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Mattia Loppini, Francesco Manlio Gambaro, Rob G H H Nelissen, and Guido Grappiolo

  • The study investigated the existing guidelines on the quality and frequency of the follow-up visits after total hip replacement surgery and assessed the level of evidence of these recommendations.

  • The review process was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional works were retrieved by direct investigation of the available guidelines of the most important orthopedic societies and regulatory agencies.

  • The current systematic review of the literature resulted in zero original papers, four guidelines for routine follow-up and three guidelines for special cases. Concerning the quality of evidence behind them, these guidelines were not evidence based but drafted from expert consensus.

  • The most important finding of this review is the large variation of recommendations in the follow-up schedule after total hip arthroplasty and the lack of evidence-based indications. Indeed, all the above-reported guidelines are the result of a consensus among experts in the field (level of recommendation class D ‘very low’) and not based on clinical studies.

J R W Crutsen, M C Koper, J Jelsma, M Heymans, I C Heyligers, B Grimm, N M C Mathijssen, and M G M Schotanus

  • Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty.

  • The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms.

  • A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients.

  • The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases).

  • Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system.

  • The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings.

  • We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing.

  • Level of Evidence: Level V, systematic review

Catalin Cirstoiu, Bogdan Cretu, Sergiu Iordache, Mihnea Popa, Bogdan Serban, and Adrian Cursaru

  • Bone metastases are difficult to treat surgically, necessitating a multidisciplinary approach that must be applied to each patient depending on the specifics of their case.

  • The main indications for surgical treatment are a lack of response to chemotherapy, radiation therapy, hormone therapy, immunotherapy, and bisphosphonates which is defined by persistent pain or tumor progression; the risk of imminent pathological bone fracture; and surgical treatment for single bone metastases.

  • An important aspect of choosing the right treatment for these patients is accurately estimating life expectancy. Improved chemotherapy, postoperative radiation therapy, and sustainable reconstructive modalities will increase the patient’s life expectancy.

  • The surgeon should select the best surgical strategy based on the primary tumor and its characteristics, the presence of single or multiple metastases, age, anatomical location, and the functional resources of the patient.

  • Preventive osteosynthesis, osteosynthesis to stabilize a fracture, resections, and reconstructions are the main surgical options for bone metastases.

  • Resection and reconstruction with a modular prosthesis remain the generally approved surgical option to restore functionality, increase the quality of life, and increase life expectancy.

  • Preoperative embolization is necessary, especially in the case of metastases of renal or thyroid origin. This procedure is extremely important to avoid complications, with a major impact on survival rates.

Stefan Bauer, Taro Okamoto, Stephanie M Babic, Jonathon C Coward, Charline M P L Coron, and William G Blakeney

  • Variable definitions of pseudoparalysis have been used in the literature.

  • Recent systematic reviews and biomechanical studies call for a grading of loss of force couple balance and the use of the terms ‘pseudoparesis’ and ‘pseudoparalysis’.

  • Pain should be excluded as the cause of loss of active function.

  • Key players for loss of force couple balance seem to be the lower subscapularis as an anterior inferior checkrein and the teres minor as a posterior inferior fulcrum.

  • Loss of three out of five muscle–tendon units counting upper and lower subscapularis separately is predictive of pseudoparalysis.

  • Shoulder equator concept: loss of all three posterior, or all three superior, or all three anterior muscle–tendon units is predictive of pseudoparalysis (loss of fulcrum for deltoid force).

  • Every effort should be made to prevent propagation of rotator cuff tears into the subscapularis and posterior rotator cuff (infraspinatus and teres minor) to maintain force couple balance (value of partial cuff repair).

  • Clinical assessment of active forward elevation, active external rotation, and active internal rotation is important to define and grade the severity of loss of force couple balance.

  • Additional features such as patient age, traumatic aetiology, chronicity, fatty infiltration, and stage of cuff tear arthropathy are useful for a specific diagnosis with implications for treatment.

Jonathon C Coward, Stefan Bauer, Stephanie M Babic, Charline Coron, Taro Okamoto, and William G Blakeney

  • Decision-making for the treatment of pseudoparalytic shoulders is complex and a high level of experience in shoulder surgery and outcome evaluation is required.

  • Management and results depend on clinical findings, tear and tissue quality, patient and surgeon criteria. Clinical findings determine the exact definition and direction of pseudoparesis and pseudoparalysis.

  • Tear pattern and tissue quality determine if the rotator cuff is repairable or irreparable. Age and general health are important patient factors.

  • Non-operative treatment is the first option for patients with a higher risk profile for reconstruction or arthroplasty, but delineation of its value requires better evidence.

  • Tendon transfers are used for irreparable loss of the horizontal force couple balance (rotation). Options include latissimus dorsi, pectoralis minor and major for loss of active internal rotation, and latissimus dorsi ± teres major and lower trapezius for loss of active external rotation (AER).

  • Partial cuff repair with or without superior capsular reconstruction using allograft or biceps tendon is an option for loss of active forward elevation.

  • Treatment for the combined loss of elevation and external rotation patients is still not clear. Options include lateralised reverse shoulder arthroplasty (RSA) alone or combined RSA with a tendon transfer.

  • RSA with loss of AER can be revised by adding a tendon transfer.

Andy Craig, S W King, B H van Duren, V T Veysi, S Jain, and J Palan

  • Use of articular antibiotic-eluting cement spacers during two-stage revision arthroplasty for prosthetic joint infection (PJI) is a long-established and proven adjunctive technique during first-stage surgery. Articular spacers come in many forms, either static or dynamic. The authors present an instructional review of current evidence regarding their use.

  • A total of 45 studies (for spacer use in PJI involving either hip or knee) were analysed for data regarding eradication rate, functional outcomes, mechanical complications and the impact on second-stage surgery. A large number of case series and retrospective cohort studies were retrieved, with only a small number of prospective studies (2).

  • High levels of infection eradication were commonly reported (>80%). Outcome scores were commonly reported as indicating good-to-excellent function and pain levels. Second-stage procedures were often not required when dynamic spacers were used. Static spacers were associated with more mechanical complications in both the hip and the knee. In the hip, dynamic spacers were more commonly associated with instability compared to static spacers. Consideration should be given to the use of dual-mobility or constrained definitive acetabular components in these cases at second-stage surgery.

  • The use of antibiotic-eluting polymethylmethacrylate articular spacers in two-stage revision for PJI of hip and knee arthroplasty achieves a high rate of infection eradication. Dynamic spacers may confer a variety of benefits compared to static spacers, with a similar rate of infection eradication.

Hua Luo, Yu Ren, Yongwei Su, Feng Xue, and Zhenghua Hong

  • The purpose of the study was to evaluate the effect of local application of vancomycin powder (VP) to prevent surgical site infections (SSIs) after posterior spine surgery.

  • A comprehensive search of Web of Science, EMBASE, Pubmed, Ovid, and Cochrane Library databases for articles published was performed to collect comparative studies of intrawound vancomycin in posterior spine surgery before March 2021. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed the study quality, and extracted the data. Revman 5.4 software was used for data analysis.

  • A total of 22 articles encompassing 11 555 surgical patients were finally identified for meta-analysis. According to the information provided by the included literature, the combined odds ratio showed that topical use of VP was effective for reducing the incidence of SSIs (P< 0.00001) after posterior spine surgery without affecting its efficacy in the treatment of deep infections (P< 0.00001). However, there is no statistical significance in superficial infections. In a subgroup analysis, VP at a dose of 1, 2, and 0.5–2 g reduced the incidence of spinal SSIs. The result of another subgroup analysis suggested that local application of VP could significantly reduce the risk of SSIs, whether it was administered after posterior cervical surgery or thoracolumbar surgery. Moreover, the percentage of SSIs due to gram-positive germs (P< 0.00001) and MRSA (P< 0.0001) could reduce after intraoperative VP was used, but did not significantly reduce to gram-negative germs.

  • The local application of VP appears to protect against SSIs, gram-positive germs, and MRSA (methicillin-resistant Staphylococcus aureus) infections after the posterior spinal operation.

Jonny K Andersson, Pelle Gustafson, and Philippe Kopylov

  • Misdiagnosed and maltreated scaphoid fractures filed to the Swedish National Patient Insurance Company (LÖF) 2011–2018 were analyzed in terms of complications and costs for society. All filed claims are database-registered (altogether 200 000 claims since 2000). This database was assessed in June 2019 through injury ICD10-SWE-diagnoses. Demographics, complications, complaints, corrective surgeries and costs were analyzed. The numbers of claims for scaphoid fractures were reviewed and compared with all claims.

  • There was a statistically significant trend towards decreasing numbers of notified scaphoid fracture cases during this time. This is not the case compared with the total annually notified injuries to LÖF during the same time, where we instead can see statistically significant increased numbers.

  • Median age for the 128 patients was 24 years. Men represented 76%. Seventy-eight of the 128 (61%) claims were judged as avoidable, compared with 42% in terms of all notified injuries. Pseudoarthrosis dominated as complication (n  = 71). Total numbers of complications were 117, and 47 of the 78 patients had medical invalidity as a consequence. Up to six secondary corrective surgeries per patient were required. Complications and disabilities were more severe if patients needed more than one surgery. The total costs were calculated to €1 226 193.

  • Level of Evidence: LoE III, Therapeutic.

K Venkatadass, V Durga Prasad, Nasser Mohammed Mansor Al Ahmadi, and S Rajasekaran

  • Acetabular dysplasia is a significant problem in the spectrum of developmental dysplasia of hip. In a younger child, positioning the femoral head into the acetabulum helps in reciprocal remodeling of the acetabulum and correction of dysplasia. In an older child, the remodeling potential is limited and often the acetabular dysplasia needs surgical intervention in the form of a pelvic osteotomy.

  • Thus, pelvic osteotomy forms an integral part of surgical management of hip dysplasia. The ultimate goal of these osteotomies is to preclude or postpone the development of osteoarthritis and add more years of life to the native hip.

  • Pelvic osteotomies play a pivotal role in normalizing hip morphology. The choice of pelvic osteotomy depends on the age of a child, the type of dysplasia and the status of the tri-radiate cartilage.

  • Several types of re-directional and reshaping pelvic osteotomies have been described in the literature to improve the stability and restore the anatomy and biomechanics of the dysplastic hip.

  • This article attempts to review the current indications for various pelvic osteotomies with a brief description of their techniques along with the outcomes and complications published thus far. Besides, the guidelines to choose the right pelvic osteotomy are also provided.

Theofilos Karachalios, Katre Maasalu, and Li Felländer-Tsai

  • Orthopaedic and trauma surgeons performing surgery in the COVID-19 pandemic environment faced problems with availability, use, rationing, modification, compliance and recycling of personal protection equipment (PPE).

  • Orthopaedic and trauma surgeons were not well informed concerning the use of PPE for aerosol-generating orthopaedic and trauma procedures.

  • Scientific bodies, health authorities and management have provided insufficient guidelines for the use of PPE in aerosol-generating orthopaedic and trauma procedures.

  • The availability of specific PPE for orthopaedic and trauma operating theatres is low.

  • Hospital management and surgeons failed to address the quality of operating theatre ventilation or to conform to recommendations and guidelines.

  • Operating theatre PPE negatively affected surgical performance by means of impaired vision, impaired communication, discomfort and fatigue.

  • Existing PPE is not adequately designed for orthopaedic and trauma surgery, and therefore, novel or modified and improved devices are needed.