Femoral Fixation Research Articles

Five-Strand Hamstring Grafts are Biomechanically Comparable to Four-Strand Grafts and Offer Greater Diameter for Anterior Cruciate Ligament Reconstruction

PurposeThe purpose of this study was to compare the biomechanics of 4-strand and 5-strand hamstring constructs for anterior cruciate ligament grafts.MethodsThirty-six human cadaveric hamstring grafts were tested in 3 different conditions: (1) graft femoral fixation complex, (2) graft femoral and tibial fixation (GFTF) complex using a human model, and (3) GFTF complex using a porcine model. Grafts were tested on a tensile testing machine. Four-stranded grafts served as the control group, and 5-stranded grafts served as the experimental group. Cyclic elongation, ultimate load to failure, stiffness, and diameter of the grafts were analyzed.ResultsAverage 4-strand graft diameter was 7.96 mm compared to 9.32 mm for the 5-strand graft (P = .00017). Average stiffness of grafts ≥8 mm was 105.04 N/mm compared to 85.05 N/mm for grafts <8 mm (P = .04988). There was a positive correlation between graft diameter and stiffness (13.4 N/mm per every 1 mm increase in diameter, r2 value of 13.1%, and F-significance of 0.02778). There were no significant differences in terms of ultimate load to failure, cyclic elongation, or stiffness between the experimental groups.ConclusionFive-strand hamstring grafts offer greater diameter and are biomechanically comparable to 4-strand equivalents at time 0. Grafts >8 mm offer significantly greater stiffness compared to grafts sized <8 mm. There is a weak positive correlation between graft diameter and stiffness.Clinical RelevanceA potential drawback to hamstring grafts is their variability in size. Five-strand hamstring grafts provide increased diameter in comparison to 4-strand equivalents and might be used when quadrupled graft diameter is <8 mm.

Physical Therapy Interventions for Post-Operative a Giant Femoral Tumor: A Case Report

Background: Giant cell tumor (GCT) is a relatively rare type of primary benign bone tumor, characterized by multinucleated giant cells resembling osteoclasts. Treatment of GCT with intralesional resection and bone cement filling, especially in tumors that develop around the knee joint. After GCT surgery around the knee joint, in general, patients will experience several symptoms such as pain in the operating area and surrounding structures, limited range of motion, then symptoms that are quite worrying, namely related to the ability of knee function in the future. The role of physiotherapy after GCT surgery around the knee joint, especially the distal anterolateral part of the femur, was stated to be able to restore the functional ability of the knee without limitations.&#x0D; Case Description: A 24-year-old male employee of the laboratory analysis division of Udayana University Hospital was diagnosed with GCT in the distal right femur. The diagnosis was made on September 30, 2021, using a biopsy with bone, joint, and articular cartilage specimens of the distal right femur. The patient underwent intralesional resection surgery, bone cement filling, and internal fixation of the distal femur in November 2021. Postoperatively the patient complained of pain in the posterior and medial distal right thigh, as well as limitations when bending the right knee. In addition, the patient also admitted to having difficulty doing squat movements.&#x0D; Conclusion: Patients experienced an improvement in their symptoms after carrying out 7 physiotherapy sessions for 3 weeks. However, the patient still needs further exercise so that the walking pattern can show better development.

Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results.

Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement. Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed. Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r = - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r = - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year. In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.

Hardware Impingement Is Associated With Shorter Screw Length in Patients Treated With In Situ Screw Fixation for Slipped Capital Femoral Epiphysis: An In Vivo Arthroscopic Evaluation

PurposeTo determine the incidence of screw impingement on dynamic exam during hip arthroscopy in patients undergoing treatment for femoroacetabular impingement after previous slipped capital femoral epiphysis fixation and to evaluate screw characteristics with hardware impingement.MethodsA retrospective review from 2008 to 2020 was performed of slipped capital femoral epiphysis (SCFE) patients that underwent arthroscopy for symptoms of hip impingement. Patients underwent a dynamic exam under direct arthroscopic visualization to assess for sources of impingement, including bony anatomy and fixation hardware. Slip angle was calculated on lateral radiographs prior to arthroscopy, and screw length was noted in the initial operative reports at treatment of SCFE and reported in millimeters. Normality of data was assessed using Shapiro-Wilk tests, with statistical analysis performed using independent sample t-tests, Mann-Whitney U-nonparametric tests, and multivariable logistic regression. An alpha level of <0.05 was used to indicate statistical significance.ResultsThirty-nine hips were included, with 13 (33.3%) having screw impingement on dynamic exam. Slip angle was found to be increased in the screw impingement group (42.4° vs 35.5°; P = .11). Screw length was noted to be significantly shorter in the screw impingement group (53.1 vs 61.6 mm; P = .021). The presence of screw impingement was found to be associated with shorter screw length (β = −0.172, R2 = 0.329; P = .036).ConclusionsShorter screws (55 mm or less) are at greater risk of causing hardware hip impingement after in situ SCFE fixation. When considering hip arthroscopy for the treatment of femoroacetabular impingement in patients with a previous SCFE, hardware impingement and subsequent hardware removal should be considered in hips with shorter screws and in hips that show objective hardware impingement on dynamic exam.Level of EvidenceLevel IV, therapeutic case series.

Integrating Simulation for Developing Slipped Capital Femoral Epiphysis Fixation Skills into an Orthopaedic Surgery Residency Program

Slipped capital femoral epiphysis (SCFE) in pediatric and adolescent patients is a common hip injury treated at tertiary care centers and children’s hospitals. The relatively uncommon nature of SCFE in association with the reliable and reproducible resulting deformity make for the ideal opportunity to supplement orthopedic resident and/or fellow operative experience with simulation training. This approach will allow trainees to develop expert performance and ensure that a benchmark proficiency skill level is attained.

Comparison of Functional Outcome of closed Retrograde Nailing and Mippo (Minimally Invasive Percutaneous Plate Osteshnthesis) Distal Femoral Locking Plate Fixation for Distal Femoral Fractures

Objective: The purpose of our study is to compare the safety and efficacy of MIPPO distal femoral locking plate versus retrograde nailing in distal locking plate fixation among patients suffering from distal femoral fractures. Study Design: Quasi Experimental study Place and Duration: Nishtar Hospital Multan. August 2021-May 2022 Methods: There were 112 patients of both genders with ages 15-48 years had distal femoral fractures and underwent for surgery were included in this study. After obtaining informed written consent, demographically detailed of enrolled cases were recorded. Causes of distal femoral fractures were assessed. Patients were equally categorized in two group. 56 patients in group O received MIPPO DFLP and in group P 56 cases received retrograde nailing. All patients were radiographed and categorized according on the criteria established by the AO/OTA categorization system.[13] Outcomes among both groups were assessed and compared in terms surgery duration, efficacy and complications. HSS score was used to describe effectiveness of both groups. SPSS 24.0 was used to analyze all data. Results: We found that males were higher in numbers 80 (71.4%) than females (32 (28.6%). Mean age of the included patients were 29.5±9.81 years and had mean BMI 24.8±11.44 kg/m2. Most common cause of fracture was road traffic accident (RTA) in 51 (45.5%) cases, followed by falling in 35 (31.3%) cases, sports in 17 (15.2%) cases and violence in 9 (8.04%). Most common affected side was right. As per AO classification, numbers were higher in Type 43A1 classification found in 65 (58.04%) cases. Mean union time in group O was lower 2.5±4.87 months as compared to group P 3.9±6.54 significantly with p value &lt;0.005. We found significantly higher number of excellent results in MIPPO DFLP group found in 29 (51.8%) cases as compared to retrograde nailing group in 14 (25%) cases with p value &lt;0.003. Complications (delayed union, non-union, deformity, bone stiffness) were found higher in group P. Conclusion: We concluded in this study that use of MIPPO DFLP for the treatment of distal third femoral shaft fractures is highly effective and useful as compared to retrograde nailing with p value &lt;0.04 in terms of less unions time, higher excellent results and lower number of complications. Keywords: Retrograde Nailing, Distal Femoral Fractures, MIPPO DFLP, Efficacy, Complications

Finite element analysis of femoral neck system in the treatment of Pauwels type III femoral neck fracture.

The optimal treatment strategy for femoral neck fractures remained controversial, especially the Pauwels type III femoral neck fracture of young patients was a challenge. Femoral neck system (FNS) was a newly developed internal fixation for treating femoral neck fracture and this study aimed to compare the biomechanical advantages and disadvantages between FNS and 3 cannulated configuration screws (CCS) with or without an additional medial buttress plate (MBP). In this study, Pauwels type III femoral neck fracture model with an angle of 70° was constructed and 3 different fixation models, FNS, CCS + MBP, CCS alone, were developed. A vertical force of 2100N was applied on the femoral head, then the maximum von Mises stress of whole model, distal femur, femoral head, and internal fixation was recorded, as well as the stress distribution of whole model, proximal fracture section, and internal fixation of the 3 models. Moreover, the maximum displacement of the whole model, distal femur, femoral head, internal fixation, and the relative displacement of the proximal and distal portion was also compared. The maximum von Mises stress value was 318.302 MPa in FNS, 485.226 MPa in CCS + 1/3 plate, and 425.889 MPa in CCS. The FNS showed lowest maximum von Mises stress values in distal part, femoral head, and internal implant. All fixation configurations were observed stress concentrated at the posteroinferior area of cross-section of femoral head and at the fracture section area of implant; however, FNS had more uniform stress distribution. For displacement, the maximum displacement value was 8.5446 mm in FNS, 8.2863 mm in CCS + 1/3 plate, and 8.3590 mm in CCS. However, FNS had higher maximum displacement in femoral head and internal implant, but lower maximum displacement in the distal part of fracture model. The FNS represented a significantly higher relative displacement between the femoral head and distal femur when compared with the other 2 fixation configurations. The newly developed FNS could achieve the dual effect of angular stability and sliding compression for the treatment of Pauwels type III femoral neck fractures, which provided superior biomechanical stability than CCS alone and CCS with additional MBP.

Femoral osteomyelitis caused by oral anaerobic bacteria with mixed bacteremia of Campylobacter rectus and Parvimonas micra in a chronic periodontitis patient: a case report

BackgroundCampylobacter rectus is a gram-negative rod, and Parvimonas micra is a gram-positive coccus, both of which are oral anaerobes that cause chronic periodontitis. Chronic periodontitis can cause bacteremia and systemic diseases, including osteomyelitis. Hematogenous osteomyelitis caused by anaerobic bacteria is uncommon, and to date, there have been no reports of mixed bacteremia with C. rectus and P. micra. Here, we report the first case of osteomyelitis of the femur caused by anaerobic bacteria with mixed bacteremia of C. rectus and P. micra caused by chronic periodontitis.Case presentationA 75-year-old man with chronic periodontitis, hyperuricemia, and benign prostatic hyperplasia was admitted to the hospital with a fracture of the left femur. The patient had left thigh pain for 4 weeks prior to admission. Left femoral intramedullary nail fixation was performed, and a large amount of abscess and necrotic tissue was found intraoperatively. The cultures of abscess specimens were identified as P. micra, Fusobacterium nucleatum, and C. rectus. C. rectus and P. micra were also isolated from blood cultures. C. rectus was identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and 16 S ribosomal RNA sequencing. Sulbactam-ampicillin was administered for approximately 1 month, after which it was replaced by oral clavulanic acid-amoxicillin for long-term suppressive treatment.ConclusionsOnly five cases of bloodstream infection with C. rectus have been reported, and this is the first report of mixed bacteremia with P. micra. Clinicians should consider that chronic periodontitis caused by rare oral anaerobic bacteria can cause systemic infections, such as osteomyelitis.

Comparative Results of Anterior Cruciate Ligament Reconstruction with Full Tibial Tunnel: Quadrupled Semitendinosus Suspensory Femoral and Tibial Fixation versus Quadrupled Semitendinosus and Gracilis Suspensory Femoral and Tibial Screw and Staple Fixation.

This study compared the clinical outcomes of patients treated with described "modified all-inside" anterior cruciate ligament reconstruction (ACLR) technique with those of patients treated with suspensory femoral fixation and a bioabsorbable tibial interference screw with the ACLR technique. From 2017 to 2019, 98 patients who underwent ACLR surgery by two surgeons using either of the techniques were included in this study. Patients in group 1 were treated with the "modified all-inside" ACLR technique. In this technique, only the semitendinosus tendon was harvested as a four-strand graft and fixed to the tibia and femur with suspensory buttons. Patients in group 2 were treated with suspensory femoral fixation and a bioabsorbable tibial interference screw ACL reconstruction technique. Patients' functional outcomes were evaluated by the Lysholm score, Tegner activity scale, and International Knee Documentation Committee (IKDC) subjective score. Postoperative knee stability of the patients was evaluated using the Lachman test and the pivot-shift test. The mean ages of the patients were 31.1 (16-55) and 28.7 (18-48) years in groups 1 and 2, respectively. The average follow-up durations were 26 (20-30) and 25.9 (22-30) months for both groups. There was no significant difference between the preoperative and postoperative Lysholm's score, Tegner's activity score, and IKDC subjective score in groups 1 and 2. There were no major complications or reruptures in either group. ACLR incorporating the "modified all-inside" ACLR technique obtained significant clinical outcomes compared to ACLR with a suspensory femoral fixation and a bioabsorbable tibial interference screw.

Adrenal hemorrhage following direct oral anticoagulant (DOAC) therapy: two case reports and literature review

BackgroundAdrenal hemorrhage (AH) is a rare condition that can result in a life-threatening medical emergency. This medical condition could be caused by several underlying factors, one of which is the use of anticoagulants. As far as we are aware, direct oral anticoagulant (DOAC) agents are a rare but possible cause of AH.Case presentationHerein, we described two cases of AH due to DOACs. The first case was a 35-year-old Iranian woman with a past medical history of Hashimoto thyroiditis who was being treated with apixaban due to the previous thrombosis. Her first symptoms of AH (November 2021) were strangely similar to symptoms of autoimmune Addison disease (AAD) which led to a confirmed diagnosis of autoimmune polyendocrine syndrome type 2 (APS-2). An abdominal MRI revealed an oval shape well-encapsulated cystic mass with a diameter of 20 × 14 mm with a thick and low signal intensity rim in the left adrenal gland, highly suggestive of sub-acute left-sided AH. Our second case was an 89-year-old Iranian woman who had been admitted to the hospital (August 2021) with low blood pressure and disorientation. At the beginning of her admission, the evaluation showed hyponatremia, and further evaluations confirmed adrenal insufficiency (AI). The patient reported rivaroxaban usage for deep vein thrombosis prophylaxis after femur fixation surgery. Her abdominal CT scans showed bilateral adrenal masses highly suggestive of AH. Her follow-up examination showed persistent AI after three months.ConclusionGiven the history of our cases, physicians should be aware of AH in patients receiving DOACs, particularly in elderly patients who are at high risk of bleeding. It is also worth noting that AH can occur in any patient with any medical history and history of DOAC use, which is why patients must be closely monitored.

Posterior wall blowout on computed tomography after anterior cruciate ligament reconstruction

BackgroundDuring anterior cruciate ligament (ACL) reconstruction, even when a posterior wall of the femoral bone tunnel is identified, computed tomography (CT) occasionally demonstrates a breach of the posterior femoral cortex of the femoral bone tunnel, i.e., posterior wall blowout, after ACL reconstruction (posterior wall blowout-like phenomenon). This study aimed to investigate the influence of the posterior wall blowout-like phenomenon on clinical outcomes after ACL reconstruction using hamstring tendon. MethodsA total of 105 patients who underwent CT examination two weeks after ACL reconstruction were enrolled. A cortical suspension device was used for femoral side fixation in all cases. Posterior wall was identified in all cases during the surgery. The side-to-side difference in anterior knee laxity, pivot shift test, Lysholm knee score, the International Knee Documentation Committee (IKDC) subjective form, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were evaluated one year after the surgery. A second CT examination was performed 6–12 months after the surgery, if a posterior wall blowout-like phenomenon was identified in the first CT examination. ResultsTwo weeks after the surgery, 16 of the 105 patients showed a posterior wall blowout-like phenomenon. Twelve of the 16 cases demonstrated a regenerated posterior femoral cortex of the femoral bone tunnel on their second CT images. There were no significant differences between the posterior wall blowout-like phenomenon group and the normal posterior wall group in terms of a side-to-side difference in anterior knee laxity (0.4 ± 1.5 mm and 0.1 ± 1.6 mm, respectively), pivot shift test, Lysholm knee score, IKDC score, and KOOS at one year after surgery. The length and diameter of the femoral bone tunnel were not significantly different between the two groups. ConclusionsPosterior wall blowout-like phenomenon after ACL reconstruction using a cortical suspension device did not negatively influence clinical outcomes. Level of evidenceIII – retrospective comparative clinical study.

Poster 252: Revision Risk of Hamstring Versus Hybrid Graft in Anterior Cruciate Ligament Reconstruction

Objectives:Hamstring autograft (HA) is a commonly used graft for anterior cruciate ligament reconstruction (ACLR). Hamstring tendon harvest can occasionally result in a small diameter graft, leaving the surgeon with several options. One option is to augment the hamstring graft with allograft tendon to increase the combined graft diameter forming a hybrid graft (HG). Inconsistent results of HG reconstructions have been reported, with some studies reporting worse outcomes for HG while others showing no difference between the two types of grafts. However, these studies have small sample sizes or are of an older patient population. The purpose of our study was to compare the revision rates of HA versus HG grafts in a young patient population.Methods:We conducted a retrospective cohort study of prospectively collected data from our integrated healthcare system’s ACLR Registry. Patients <25 years of age with a primary, isolated ACLR performed between 2005-2020 were identified; those with prior surgery in the index knee, double bundle, and infections (septic revisions) were excluded. The exposure of interest was graft type and diameter size, including <8mm HA and >8mm HG. Hybrid graft was defined as a hamstring tendon augmented with an allograft tendon to increase the graft diameter. Grafts with unknown diameter sizes and other graft types were excluded. A secondary analysis examined 7mm and 7.5mm HA vs >8mm HG. Propensity score-weighted Cox proportional hazard regression was used to evaluate the risk of aseptic revision during follow-up. Propensity score weights were calculated prior to evaluation of the outcome using multivariable logistic regression analysis and included age, sex, body mass index, race/ethnicity, femoral fixation, tibial fixation, femoral tunnel method, and activity at injury. Hazard ratios (HR) and 95% confidence intervals (CI) are presented. A P<0.05 was considered statistically significant.Results:The final cohort comprised 1,945 ACLR (548 were >8mm HG and 1397 were <8mm HA, including 651 with 7mm diameters and 672 with 7.5mm). At 8-years follow-up, the crude cumulative aseptic revision probability for >8mm HG was 9.1%, while <8mm HA was 10.9% (Figure 1); corresponding cumulative probabilities for 7mm and 7.5mm HA were 11.1% and 11.2% respectively. After adjustment with propensity score weighting, we failed to observe a difference in aseptic revision risk for <8mm HA compared with >8mm HG (HR=1.15, 95% CI = 0.72-1.82, p=0.56) (Table 1). Similarly, no difference was observed for 7mm HA (HR= 1.23, 95% CI=0.71-2.11, p=0.46) and 7.5mm HA (HR=1.16, 95% CI =0.74-1.82, p=0.52) compared to HG.Conclusions:In our cohort study of 1,945 patients, we failed to detect a statistical difference in the risk of aseptic revision between a HA < 8mm and a HG > 8mm. The clinical significance is that augmentation of HA with an allograft does not appear to decrease the risk of aseptic revision and may not be necessary. Future studies should be conducted to confirm these findings.Figure 1.Cumulative Incidence of Aseptic Revision by Graft Type/Diameter Size.Table 1.Crude Cumulative Revision Probability And Adjusted Risk After Aclr By Graft Type/Diameter Size.

Poster 251: Autograft Associated with Lower Risk of Repeat Revision Anterior Cruciate Ligament Reconstruction than Allograft: Results from a Large Integrated Healthcare System

Objectives:With the rising utilization of primary anterior cruciate ligament reconstruction (ACLR), the burden of revision ACLR (rACLR) has also increased. Graft choice for rACLR is complicated by patient factors and the remaining available graft options. This study examines the relationship between graft type at the time of rACLR and the risk of repeat rACLR (rrACLR).Methods:We conducted a cohort study from a US integrated healthcare system’s ACLR registry. The study population included patients with a primary isolated ACLR, between 2005-2020, who then went on to have an aseptic rACLR. Graft type used at revision surgery, classified as autograft versus allograft, was the exposure of interest. Multivariable Cox proportional hazard regression was used to evaluate the risk of aseptic rrACLR with ipsilateral and contralateral reoperation as secondary outcomes. Models included factors at the time of the revision procedure (age, gender, body mass index, smoking status, staged revision, femoral fixation, tibial fixation, femoral tunnel method, lateral meniscus injury, medial meniscus injury, and cartilage injury) and a factor from the primary ACLR (activity at injury) as covariates.Results:1747 rACLR procedures were included. The crude cumulative aseptic rrACLR incidence at 8-years follow-up was 13.9% for allograft and 6.0% for autografts (Figure 1). Cumulative ipsilateral reoperation incidence at 8-years follow-up was 18.3% for allograft and 18.9% for autograft; contralateral reoperation cumulative incidence was 4.3% for allograft and 6.8% for autograft. With adjustment for covariates, a lower aseptic rrACLR risk was observed for autografts compared with allografts (HR=0.30, 95% CI=0.18-0.50, p <0.0001). No differences were observed for ipsilateral reoperation (HR=1.05, 95% CI=0.73-1.51, p=0.78) nor for contralateral reoperation (HR=1.33, 0.60-2.97, p=0.48) for autografts compared with allografts.Conclusions:The use of autograft at rACLR was associated with a 70% reduced risk of rrACLR compared to allograft in this large integrated health care system registry. When accounting for all reoperations after rACLR, we found no significant difference in risk between autograft and allograft. In order to minimize the risk of rrACLR, surgeons should consider using autograft for rACLR when possible.Figure 1.Cumulative Incidence of Asceptic Re-revision by Graft Type.

Study of prevalence and operative results of fracture shaft femur in adults

Background: Being the principal weight bearing of the lower limb, fractures related to the femur pose a threat to humans and affect the overall quality of life. Conservative management is no longer preferred, and stable internal fixation is the modality of treatment these days. Aims and Objectives: The aim of this article is to study the operative outcomes of fixation of fracture shaft femur in terms of union, stability, functional outcomes, and complications. Materials and Methods: This study is a retrospective study of 35 patients with proximal, mid-shaft, and extra-articular distal shaft femur fractures admitted to Smt. SCL Municipal Hospital for 3 years from May 2019 to May 2022. Results: The results showed improvement in all the functional and radiological outcomes. More than 70% of the patients achieved greater than 125° of knee flexion. The radiological union of fractures was 4.4 months in our study. According to Neer’s score, 33 patients scored excellent to satisfactory. Conclusion: Internal fixation of fractures in the femoral shaft is an absolute must and has gained widespread acceptance as implants and technology have improved. The rationale for internal fixation is that it restores anatomical alignment and allows early mobilization of the patient and limb.

Current Trends in Revision Hip Arthroplasty: Indications and Types of Components Revised.

The materials and techniques for both primary and revision total hip arthroplasty (THA) have changed over time. This study evaluated if the indications for revision THA, rates of components utilized (femoral or acetabulum, both, or head/liner exchange), length of stay (LOS), and payments to surgeons and facilities have also changed. A retrospective study, utilizing the PearlDiver database, of 38,377 revision THA patients from January 2010 through December 2018 was performed. Data included the indication for revision, components revised (femoral or acetabulum, both, or head/liner exchange), LOS, and payments. Indications and components were analyzed by logistic regression (Dunnett's post hoc test). Revision totals were analyzed with a linear regression model. Analysis of variance assessed changes in LOS and payments. Patients' median age was 67 years (Q1-Q3: 59-74), and 58.7% were female. Revisions for dislocation decreased between 2010 and 2018 (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.68-0.98). Revisions for component loosening increased (OR 1.54, 95% CI 1.25-1.91). Dislocation remained the most common indication (19.3%), followed by PJI (17.3%) and loosening (17.1%). Both-component (OR:1.45; 95% CI:1.25-1.67) and femoral component only revisions increased; acetabular component only and head/liner exchanges decreased. Acetabular (OR 0.57, 95% CI 0.47-0.70) and head/liner exchange (OR 0.29, 95% CI 0.20-0.43) revisions decreased, while both component exchange (OR 1.45, 95% CI 1.25-1.67) and femoral revisions (OR 1.17, 95% CI 0.99-1.37) increased. Average LOS (-0.68 days; P < .001) and surgeon payments decreased (-$261.8; P < .001) while facility payments increased ($4,211; P < .001). Indications for revision THA in this database study changed over time, with revision for dislocation decreasing and revision for loosening increasing over time. Both component and femoral revisions increased, and acetabular component and head/liner exchanges decreased. It is possible that these associations could be attributed to a number of details, the method of femoral fixation, surgical approach, and cementing, all of which require additional study.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery

ObjectivesTo inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country’s ability...

A prospective comparison of 3 hamstring ACL fixation devices—rigidfix, bioscrew, and intrafix—randomized into 4 groups with a minimum follow-up of 5 years

BackgroundACL (anterior cruciate ligament) reconstruction remains the gold standard surgical option for patients with ACL tears. There are many fixation devices available for ACL reconstruction. Recent ACL reconstruction strategies are aiming to reproduce the native anatomy and normal kinematics of the knee. This is a five years follow-up report of some of the new devices for graft fixation. A two years follow-up data was published previously.Methods120 patients were randomized into four different groups (30 each) for ACL reconstruction with hamstring tendons: group I femoral Rigidfix cross-pin and Intrafix tibial extension sheath with a tapered expansion screw; group II Rigidfix femoral and BioScrew interference screw tibial fixation; group III BioScrew femoral and Intrafix tibial fixation; group IV BioScrew fixation into both tunnels. The evaluation methods were clinical examination, knee scores, and instrumented laxity measurements.ResultsIn this 5 years follow-up there were 102/120 (85%) patients available, but only 77 (64,2%) attended the clinical examinations. No significant difference between the groups in the clinical results was detected. Between the 2 and 5 years follow-up there were 6 additional procedures in group I and one in group II. There was a significant difference in additional procedures between group I and the other groups (P = .041).ConclusionThere was a statistically significant difference in the additional procedures, most in group I (six). The ACL grafts were intact. Other statistically or clinically significant differences in the 5 years follow-up results were not found.Study designRandomized controlled clinical trial; Level of evidence, 1.Trial registration ISRCTN registry with study ID ISRCTN34011837. Retrospectively registered 17.4.2020.

Modified Lemaire Lateral Extra-articular Tenodesis With the Iliotibial Band Strip Fixed on the Femoral Cortical Surface Reduces Laxity and Causes Less Overconstraint in the Anterolateral Lesioned Knee: A Biomechanical Study

To compare the biomechanical effects of femoral cortical surface fixation and intra-tunnel fixation in modified Lemaire tenodesis on the restoration of native kinematics in anterolateral structure-deficient knees. Eight fresh-frozen cadaveric knees were mounted in a knee-customized jig to evaluate anterior translation in anterior load and internal rotation degree in internal rotation torque at 0°, 30°, 60°, and 90°, as well as anterolateral translation (ALT) in a simulated pivot-shift test at 0°, 15°, 30°, and 45°. Kinematic tests were performed in the following states: intact; anterolateral knee lesion (AL-Les); modified Lemaire lateral extra-articular tenodesis (LET) with the femoral iliotibial band (ITB) strip fixed on the cortical surface (cortical fixation), deep to the lateral collateral ligament (LCL) (deep LET-C); and LET with the femoral ITB strip fixed into a tunnel (intra-tunnel fixation), deep to the LCL (deep LET-IT) or superficial to the LCL (superficial LET-IT). The knee kinematic changes in the AL-Les state and the 3 LET states were compared with each other, with the intact state as the baseline. In the AL-Les state, the increased anterior translation instabilities were significantly mitigated by the 3 LETs at 30°, 60°, and 90° (all P < .001), with overconstraint observed in both the deep LET-IT and superficial LET-IT states at 60° (P= .047 and P < .001, respectively) and 90° (both P < .001). Similarly, the 3 LETs significantly reduced the internal rotation instabilities in the AL-Les state at all flexion angles. The superficial LET-IT state overconstrained the knee at 60° (P= .009) and 90° (P < .001) during internal rotation torque, and the deep LET-IT state did so at 60° (P= .012). Furthermore, the ALT instabilities found in the AL-Les state were significantly reduced by the 3 LETs during the simulated pivot-shift test. At 30° and 45°, these LET states resulted in overconstraint when compared with the intact state, but the superficial LET-IT state (P < .001) or deep LET-IT state (P = .016) presented a larger overconstraint than that in the deep LET-C at 45°, respectively. The 3 Lemaire LET procedures evaluated reduced the anterior, internal rotational, and ALT laxities in AL-Les knees and restored these parameters to the native baseline of the intact state at most flexion angles. However, in deep flexion, some overconstraint occurred in all LETs when compared with the intact state, of which the deep LET-C state resulted in less overconstraint in anterior translation and internal rotation than the deep LET-IT and superficial LET-IT states. This biomechanical study supports using the femoral cortical fixation technique to fix the ITB strip in the modified Lemaire LET, which similarly improves knee kinematic stability and causes less overconstraint compared with conventional intra-tunnel fixation. These findings need more verification in clinical scenarios.

3D-Printed Gentamicin-Releasing Poly-ε-Caprolactone Composite Prevents Fracture-Related Staphylococcus aureus Infection in Mice.

Bacterial infections are a serious healthcare complication in orthopedic and trauma surgery worldwide. Compared to systemic, local antibiotic prophylaxis has been shown to provide a higher antibiotic dose and bioavailability at the bone site with minimum toxic effects. However, there are still not enough biomaterial and antibiotic combinations available for personalized implant sizes for patients. The aim of this study was to develop a bone fixation plate coating made of a composite of poly-ε-caprolactone, hydroxyapatite and halloysite nanotubes loaded with gentamicin sulphate and fabricated via fused filament fabrication 3D printing technology. The mechanical and thermal properties of the biomaterial were analyzed. The in vitro release kinetics of gentamicin sulphate were evaluated for 14 days showing a burst release during the first two days that was followed by a sustained release of bactericidal concentrations. The composite loaded with 2 and 5% gentamicin sulphate exhibited complete antimicrobial killing of Staphylococcus aureus in an ex vivo mouse femur fixation plate infection model. Moreover, a fixation plate of the composite loaded with 5% of gentamicin sulphate was able to prevent S. aureus infection in the bone and surrounding tissue in an in vivo mouse bone fixation plate infection model 3 days post-surgery. In conclusion, the newly developed composite material successfully prevented infection in vivo. Additionally, the ability to use fused filament fabrication 3D printing to produce patient-specific implants may provide a wider range of personalized solutions for patients.

Adjustable-loop implants are non-inferior to fixed-loop implants for femoral fixation in anterior cruciate ligament reconstruction.

Button implants with an adjustable-loop device (ALD) are often used in anterior cruciate ligament reconstruction (ACLR). Clinical research comparing ALDs with fixed-loop devices (FLD) has mainly been conducted in small patient populations with short follow-up times. To determine whether ALDs are safe to use in ACLR, a non-inferiority study with a large sample population and a long follow-up period would be beneficial. This study compared ALDs with FLDs to determine non-inferior revision surgery rates, knee stability, and patient-reported outcomes (PROM) in ACLRs. This non-inferiority register-based cohort study was conducted using data from the Danish Knee Ligament Reconstruction Registry (DKRR). A total of 12,723 patients > 15years of age with primary ACLR using hamstring tendon autografts and either an FLD or ALD for femoral fixation were included: 9719 patients were in the FLD group, and 3014 patients were in the ALD group. The primary outcome was revision ACLR with a non-inferiority margin for ALDs at 4% at the 2-year follow-up. The secondary outcomes were anterior and rotatory knee stability and PROMs based on the Knee Injury and Osteoarthritis Outcome Score (KOOS) at the 1-year follow-up. The crude cumulative revision rates in ALD implants at 2 and 5 years were 2.1% (95% CI 1.62-2.68) and 5.0% (95% CI 4.22-5.96), respectively. In the FLD group, the rates were 2.2% (95% CI 1.89-2.48) at 2 years and 4.7% (95% CI 4.31-5.20) at 5 years. The 1-year side-to-side differences were 0.97mm (95% CI 0.90-1.03) in the ALD group and 1.45mm (95% CI 1.41-1.49) in the FLD group. In the FLD group, 13% had a positive pivot shift, and in the ALD group, 6% had a positive pivot shift. There were no differences in KOOS. ALDs were non-inferior to FLDs regarding revision rates, knee stability, and patient-reported outcomes. Based on this conclusion, ALDs are safe to use for femoral fixation in ACLR. III.