusion in the study being a combination of respiratory signs along with general signs. The most reported sign was cough, followed by aspecific distresses. Other respiratory signs were dyspnoea, tachypnoea and breathing sounds, while bleeding diathesis occurred in one dog. Gastrointestinal disorders were diarrhoea and vomitus, while no neurological signs were detected. Four key cases are herein described, with a special focus on their clinical description, findings at the collateral diagnostic imaging and therapeutic options with moxidectin. This survey provides new data on distribution of A. vasorum in Europe and on the clinical impact of the disease. The results confirm that clinical angiostrongylosis overlaps a series of other conditions of dogs. Awareness among vet practitioners is discussed along with the importance of including A. vasorum on the list of differential diagnoses in canine clinical practice and of performing appropriate diagnostic methods.

Purpose Hip fracture treatment is controversial, with high complication rates. An algorithm for hip fracture surgery has shown reduced reoperation rates, but choice of implant is based on the commonly used fracture classifications, which were previously evaluated to be unreliable. The purpose of this study was to investigate the reliability of the algorithm.

Pigmented villonodular synovitis (PVNS) is a relatively rare, benign proliferation lesion of the synovium of large joints, but there is not much information available about the disease's aetiology, clinical history, differential diagnosis, treatment, and long-term effects. We conducted a study to analyse these aspects of PVNS.We reviewed all clinical data for 75 patients with PVNS (81 joints) who were treated either by synovectomy alone or synovectomy plus arthroplasty.In all cases, the diagnosis of PVNS was confirmed by pathological examination. The ratio of males to females was 27:48, and the average age of patients was 46 years (range, 15-80 years). Lesions were located in the knee, hip, or ankle, and pain and swelling were the main symptoms. Of 75 patients, 42 had a history of trauma to the involved joint. Forty-one patients (43 joints) underwent synovectomy alone, and 34 patients (38 joints) underwent synovectomy and arthroplasty together. Of the 75 patients, 61 had full follow-up data. Twelve patients had recurrent legions detected by pathological examinations; four patients had more than two recurrences. Moreover, five patients developed PVNS after arthroplasty.PVNS occurs most often in middle-aged women and most frequently involves the knee, followed by the hip and ankle. The disease's etiology is varied and unclear. Surgical excision alone or with arthroplasty is an effective treatment, but there is a high rate of recurrence.

We have come a long way in reporting about what really matters in clinical research. In the early 1960s, Neviaser summarized his results of surgery for large rotator cuff tears rather simply: “My own experience has shown that … massive ruptures with marked separation and retraction of the cuff do not do well by operative repair” [1]. He reported nothing regarding patients’ pain or function after surgery. This was common at the time. More recently, an appropriate focus has been placed on patient-centered outcomes tools. Instead of qualitative comments like Neviaser’s, and in lieu of lists of physical findings or radiographic signs — ROM, lucent lines — that may or may not correlate with patient satisfaction, we now use numerous surveys which are “validated” to greater or lesser degrees. This is a clear improvement, but the problem is far from solved. In clinical research, if one gathers enough patients or measures enough x-rays, small differences can be detected as statistically different. How can we know whether those modest differences are clinically important? Does a 1°-difference in tibial varus matter, even if the difference is statistically significant? What about a 1 cm-difference on a 10-cm VAS pain scale? Even if “real,” would a patient even notice? It turns out that there is a way to get that answer, although as a specialty, we have not put nearly as much effort into working it out as we should. In “Comparative Responsiveness and Minimal Clinically Important Differences for Idiopathic Ulnar Impaction Syndrome,” Drs. Kim and Park take a step in the right direction in their study of a concept that is unfamiliar to many surgeons and clinician-scientists: the minimum clinically important difference (MCID). The MCID is the smallest difference in a score that a patient would identify as important. In principle, we should know the MCID for every outcomes tool that we use. We do not. To begin to chip away at this important gap in our collective knowledge, Kim and Park calculated MCIDs for two common upper extremity instruments by testing them in a population of patients undergoing ulnar shortening osteotomy. If you are not a hand surgeon, the actual finding of this particular study (the MCID for two upper extremity instruments, the Patient-Rated Wrist Evaluation [PRWE] and the Disabilities of the Arm, Shoulder and Hand [DASH], are about 15 points on a 100-point scale) may not grab you. But if you read clinical research of any sort, and certainly if you perform clinical research, the study by Drs. Kim and Park should be required reading. The methods are interesting, generalizable, and worth understanding; the topic itself, as mentioned, is critically important. Going forward, patients, payers, and government entities will demand that we show that the work we do actually improves health. Knowing our MCIDs, and showing that the treatments we advocate exceed them, will help us do that. We have come a long way since Neviaser’s work in terms of outcomes reporting, but given that we do not know the MCIDs for most of the outcomes instruments we use, we still have a long way to go. Take 5 with Jae Kwang Kim MD, PhD Lead author of Comparative Responsiveness and Minimal Clinically Important Differences for Idiopathic Ulnar Impaction Syndrome Seth S. Leopold MD:What sparked your interest in MCIDs? It is a somewhat unusual area of inquiry. Jae Kwang Kim MD, PhD: There are two reasons for my interest in MCIDs. First, several years ago, I submitted a report about a new treatment method with a significant clinical outcome for a certain disease. The reviewer asked whether my result was clinically important, even though it showed a statistically significant improvement. So I searched for the MCID for that disease, but no studies related to the MCID for that disease had been reported. Additionally, the MCID is an important determinant in calculating the sample size in prospective randomized trials. I had trouble planning a clinical trial, because limited studies related to MCID in this area of orthopaedic research had been reported; this further motivated my interest. Dr. Leopold:What should every reader of clinical research know about the concept of MCIDs? Dr. Kim: In general, we have used statistical methods to show whether there are improvements in outcomes after treatment, or to compare our results with outcomes of other treatments. But statistically significant differences are largely driven by sample size. In other words, a clinically small improvement might show up as a statistically significant difference, if a large enough population is analyzed. In the realm of clinical medicine and surgery, though, a small difference, even if statistically significant, may be of little or of no importance to the health or the quality of life of patients. The concept of MCID evolved as a way to overcome this shortcoming of statistical methods in clinical research. The MCID represents a change that would be considered meaningful and worthwhile by the patients studied, and provides a threshold value for that clinically relevant change in a patient’s health. Dr. Leopold:MCIDs for many of our commonly used orthopaedic outcomes tools are not known. Is this a problem, and if so, is it one shared by other medical specialties? How does orthopaedic surgery compare with other specialties in this regard? Dr. Kim: Although the concept of MCID was first described in 1989, this is not a familiar concept for many orthopaedic surgeons, as you mentioned. MCID studies usually were performed by internists, statisticians, or epidemiologists, often in departments of epidemiology or preventive medicine. These publications were not widely seen by surgeons. However, I feel that there is an increasing demand for the study of MCID among orthopaedic surgeons, because so many patient-reported outcome measurements are being used in our area. Dr. Leopold:Do we know whether the MCID is driven by the outcomes instrument used, the surgical intervention studied, the diagnosis treated, or all of those criteria? In other words, should we surmise that the MCID for the DASH questionnaire (one of the tools you studied) would be the same in a population of patients who underwent wrist fusion instead of ulnar shortening osteotomy? If not, is this line of research practical? Dr. Kim: The MCID varies according to diseases and outcome instruments, but it does not depend on treatment methods. Therefore, we can compare the ulnar shortening osteotomy and wafer procedure for ulnar impaction syndrome using the PRWE or DASH, because the MCIDs of the PRWE and the DASH for ulnar impaction syndrome were reported in our paper. Dr. Leopold: I hope that your study inspires other investigators to try to determine MCIDs for other commonly used outcomes tools. What advice do you have for clinician scientists who want to begin to look at these questions? What pitfalls might you avoid in your next study given all you learned from doing this one? Dr. Kim: The MCID can be established in two ways. One is through an anchor-based method that compares changes in scores on the instrument with an anchor, where the patient indicates whether he or she is better than at baseline (the anchor). The other is a distribution-based method that evaluates the minimal difference in excess of that expected by random sample variation or by measurement errors in the instrument. Several methods to calculate an anchor-based MCID have been reported. However, only sensitivity- and specificity-based methods, using receiver operating characteristic curves (the approach we used in our study), can show that the calculated MCID is able to distinguish improved from unchanged patients. Importantly, though, this method is not suitable for conditions where most of patients will improve and few will remain unchanged, such as routine fracture care.

Since its description by Paul Grammont from Dijon, France, several tens of thousands of reverse total shoulder arthroplasties (RTSA) have been performed for diverse conditions. The purpose of this analysis is to identify the complications of this procedure in the literature and in clinical practice. A total of 240 papers concerning RTSA published between 1996 and 2012 have been identified. Over 80 papers describe complications associated with this type of implant. A list of prostheses satisfying European and US standards, CE and FDA approved, has been produced on the basis of information provided by the manufacturers. Data from the literature do not support a meta-analysis. The inventory of best practices shows excellent results in the short and medium term in specific indications, while the number of complications varies between 10 and 65 % in long-term series. Complications can be classified into (A) non-specific including infections (superficial and deep), phlebitis, haematoma, neurological complications of the suprascapular, radial and axillary nerves and (B) specific complications associated with RTSA including (1) on the glenoid side: intraoperative fracture of the glenoid and acromion, late fracture of the scapula, impingement at the scapular neck (notching), glenoid loosening, dissociation of the glenoid component (snatching of the glenosphere) and fractures of the glenoid baseplate; (2) on the humeral side: metaphyseal deterioration, humeral loosening, instability of the shoulder, stiffness with limitation of external and/or internal rotation; and (3) muscular complications with fatty degeneration of the deltoid. Additionally we have identified specific situations related to the type of implant such as the disassembly of the humeral or the glenoid component, dissociation of the polyethylene humeral plate, dissociation of the metaphysis and osteolysis of the tuberosities. The integration of results from different clinical series is difficult because of the lack of a database and the multitude of implants used.

Although the resumption of low-impact sports activities is compatible with total hip arthroplasty (THA), participation in high-impact sports seems problematic, and there is no consensus as to whether it is advisable. The purpose of this article is to evaluate the quality and possibility of resuming high-impact physical activities after hip resurfacing.The study was performed in an on-going, single-surgeon, prospective series of 215 resurfacing arthroplasties (RSA). Mean follow-up was 44.1 months (range, 39.1-54.5). Clinical evaluation included the Postel-Merle d'Aubigné (PMA) score, the Oxford hip score, the Harris hip score (HHS), Devane score, and UCLA activity score. A specific questionnaire analysing sports activities was administered to each patient to assess the number and level of physical activities performed (both before the operation and at final follow-up).In the series of 202 consecutive patients (215 RSA), 50 patients (55 RSA) engaged regularly in at least one high-impact activity before their operation and the onset of pain, 102 patients practised at least one intermediate-impact activity, and the 50 remaining patients undertook only low-impact activities. Harris hip score increased from 44.8 (range, 23-68) before the operation to 97.8 (range, 85-100) at the last follow-up. Mean time to sports resumption after surgery was 14.6 weeks (range, 7-29). The resumption rate was 98 % for sports of any impact level and 82 % for high-impact activities. No osteolysis or implant loosening was observed at follow-up. No revision was performed.In 2012, no consensus recommendations yet exist for the resumption of sports activities after RSA. Existing recommendations concern only conventional THA. We believe that RSA allows younger and more active patients to resume physical and sports activities without restriction. The rate of return to sports after RSA appears to be excellent and unequalled by conventional hip prostheses. High-impact sports seem to be compatible with hip resurfacing, although no long-term studies have analysed the impact of these activities on wear and/or aseptic loosening.

The aim of this health economic analysis was to compare the cost-effectiveness of ticagrelor versus clopidogrel within the German health care system. A two-part decision model was adapted to compare treatment with ticagrelor or clopidogrel in a low-dose acetylsalicylic acid (ASA) cohort (≤150 mg) for all ACS patients and subtypes NSTEMI/IA and STEMI. A decision-tree approach was chosen for the first year after initial hospitalization based on trial observations from a subgroup of the PLATO study. Subsequent years were estimated by a Markov model. Following a macro-costing approach, costs were based on official tariffs and published literature. Extensive sensitivity analyses were performed to test the robustness of the model. One-year treatment with ticagrelor is associated with an estimated 0.1796 life-years gained (LYG) and gained 0.1570 quality-adjusted life-years (QALY), respectively, over the lifetime horizon. Overall average cost with ticagrelor is estimated to be EUR 11,815 vs. EUR 11,387 with generic clopidogrel over a lifetime horizon. The incremental cost-effectiveness ratio (ICER) was EUR 2,385 per LYG (EUR 2,728 per QALY). Comparing ticagrelor with Plavix® or the lowest priced generic clopidogrel, ICER ranges from dominant to EUR 3,118 per LYG (EUR 3,567 per QALY). These findings are robust under various additional sensitivity analyses. Hence, 12 months of ACS treatment using ticagrelor/ASA instead of clopidogrel/ASA may offer a cost-effective therapeutic option, even when the generic price for clopidogrel is employed. Electronic supplementary material The online version of this article (doi:10.1007/s00392-013-0552-7) contains supplementary material, which is available to authorized users.

The haematoma at a fracture site plays an important role in fracture healing. Previously, we demonstrated that a fracture haematoma contains multilineage mesenchymal progenitor cells. We postulated that the haematoma provided a source of chondrogenic cells for endochondral ossification during fracture healing and preservation of the cells contributed to biological fracture healing. In this study, we investigated whether haematoma-derived cells (HCs) could differentiate into hypertrophic chondrocytes and finally induce calcification of the extracellular matrix in vitro.Fracture haematomas were obtained from four patients. HCs were cultured for five weeks under conditions that induce chondrogenic differentiation, followed by two weeks of hypertrophic induction using a pellet culture system. The pellets were analysed histologically and immunohistochemically. The gene expression levels of chondrogenic, hypertrophic, osteogenic, and angiogenic markers were measured by real-time PCR.The histological and immunohistochemical analyses revealed that HCs differentiated into chondrocytes and hypertrophic chondrocytes, followed by calcification of the extracellular matrix. This sequential differentiation was also reflected in the gene expression profiles. After chondrogenic induction, expression of osteogenic and angiogenic markers was not significantly upregulated. However, the expression of these markers was significantly upregulated following hypertrophic induction. These in vitro observations mimicked the process of endochondral ossification during fracture healing.Our results suggest that the fracture haematoma may offer a source of cells with chondrogenic potential that play key roles in endochondral ossification during fracture healing. These findings support the opinion that the haematoma should be preserved for biological fracture healing.

Post arthroplasty gait analysis has up till now been performed on subjects walking slowly on flat ground rather than challenging them at faster speeds or walking uphill. We therefore asked: (1) Is there a measurable difference in the performance of hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) limbs at patients' self-determined fastest walking speeds and steepest inclines? and (2) Is there a relationship between the observed differences between the gait of HRA and THA implanted limbs and patient walking speeds and inclines.In an ethically approved study we recruited patients with bilateral hip arthroplasties: one HRA and one THA. Nine subjects were assessed using an instrumented treadmill at a range of speeds and inclines by a blinded observer. The ground reaction forces of subjects were recorded and an age, sex and BMI matched control group was used for comparison.Increasing walking speed correlated strongly with between leg differences in weight acceptance (r = 0.9, p = 0.000) and push-off force (r = 0.79, p = 0.002). HRA implanted limbs accepted significantly more weight at top walking speeds (1208 N ± 320 versus 1279 N ± 370, p = 0.026) and pushed off with greater force when walking uphill (818 N ± 163 versus 855 ± 166, p = 0.012). HRA limbs more closely approximated to the gait of the normal control group.Arthroplasty implants do have an impact on the gait characteristics of patients. Differences in gait are more likely to be evident when assessment is made at fast speeds and walking uphill. This study suggests that HRA may enable a more normal gait.

Purpose The purpose of the study was to review the results of modified infratubercle displacement osteotomy in patients with severe varus gonarthrosis and to determine the factors influencing outcomes.

Purpose The purpose of this study was to evaluate the impact of tobacco abuse in the consolidation of fractures.

The purpose of this study was to examine retrospectively the effectiveness of Sugioka's transtrochanteric valgus osteotomy (TVO) combined with the shelf procedure for patients who had advanced osteoarthritis (OA) of the hip with severe acetabular dysplasia.Sixty-two hips in 61 patients were reviewed retrospectively between April 1993 and March 2009. Of these hips, 25 hips with the pre-operative acetabular head index (AHI) ≥ 60 % (single group) underwent a TVO, whereas the other 37 with AHI60 % (combined group) underwent a TVO combined with the shelf procedure.Using conversion to total hip arthroplasty as the endpoint, the Kaplan-Meier survival rates at ten years were calculated to be 85.5 % for the single group and 100 % for the combined group; there was a significant difference between the two groups (p 0.05, log-rank test). Similarly, calculated using progressive OA as the endpoint, survival rates at ten years were 69.5 % and 89.3 % respectively; there was also a significant difference between the two groups (p0.05, log-rank test). In the single group, the latest radiographic evaluations of the patients with the pre-operative AHI ≥ 70 % were significantly better than those of the patients with the pre-operative AHI70 % (P 0.05).More satisfactory ten year results of TVO were obtained in cases that had a pre-operative AHI of ≥70 %, or where the shelf procedure was added. It is desirable that acetabuloplasty be added for patients with pre-operative AHI70 %.

Ambroise Pare (1510–20 December 1590) was a French barber-surgeon who served in that role for Kings Henry II, Francis II, Charles IX and Henry III. Ambroise Pare is considered one of the fathers of surgery and modern forensic pathology; a pioneer in surgical techniques and battlefield medicine, especially in the treatment of wounds. He was also an anatomist and invented several surgical instruments.

Purpose The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA). Methods We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices. Results In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications. Conclusions Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.

Purpose Recurrences and deaths are known to occur, even if less frequently, in small, node-negative breast cancer patients, and decision on adjuvant treatments remains controversial. In the present analysis, we evaluate recurrence risk in patients with pT1 a, b, c, node-negative, breast cancer, accordingly with some prognostic biological factors. Methods We retrospectively evaluated 900 node-negative patients (pT1a, b, c) surgery treated between 2000 and 2009 in four Italian oncologic centers. We defined 3 different cohorts: ER positive (ER+); Her-2 positive (Her-2+); and triple negative (TN). Results pT1a was seen in 7.6% of patients, 37.7 % pT1b, 54.8 % pT1c. Concerning the 3 different cohorts, 58.2 % were ER+; 10.8 % were Her-2+; 8.2 % were TN. Overall, chemotherapy was given to 3.0 %, 27.2 %, 69.8 % of pT1a, b, c, respectively, and to 22.7 %, 58.8 %, 68.9 % of ER+, Her-2+, TN subgroups. At a median follow-up of 67 months, 5-year DFS was 96.3 %, 89.2 %, 89.4 % in pT1a, b, c, respectively (100 %, 93.6 %, 89.8 % in ER+; 100 %, 78.7 %, 85.0 % in Her-2+; 100 %, 76.8 %, 85.2 % in TN) (p = ns). At multivariate analysis, histologic grade and Ki-67 resulted independent prognostic factors. Overall, 5-year OS was 98 %, without differences among pT1a, b, c, or among the 3 cohorts. Conclusions Overall, 5-year DFS was very favorable in this series of small, node-negative breast cancers, but Her-2+ and TN cohorts have a higher recurrence rate than ER+ cohort (p

Individual physiological knee kinematics are highly variable in normal knees and are altered following cruciate-substituting (PS) and cruciate-retaining (CR) total knee arthroplasty (TKA). We wanted to know whether knee kinematics are different choosing two different knee designs, CR and PS TKA, during surgery using computer navigation.For this purpose, 60 consecutive TKA were randomised, receiving either CR (37 patients) or PS TKA (23 patients). All patients underwent computer navigation, and kinematics were assessed prior to making any cuts or releases and after implantation. Outcome measures were relative rotation between femur and tibia, measured medial and lateral gaps and medial and lateral condylar lift-off.We were not able to demonstrate a significant difference in femoral external rotation between either group prior to implantation (7.9° CR vs. 7.4° PS) or after implantation (9.0° CR vs. 11.3° PS), both groups showed femoral roll-back. It significantly increased pre- to postoperatively in PS TKA. In the CR group both gaps increased, the change of the medial gap was significantly attributable to medial release. In the PS group both gaps increased and the change of the medial and of the lateral gap was significant. Condylar lift-off was observed in the CR group during 20° and 60° of flexion.This study did not reveal significant differences in navigation-based knee kinematics between CR and PS implants. Femoral roll-back was observed in both implant designs, but significantly increased pre- to postoperatively in PS TKA. A slight midflexion instability was observed in CR TKA. Intra-operative computer navigation can measure knee kinematics during surgery before and after TKR implantation and may assist surgeons to optimise knee kinematics or identify abnormal knee kinematics that could be corrected with ligament releases to improve the functional result of a TKR, whether it is a CR or PS design. Our intra-operative finding needs to be confirmed using fluoroscopic or radiographic 3D matching after complete recovery from surgery.

The advent of supermicrosurgery, which allows the anastomosis and dissection of small-caliber vessels ranging from 0.5 to 0.8 mm in diameter, has led to the development of new reconstructive operations. Lymphaticovenous anastomosis, fingertip replantation and perforator flap surgery all require the supermicrosurgical techniques. In this paper, a rat model is described for the training of anastomosis of submillimeter vessels. Spraque-Dawley rats with the weight of 300 to 500 g were used as the training models. The gender, weight and size of the femoral vessels of 20 rats were recorded. The segment of the femoral vessel which was lying on the ventral muscle group of the hind limb and distal to the origin of the superficial inferior epigastric vessels was used for the practice of microvascular anastomosis. In this study, there were 13 male and 7 female rats. The mean weight of the 20 rats was 395.6 g. The mean diameters of the femoral artery and femoral vein were 0.54 mm and 0.56 mm respectively. The consistent size and anatomy of the femoral vessel make it a suitable training model for microvascular anastomosis of submillimeter vessels.

To investigate the curative efficacy of osteonecrosis of the femoral head (ONFH) in a hip-preserving operative approach, by grafting a vascularized greater trochanter flap combined with a free iliac flap, in an attempt to seek an innovative approach for patients who suffered middle to late stage ONFH without total hip arthroplasty (THA) surgery.Our research included a total of 60 patients (66 hips) who accepted hip-preserving surgery by grafting a vascularized greater trochanter flap combined with a free iliac flap which was tightly filled by hammering because of ONFH (most were Association Research Circulation Osseous (ARCO) stage III patients) from January, 2006 to December, 2010. A Harris Hip Score was obtained during follow-ups, evaluating the clinical efficacy, X-rays were taken regularly for image assessing, and the SF-36 scale was used for estimating quality of life. Terminal observation time was considered when patients had symptom-dependant indications for performing another hip-preserving surgery or THA surgery.Fifty-eight patients (64 hips) were eventually contacted by telephone for an out-patient clinic return visit, with a mean follow-up time of 35.8 months (varied from 12 months to 60 months), but two patients lost contact for various reasons. The demographic data were as follows: there were 16 ARCO IIIA cases, 22 ARCO IIIB cases, and 26 ARCO IIIC cases, respectively. Postoperative X-rays revealed a well-repaired necrotic area of the femoral head and improvement of femoral-acetabulum coverage. The last follow-up mean Harris Hip Score was 86.56 ± 7.38 (excellent results reached 87.50%), which were greatly improved compared to 50.95 ± 6.86 pre-operatively. Also the postoperative mean scores of all dimensions of the SF-36 scale were improved to some extent. Additionally the physical component summary (PSC) scores were enhanced from 42 ± 13 pre-operatively to 78 ± 11, while the postoperative mental component summary (MCS) scores (76 ± 11) largely increased in contrast to pre-operative scores (51 ± 10), with both target indices having statistical significance (p = 0.005, p = 0.01), signifying hugely improvement of the quality of life of the patients. A correlation was found between Harris Hip Score and all dimensions of SF-36 scale (r = 0.32-0.72), especially closely correlated with physical functioning (PF), role-physical (RP) and bodily pain (BP) in PCS aspect (r = 0.72, p 0.01; r = 0.58, p 0.01; r = 0.65, p 0.01, respectively).There is definite curative efficacy for the treatment of ONFH with an hip-preserving operative approach by grafting a vascularized greater trochanter flap combined with a free iliac flap which was tightly filled by hammering. This kind of operative approach reconstructs the biological stability of femoral head, which promotes repair of necrotic areas and indirectly preserves the femoral head of patients and a majority of hip function. It possesses vast clinical as well as practical significance, because the long-term efficacy can satisfy fundamental life requirements, especially for those young and middle-aged patients who suffer ONFH to avoid or put off the time of total hip arthroplasty (THA) surgery.

The aim of this study was to investigate the expression of insulin-like growth factor (IGF)-1 and programmed cell death 5 (PDCD5) in osteoarthritis chondrocytes, and to explore the potential correlation between them in the apoptosis process of osteoarthritis chondrocytes.Patients with knee osteoarthritis were placed into four categories according to radiological staging. The mRNA and protein levels of IGF-1 and PDCD5 in osteoarthritis chondrocytes were respectively detected by quantitative reverse transcriptase polymerase chain reaction (qPCR) and western blotting. In addition, IGF-1 and PDCD5 protein expression in chondrocytes were also measured by immunohistochemistry. Apoptotic cells were measured by TUNEL staining.Both the mRNA and protein levels of IGF-1 were down-regulated, while the levels of PDCD5 were up-regulated, and the mRNA and protein levels of IGF-1 were negatively correlated with those of PDCD5, respectively. The apoptotic cell was significantly increased in osteoarthritis chondrocytes compared with control. Importantly, the apoptosis rate was positively correlated with PDCD5 protein expression and negatively correlated with IGF-1 protein expressionWe concluded that IGF-1 may down-regulate the expression of PDCD5 and thus inhibit the apoptosis of osteoarthritis chondrocytes.

The functional results after reconstruction of the proximal humerus in tumour surgery are poor. Therefore, a reversed proximal humerus replacement was developed in our institution (MUTARS humerus inverse). A low degree of wear on the polyethylene is required because of the patients' youth and demands on shoulder function. A special type of polyethylene with shock-absorbing properties has been developed to minimise polyethylene wear in the MUTARS inverse proximal humerus replacement. We compared the tribological properties of an anatomical shoulder prosthesis (CAPICA) with the new reversed proximal humerus replacement (MUTARS humerus inverse).Both prostheses were tested up to 5 × 10(6) cycles. Every millionth cycle the surface was inspected and a gravimetric measurement was performed. A measurement of surface roughness was done before testing and after 5 × 10(6) cycles.In both prostheses after 5 × 10(6) cycles there were no major defects, such as delamination, observed. In the reversed proximal humerus replacement abrasion of 28 mg/10(6) cycles was detected. The mean abrasion of the anatomical prosthesis was 9.28 mg/ 10(6) cycles.The glenoid component of the first reversed humerus replacement (MUTARS humerus inverse) has wear properties comparable to those of normal reversed shoulder prostheses. This is important, as this type of prosthesis is used in young patients after resection of bone tumours, with a good functional outcome. It can, therefore, be expected that the revision rate due to wear will be as high as in patients with normal reversed shoulder prostheses.

Purpose The aim of this study was to investigate the biomechanics of the pelvis reconstructed with a modular hemipelvic prosthesis using finite element (FE) analysis.

Based on biomechanical cadaver studies, anatomical double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of this study was to compare rotational and translational stability after computer-navigated standard single-bundle and anatomical double-bundle ACL reconstruction.The authors investigated 42 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure using autogenous hamstring tendon grafts and ENDOBUTTON fixation in patients who had been followed up for a minimum of 24 months. Post-operative anteroposterior and rotational laxity was measured with the KT3000 and compared between groups.Both surgical procedures significantly improve rotational and translational stability compared to the preoperative ACL-deficient knee (P0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. The International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher in the double-bundle group. However, the results were excellent in both groups.The use of computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Long-term results of at least five years are needed to determine whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, exerts an influence in terms of avoiding osteoarthritis or meniscus degeneration.

The Deputy Editor has explained in his editorial the reason for this review. I found it a challenging but very rewarding project. The overall quality of papers was so good that it was very difficult to select the necessarily few which space would allow me to review. Inevitably I am influenced by my particular interests, and hence very many excellent papers will not be discussed; failure to discuss a paper is not a reflection on its quality or importance. Criticisms of papers again reflect my own prejudices.

We agree with Dr. Mattei in considering that the proposed classification [1] addresses well the cases with severe sagittal imbalance without coronal imbalance (Type IV) and those with significant coronal imbalance with moderate sagittal imbalance (Type III) but does not clearly include those cases with both significant coronal and sagittal imbalance. While recognizing that the category has not been well represented in the proposed classification, the authors consider that these patients would be better classified in the sagittal imbalance group (Type IV). The reasons for this are two: 1. sagittal imbalance is the most important predictor of HRQoL and outcomes in adult deformity patients; 2. as the classification has been proposed as a guide for treatment, sagittal plane deformity in patients with both coronal an sagittal imbalance dictates in the authors’ opinion one important step in the surgical strategy, that is the choice of the technique that allows to obtain the amount of correction needed. After publication of their classification of adult scoliosis regarding type of lateral access fusion the authors have been still involved in an active discussion on the value and limitations of the classification. They feel that the classification can be improved and completed. Furthermore, the classification probably raises a major point in the comprehension of adult deformity and thus it deserves being improved and extended. Sagittal imbalance with or without scoliosis, and de novo adult scoliosis [2], are different from adolescent idiopathic scoliosis (AIS), because they are in their nature a consequence of degenerative disc disease (DDD), and their clinical manifestations are closely related to DDD. Idiopathic scoliosis in the adult and secondary scoliosis, frequently also present in the adult with symptoms that arise mainly from disc degeneration. This took us to expand the concept and propose a new “Classification of Degenerative Disc Disease in Subjects with Lumbar or Thoracolumbar Deformity” currently under manuscript preparation. In this classification, we have introduced some variations that in our opinion improve the completeness and usefulness of the classification. First, the classification is no longer a “classification of adult scoliosis regarding type of lateral access surgery strategy” but focuses a wider field, that of the interpretation of disc disease in adult patients with deformity. Second, categories have been redefined (Table 1) in order to make of it an exhaustive and exclusive classification. Third, the classification helps identifying the goals of treatment in each category, helping the surgeon to devise his own surgical strategy (whatever the surgical method is). Table 1 Classification of degenerative disc disease in subjects with lumbar or thoracolumbar deformity Regarding the other interesting question pointed out in his letter, Dr. Mattei shows a case with lumbar scoliosis (38°) and both mild coronal (the picture does not allow an exact measurement, but lateral displacement of the coronal dens and C7 plumbline does not seem to be more than 4 cm)(Fig. 1) and severe sagittal imbalance. In this case, we agree that a good strategy to improve coronal alignment is to begin with multilevel lateral access partial release and fusion. This will result in a better correction of the lumbar coronal deformity. Regarding the more relevant (in terms of outcomes) sagittal deformity, Dr. Mattei shows how the five-level XLIF procedure has been able to increase the L1–L4 lordosis from 0° to 34° after the anterior procedure (we have estimated that the total L1-S1 lordosis has increased from 31° to nearly 38°) and finally to 20.4° (L1–S1 47° after L5–S1 ALIF and posterior L1–S1 instrumentation). It is well known that spinopelvic harmony (a numeric correspondence between pelvic incidence and lumbar lordosis values) pelvic tilt (PT) and Sagittal Vertical Axis (SVA) are important predictors of surgical outcomes [3]. Other less popular, independent predictor of surgical is spinopelvic balance [4] (a ratio between the difference in absolute values between lumbar lordosis and thoracic kyphosis and the pelvic incidence value), described in a paper that has confirmed the value of SVA as predictor of surgical outcomes. Furthermore, theoretical pelvic tilt can be predicted for a given patient based only on pelvic incidence [5], and postoperative pelvic tilt and SVA can be predicted with a high degree of confidence with validated formulae [6]. Literature also provides a method to estimate “ideal” lumbar lordosis from pelvic incidence [7]. In the case presented in their letter, pelvic incidence (PI) can be estimated from postoperative lateral films within the limits of visibility of S1 endplate (we have calculated it to be nearly 67°, after double checking with the relative position of S1 endplate—better visible in preop. films—and the anterior surface of the sacrum—visible in both preop. and postop. films (Fig. 2). This would mean that the theoretical pelvic tilt of this patient should be 18°. Assuming that the thoracic kyphosis was 35 degrees (in our opinion, patients with pelvic incidence more than 60 degrees have seldom thoracic kyphosis below that magnitude unless a pathologic compensatory thoracic lordosis is present) application of Lafage’s formula to the postoperative alignment (maximum lumbar lordosis equals 49 degrees), the postoperative pelvic tilt of this patient would be 30°. Postoperative SVA would be estimated as + 65 mm if the patient was 60 year old and + 73 mm if he or she was 75 year old. Other estimations of thoracic kyphosis would in any case cause an imbalanced spine with this pelvic incidence and this postoperative lumbar lordosis (the combination 49° lordosis and 15° kyphosis would cause a 26° pelvic tilt; on the other side, 49° lordosis and the most likely 50° kyphosis would estimate 32° of pelvic tilt). In other words, in spite of the increase in lumbar lordosis after multilevel XLIF, it is likely that the patient showed by Dr. Mattei had a postoperative sagittal imbalance or compensated imbalance. It would be interesting to be able to see the final full spine lateral standing films of this patient to verify if our calculations were wrong. Fig. 1 Mild coronal imbalance is present in this case of adult scoliosis. C7 coronal plumbline is within the lateral edge of S1 pedicle, indicating an estimated lateral displacement under 4 cm Fig. 2 Postoperative lateral spine films including the hip joints allow for calculation of total lumbar lordosis an pelvic incidence This takes to the key point of the argument in favor of multilevel XLIF procedures to obtain sagittal realignment. To our knowledge, current literature does not support that standard XLIF procedures provide sufficient sagittal alignment in sagittally imbalanced patients, though it can provide some increase in lordosis and it can be statistically significant. It’s the authors’ experience that XLIF procedures provide an increase in lumbar lordosis of 5–6° per level on average (in occasional discs or cases a XLIF procedure can increase more substantially the lordosis, but we don’t feel that the standard XLIF procedure can predictably produce corrections near 10° per level). In surgery for sagittal imbalance, the key point is restoring as much lordosis as needed to restore a physiological pelvic tilt and to reduce to less than 2.5 cm [4] the anterior translation of C7 plumbline from posterior S1 endplate. In our current understanding of the problem, sagittal undercorrection correlates with poor results and increased revision rate, and should not be accepted unless full correction cannot be tolerated by the patient. This made the authors suggest that multilevel XLIF could be useful without additional osteotomies to correct mild sagittal imbalance (cases with less than 20° of correction needed). In severe cases, it’s our experience that the amount of correction needed ranges 30° to 70° or more (Fig. 3). So, at the present moment we still consider that posterior osteotomies are the only reliable method to obtain such amount of correction (Fig. 4). This is the reason why we classify coronal deformity with mild sagittal imbalance as Type III and severe sagittal imbalance (with or without coronal imbalance) as Type IV, reflecting that the presence of severe sagittal imbalance guides (at the present moment) the choice of the most relevant part of surgery. If the technique of release of the anterior longitudinal ligament by lateral approach and reconstruction with hyperlordotic cages [8] proves to be reliable, safe and reproducible to increase lordosis to a greater extent than the standard XLIF procedure, it could change the role of this approach in the treatment of severe sagittal imbalance. Fig. 3 A case of severe sagittal imbalance. Pelvic incidence 54°. Pelvic tilt 40°, SVA 22 cm, lumbar kyphosis 1°. Predicted values for a good alignment are lumbar lordosis 64° and pelvic tilt less than 16° Fig. 4 The same patient in Fig. 3, postoperatively. L4 pedicle subtraction osteotomy (PSO) creates a lordosis of 49° at L3–L4. Global lumbar lordosis is corrected to 64°. Pelvic tilt is restored to 15°. SVA -3.8 cm. ...

Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditionally been considered an elusive and rare diagnosis, as it is seldom detectable using electrophysiological techniques. In this paper, the clinical manifestations, physical diagnosis, surgical technique, and results of surgical treatment of PMNE are presented, with accompanying instructional video. Patients/Methods During 2011, 44 patients with PMNE were surgically released and followed prospectively, 22 women/22 men, mean age 48.8 (range 25-66). The patients were equally distributed between right/left hands (23/21) and the dominant hand was treated in 56 % of cases. The diagnosis was based on: (1) weakness in median innervated muscles distal to the lacertus fibrosus; (2) pain upon pressure over the median nerve at the level of the lacertus fibrosus; and (3) positive scratch collapse test. A minimally invasive surgical treatment using only local anesthesia with lidocaine–epinephrine and no tourniquet was used, and direct perioperative return of strength in median innervated muscles was seen in all subjects. Results The average preoperative quick DASH was 35.4 (range 6.8–77.2); work DASH, 44.3 (6.25–100); and activity DASH, 61.6 (12.5–100). There were 71.1 % patients who completed the 6-month follow-up, and the average postoperative quick DASH was 12.7 (range 0–43.1), which is a statistically significant reduction ( pConclusions PMNE at the level of the lacertus fibrosus should be called lacertus tunnel syndrome to distinguish it from other levels of median nerve entrapment. It is a clinical diagnosis based on three distinct clinical findings: weakness, pain over point of compression, and positive scratch collapse test. Surgical release in local anesthesia allows for a safe, ambulatory, and cost-efficient procedure with low morbidity.

The aim of this study was to evaluate the clinical effectiveness of covered Niti-S stent placement under multidetector CT and fluoroscopy guidance for the palliation of dysphagia in patients with cervical esophageal cancer. Under radiological imaging guidance using axial and sagittal CT scans, and fluoroscopy, Niti-S esophageal stents were placed in ten consecutive patients with complete obstruction caused by cervical esophageal cancer (9 men and 1 woman; age range = 54–79 years; mean age = 68.1 years) between February 2010 and December 2011. The procedure time and technical success rate were evaluated. Swallowing improvement was assessed by the following items: ability to eat and/or swallow (graded as follows: 3 = ability to eat normal diet, 2 = ability to eat semisolids, 1 = ability to swallow liquids, 0 = complete obstruction). Procedural and post-procedural complications were also evaluated. Survival (mean ± SD) was examined. The mean (±SD) procedure time was 40 ± 19 min (range = 21–69 min). Stent placement was technically successful in all patients; inadequate stent deployment did not occur in any case. Ability to eat and/or swallow was improved and scored 2.4 (score 3 in 5 cases, score 2 in 4 cases, score 1 in 1 case, and score 0 in no case) after stent placement. No major or post-procedural complications were encountered. The mean survival time was 131 ± 77 days (range = 31–259 days). Niti-S stents appeared to be a safe and effective device for the palliation of dysphagia caused by advanced cervical esophageal cancer. Multidetector CT and fluoroscopy image guidance helped the operators accurately place the stents in the cervical esophagus.

Producción Científica, The current trend in hallux valgus surgery is directed toward percutaneous procedures. However, no evidence that any of these methods of treatment are superior to the others has been described, excepting studies in the long term. The aim of this study was to analyse a series of patients who had undergone a percutaneous distal retrocapital osteotomy of the first metatarsal, and had been followed up for ten years. METHODS: We carried out a clinical and radiological evaluation of 115 feet ten years after surgery. RESULTS: The AOFAS scale results in the tenth postoperative year remained significantly favourable compared to their corresponding values in the preoperative period, yielding an improvement of 42.2 points overall on average. In relation to radiological findings, the mean hallux angle was maintained below 20 °, with a mean intermetatarsal angle of 8.1 °. CONCLUSION: Percutaneous retrocapital metatarsal osteotomy for treatment of mild to moderate hallux valgus is effective in the long term, with the advantages of a minimally invasive procedure.

Producción Científica, Surgical treatment options for medial compartment osteoarthritis of the knee include high tibial osteotomy, total knee arthroplasty or unicompartmental knee arthroplasty (UKA), depending on the patient's age, level of physical activity and the degree of deformity. METHODS:In this study, we evaluated the long-term results of patients who underwent the Oxford cemented meniscal-bearing unicondylar knee prosthesis through a minimally invasive approach including a clinical, functional and radiographic assessment. RESULTS:Favourable clinical and radiological outcomes were registered overall at ten years after surgery. Overall results of UKA according to the American Knee Society (AKS) using Insall's criteria showed an excellent or good outcome for 492 knees (96.28 %), fair for 11 (2.15 %) and poor for eight (1.57 %) in the post-operative long term. CONCLUSIONS:We believe that with appropriate surgical technique, patient selection, prosthetic design and specific training, surgeons should achieve good outcomes with the added advantages of a minimally invasive approach. High volume for this technique is important in our opinion

Dislocations of components, loosening of the stem, overstuffing and removal in up to 24 % of common radial head prostheses (RHP) after implantation in complex elbow injuries signal the need for improvement. The latest biomechanical evidence shows advantages for monopolar designs. Clinical results after primary and secondary implantation of the newly designed press-fit monobloc monopolar RHP in cases of complex elbow injury are evaluated. Twenty-nine patients [median age 60 years (29–86)] were followed up retrospectively for a median of 25 months (7–54) post-operatively. Subjective parameters, the Mayo Elbow Performance Score (MEPS), the Broberg and Morrey score (BMS), latest radiographs and complications were evaluated. MEPS and BMS averaged 87.2 ± 12.9 and 81.1 ± 11.9 points, respectively. No case of implant loosening was observed; the RHP had to be removed in one case (3 %). The overall complication and revision rate was higher after secondary (53 %) than after primary (19 %) implantation. Satisfactory clinical results and low short-term removal rates emphasise the practicality of monobloc monopolar RHP. Differentiated treatment of complex elbow fracture-dislocations is compulsory to avoid the need for secondary RHP implantation which carries a higher complication rate.

The purpose of this study was to assess the safety and preliminary clinical results of platelet-rich plasma (PRP) injections for treating chronic plantar fasciitis.Fourteen consecutive patients with chronic plantar fasciitis receiving three injections of PRP into the plantar fascia were assessed 12 months after the procedure. The modified Roles and Maudsley score and a visual analogue scale (VAS) for pain were used to evaluate the clinical results.According to criteria of the Roles and Maudsley score, at 12 months of follow-up, results were rated as excellent in nine (64.3 %), good in two (14.3 %), acceptable in two (14.3 %) and poor in one (7.1 %) patient. VAS for pain was significantly decreased from 7.1 ± 1.1 before treatment to 1.9 ± 1.5 at the last follow-up (p 0.01).In this single-centre, uncontrolled, prospective, preliminary study, results indicate that treating chronic plantar fasciitis with PRP injections is safe and has the potential to reduce pain.

Insulin is a commonly used additive in chondrogenic media for differentiating mesenchymal stem cells (MSCs). The indispensability of other bioactive factors like TGF-β or dexamethasone in these medium formulations has been shown, but the role of insulin is unclear. The purpose of this study was to investigate whether insulin is essential for MSC chondrogenesis and if there is a dose-dependent effect of insulin on MSC chondrogenesis.We cultivated human MSCs in pellet culture in serum-free chondrogenic medium with insulin concentrations between 0 and 50 μg/ml and assessed the grade of chondrogenic differentiation by histological evaluation and determination of glycosaminoglycan (GAG), total collagen and DNA content. We further tested whether insulin can be delivered in an amount sufficient for MSC chondrogenesis via a drug delivery system in insulin-free medium.Chondrogenesis was not induced by standard chondrogenic medium without insulin and the expression of cartilage differentiation markers was dose-dependent at insulin concentrations between 0 and 10 μg/ml. An insulin concentration of 50 μg/ml had no additional effect compared with 10 μg/ml. Insulin was delivered by a release system into the cell culture under insulin-free conditions in an amount sufficient to induce chondrogenesis.Insulin is essential for MSC chondrogenesis in this system and chondrogenic differentiation is influenced by insulin in a dose-dependent manner. Insulin can be provided in a sufficient amount by a drug delivery system. Therefore, insulin is a suitable and inexpensive indicator substance for testing drug release systems in vitro.

Joint arthroplasty registries show an increased rate of aseptic loosening in uncemented acetabular components as compared to cemented acetabular components. Since loosening is associated with particulate wear debris, we postulated that uncemented acetabular components demonstrate a higher polyethylene wear rate than cemented acetabular components in total hip arthroplasty. We performed a systematic review of the peer-reviewed literature, comparing the wear rate in uncemented and cemented acetabular components in total hip arthroplasty. Studies were identified using MEDLINE (PubMed), EMBASE and the Cochrane Central Register of Controlled Trials. Study quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The search resulted in 425 papers. After excluding duplicates and selection based on title and abstracts, nine studies were found eligible for further analysis: two randomised controlled trials, and seven observational studies. One randomised controlled trial found a higher polyethylene wear rate in uncemented acetabular components, while the other found no differences. Three out of seven observational studies showed a higher polyethylene wear in uncemented acetabular component fixation; the other four studies did not show any differences in wear rates. The available evidence suggests that a higher annual wear rate may be encountered in uncemented acetabular components as compared to cemented components.

Background Drug-coated balloons (DCBs) have been developed for the percutaneous treatment of coronary artery disease. An initial focus has been the management of in-stent restenosis (ISR) but randomised controlled trials (RCTs) have been small and powered only for angiographic endpoints. Objective The aim of the work was to assess the clinical and angiographic outcomes of patients treated for ISR with DCB versus control (balloon angioplasty or drug-eluting stents) by a meta-analysis of RCTs. Methods A comprehensive search was performed of RCTs where patients with ISR were randomly assigned to either DCB or alternative coronary intervention. Outcome measurements were death, myocardial infarction (MI), target lesion revascularisation (TLR), binary definition of restenosis and in-lesion late luminal loss (LLL). Results Four studies were identified that fulfilled the inclusion criteria. Pooled odds ratios (ORs) were calculated for patients treated for ISR (n = 399). Mean follow-up duration was 14.5 months. DCBs were associated with lower rates of TLR [8.8 vs. 29.7 % OR (95 % confidence interval, CI) 0.20 (0.11–0.36), p

Purpose Surgical treatment of an acute Achilles tendon rupture can effectively reduce the risk of re-rupture, but it increases the probability of surgical complications. We postulated that a minimally invasive surgical treatment might reduce the number of complications related to open surgery and improve the functional results. Method We enrolled 47 patients with acute Achilles tendon ruptures in a prospective, randomised trial to compare clinical results and complications between a minimally invasive procedure with the Achillon® device and traditional open surgery with Krackow-type sutures. The average patient age was 46 years. The follow up time was 24 months. Results No Achilles tendon re-rupture or nerve injury occurred in treated patients. There were two cases of wound infections in the open surgery group, and one superficial wound infection occurred in the minimally invasive group. The groups were not significantly different in the amount of pain, range of ankle movements, the single heel-rise test, calf circumference, or time to return to work and sports. Conclusion After a two year follow-up period, we found no significant differences in clinical outcomes between groups treated with traditional open surgery or minimally invasive surgery.

The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

Several studies have reported a risk of dislocation in obese patients after total hip arthroplasty. In this study, we evaluated the interaction between obesity and dislocation by kinematic analysis using a navigation system.The intraoperative range of motion (ROM) and postoperative impingement-free ROM were measured in 38 patients, and we compared the impingement-free ROM in obese and non obese patients.The postoperatively simulated ROM was similar in the obese and non obese groups. The intraoperative ROM was smaller in the obese group. The difference values between the intraoperative ROM and postoperatively simulated ROM were larger in the obese group. These results indicate that obese patients have less ROM following primary total hip arthroplasty even when the implant positioning is performed correctly.Dislocations are multifactorial problems including soft tissue impingement. Therefore, the risk of dislocation caused by soft tissue impingement in obese patients may be increased.

The aim of this study was to investigate whether cationised gelatin and hyaluronic acid (CH) coating could induce polyethylene terephthalate (PET) artificial ligament graft osseointegration in the bone tunnel.Surface modification of PET artificial ligament graft was performed by layer-by-layer (LBL) self-assembly CH coating. Six pigs underwent anterior cruciate ligament (ACL) reconstruction on the right knees, with three pigs receiving the CH-coated PET grafts and the other three pigs non-CH-coated PET grafts as controls. They were sacrificed at three months after surgery and the graft-bone complexes were acquired for computed tomography (CT) scan and histological examination.CT scans showed a significant difference at the distal femoral site (p = 0.031) or at the distal tibial site (p = 0.0078), but no significant difference in the bone tunnel areas' enlargement at other sites (p 0.05) between the CH group and the control group. Histologically, application of CH coating induced new bone formation between graft and bone at three months compared with the controls at the distal site. The interface width of the CH group was significantly lower than that of the control group at the distal femoral site (p = 0.0327) and at the distal tibial site (p = 0.0047).The study has shown that CH coating on the PET artificial ligament surface has a positive biological effect in the induction of artificial ligament osseointegration within the bone tunnel at the distal site of the bone tunnel.

To the Editor: As one of the approximately 130 registered members of the American Academy of Orthopaedic Surgeons (AAOS) who presented within the first 30 days of the Haiti earthquake, I must admit that I initially read the article entitled “Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care” by Sonshine et al. [1] with great interest. Although I commend the authors for their efforts in documenting some of the general themes taken from a few of the Haiti earthquake volunteers, I also object to some of their notions and comments. In their paper, they opined that the performance of certain surgeries suggested inappropriate care. They stated that “revision surgeries, guillotine amputations, fasciotomies, and internal fixation, suggestive of inappropriate disaster care, were frequently reported” [1]. I am surprised and disappointed with this statement. This was an over-generalization. For example, fasciotomies for compartment syndrome are absolutely appropriate in many disaster relief scenarios. I would like to know what Sonshine et al. suggest as appropriate treatment of compartment syndrome if fasciotomy is not appropriate? Do they mean to suggest amputation or perhaps benign neglect is more appropriate? As another example, internal fixation may be appropriate in certain cases when sterilization of the implant can be adequately assured and when the clinical situation warrants its use. I presume that the point Sonshine et al. tried to make is that damage-control orthopaedics should be practiced in a mass casualty situation. I would encourage the authors to be more careful when suggesting that certain procedures are inappropriate without qualifying their statement or explaining what they mean in greater detail; this may have misled some of your readers. In addition, they also stated that “inexperienced and untrained volunteers were urged to stay home because they lacked security, equipment, patient followup systems, and cultural sensitivity.” Again, in my view this statement was an unfair generalization of the Haiti earthquake experience. I do agree that ill-prepared healthcare providers may, in certain circumstances, make the situation worse. However, many surgeons without formal disaster training and other individuals who traveled alone to Haiti did provide valuable and self-sacrificing services to fellow humans in need. As one of the earliest responders, my team from the United States was deployed to Haiti within the first few days after the earthquake. We were affiliated with a formal relief organization and this made our mission more successful. I worked with independent orthopaedic surgeons who came to Haiti alone and at great personal risk, to help others after one of the worst natural disasters in the history of our modern world. Furthermore, none of these surgeons had previous mass casualty experience. These physicians became a critical part of our evolving medical team in Haiti and ended up helping and saved countless lives. In my opinion, it does not take someone with fellowship training in trauma or someone who has enrolled in a weekend course provided by the AAOS to help others in this type of situation. Anyone with basic orthopaedic training during residency can and did help. Granted, each surgeon must know their limitations. Simply having other medically trained men and women to help apply a cast, wash out a wound, hold surgical retractors, or go triage a patient in a make-shift emergency room was invaluable. Those who suggest that untrained volunteers should have stayed home after the Haiti earthquake are off-base in their overall assessment of that crisis. With more than 250,000 Haitian people injured (many severely) after the earthquake, just about anyone could have made themselves invaluable as part of the response effort. As for their personal safety, that is a consideration every man or woman must make for him- or herself. Whether to risk one’s life is not up to me or the authors of this article, but it is up to each individual. I do agree with Sonshine et al. on several common themes. For instance, providing medical care as a team rather than as an individual was absolutely critical. Whether you went as a formal team before deployment or came to the country as an individual, team work was the first priority. Electing an operating room supervisor or medical director responsible for oversight and leadership is an important first step in any medical relief mission. Furthermore, cooperation with the military was essential as they provided valuable resources that no civilian medical organization could have provided on their own. They also helped to keep the peace among many Haitian citizens and foreign aid-workers at a time of enormous turmoil and unrest. Finally, resources that allow for further training in disaster preparedness are important for orthopaedic surgeons who wish to volunteer in these situations. However, I believe it is not accurate to suggest that formal training should be an absolute necessity in situations like Haiti where human devastation was so palpable and resources were so limited. There is no type of formal training that could have prepared an individual for this type of experience. Organization skills and surgical judgment are critically important in this type of disaster situation. Thus, courses that provide some basic training on mass casualty scenarios would likely prove to be a valuable asset to individuals involved in medical relief efforts in the future.

A number of reconstructive procedures are available for the management of hip osteoarthritis. Hip resurfacing arthroplasty is now an accepted procedure, with implant survivorship comparable to THA at up to 10 years’ followup in certain series. Most reports focus on implant survivorship, surgeon-derived results, or complications. Fewer data pertain to patient-reported results, including validated measures of quality of life (QoL) and satisfaction and baseline measures from which to determine magnitude of improvement. Validated patient-reported results are essential to guide patients and surgeons in the current era of informed and shared decision making. We determined whether patients reported improvement in disease-specific, joint-specific, and generic QoL after hip resurfacing arthroplasty; whether patients were satisfied with the results of the procedure; and latest activity level and return to sport. We retrospectively reviewed 127 patients (100 men, 27 women) who underwent 143 hip resurfacing procedures between 2002 and 2006. Mean patient age was 52 years. Patients completed the WOMAC, Oxford Hip Score, and SF-12 at baseline and again at minimum 2-year followup (mean, 2.5 years; range, 2–6 years). At latest followup, patients completed a validated satisfaction questionnaire and UCLA activity score. All QoL scores improved (normalized to a 0–100 scale, where 100 = best health state). WOMAC improved from 46 to 95, Oxford Hip Score from 42 to 95, SF-12 (physical) from 34 to 54, and SF-12 (mental) from 46 to 56. Patient satisfaction score was 96. UCLA activity score was 8. The majority of patients reported improvement in QoL, were very satisfied with their outcome, and returned to a high level of activity after hip resurfacing arthroplasty. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.