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E. Carlos Rodríguez-Merchán and Inmaculada Moracia-Ochagavía

  • Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches.

  • It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic.

  • There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG).

  • A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma.

  • Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema).

  • Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment.

  • Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%.

  • Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible.

  • A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression.

  • Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology.

Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031

Joshua B.V. Smith, Habeeb Bishi, Chao Wang, Vipin Asopa, Richard E. Field, and David H. Sochart

  • The purpose of this study was to compare the accuracy and the inter- and intra-observer reliability of preoperative digital 2D templating in prosthesis size prediction for the planning of cemented or uncemented THA.

  • This study was registered in the NIHR PROSPERO database (ID: CRD42020216649) and conducted according to the PRISMA guidelines. A search of electronic databases in March 2021 found 29 papers overall. The quality of evidence was assessed using the IHE Quality Appraisal of Case Series Studies Checklist and the CASP Randomised Controlled Trials Checklist. A meta-analysis was conducted, and the accuracy was presented as proportions and the inter- and intra-observer reliability were measured using intraclass correlation coefficients (ICC).

  • Accuracy within one prosthesis size (±1) for cemented stems was 0.89 (95% confidence interval (CI) 0.83–0.95), cemented cups 0.78 (95% CI 0.67–0.89), uncemented stems 0.74 (95% CI 0.66–0.82) and uncemented cups 0.73 (95% CI 0.67–0.79) (test of group differences: p = 0.010). Inter-observer reliability (ICC) for uncemented cups was 0.88 (95% CI 0.85–0.91), uncemented stems 0.86 (95% CI 0.81–0.91), cemented stems 0.69 (95% CI 0.54–0.84) and cemented cups 0.68 (95% CI 0.55–0.81) (test of group differences: p = 0.004). Due to lack of data, intra-observer reliability (ICC) could only be calculated for uncemented prostheses, which for the stems was 0.90 (95% CI 0.88–0.92) and for the cups was 0.87 (95% CI 0.83–0.90) (test of group differences: p = 0.124).

  • The accuracy of preoperative digital templating is greater for cemented prostheses, but the inter-observer reliability is greater for uncemented prostheses. The intra-observer reliability showed a high level of agreement for uncemented prostheses.

Cite this article: EFORT Open Rev 2021;6:1020-1039. DOI: 10.1302/2058-5241.6.210048

Keith Tucker, Klaus-Peter Günther, Per Kjaersgaard-Andersen, Jörg Lützner, Jan Philippe Kretzer, Rob G.H.H. Nelissen, Toni Lange, and Luigi Zagra

  • Off-label use is frequently practiced in primary and revision arthroplasty, as there may be indications for the application of implants for purposes outside the one the manufacturers intended.

  • Under certain circumstances, patients may benefit from selective application of mix & match. This can refer to primary hip arthroplasty (if evidence suggests that the combination of devices from different manufacturers has superior results) and revision hip or knee arthroplasty (when the exchange of one component only is necessary and the invasiveness of surgery can be reduced).

  • Within the EFORT ‘Implant and Patient Safety Initiative’, evidence- and consensus-based recommendations have been developed for the safe application of off-label use and mix & match in primary as well as revision hip and knee arthroplasty.

  • Prior to the application of a medical device for hip or knee arthroplasty off-label and within a mix & match situation, surgeons should balance the risks and benefits to the patient, obtain informed consent, and document the decision process appropriately.

  • Nevertheless, it is crucial for surgeons to only combine implants that are compatible. Mismatch of components, where their sizes or connections do not fit, may have catastrophic effects and is a surgical mistake.

  • Surgeons must be fully aware of the features of the components that they use in off-label indications or during mix & match applications, must be appropriately trained and must audit their results.

  • Considering the frequent practice of off-label and mix & match as well as the potential medico-legal issues, further research is necessary to obtain more data about the appropriate indications and outcomes for those procedures.

Cite this article: EFORT Open Rev 2021;6:982-1005. DOI: 10.1302/2058-5241.6.210080

Maria Anna Smolle, Lukas Leitner, Nikolaus Böhler, Franz-Josef Seibert, Mathias Glehr, and Andreas Leithner

  • This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

  • A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

  • Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

  • Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

Maximilian M. Menger, Benedikt J. Braun, Steven C. Herath, Markus A. Küper, Mika F. Rollmann, and Tina Histing

  • Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.

  • The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.

  • The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.

  • Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.

  • There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.

  • Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome.

Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034

Olivier Courage, Louise Strom, Floris van Rooij, Matthieu Lalevée, Donatien Heuzé, Pierre Emanuel Papin, Michael Butnaru, and Jacobus Hendrik Müller

  • The purpose of this systematic review was to synthesize studies published since the last systematic review in 2015 that compare outcomes of primary total knee arthroplasty (TKA) in older patients (≥ 80 years) and in younger patients (< 80 years), in terms of complication rates and mortality.

  • An electronic literature search was conducted using PubMed, Embase®, and Cochrane Register. Studies were included if they compared outcomes of primary TKA for osteoarthritis in patients aged 80 years and over to patients aged under 80 years, in terms of complication rates, mortality, or patient-reported outcomes (PROs).

  • Thirteen studies were eligible. Surgical complications in older patients ranged from 0.6–21.1%, while in younger patients they ranged from 0.3–14.6%. Wound complications in older patients ranged from 0.5–20%, while in younger patients they ranged from 0.8–22.0%. Medical complications (cardiac, respiratory, thromboembolic) in older patients ranged from 0.4–17.3%, while in younger patients they ranged from 0.2–11.5%.

  • Mortality within 90 days in older patients ranged between 0–2%, while in younger patients it ranged between 0.0–0.03%.

  • Compared to younger patients, older patients have higher rates of surgical and medical complications, as well as higher mortality following TKA. The literature also reports greater length of stay for older patients, but inconsistent findings regarding PROs. The present findings provide surgeons and older patients with clearer updated evidence, to make informed decisions regarding TKA, considering the risks and benefits within this age group. Patients aged over 80 years should therefore not be excluded from consideration for primary TKA based on age alone.

Cite this article: EFORT Open Rev 2021;6:1052-1062. DOI: 10.1302/2058-5241.6.200150

E. Carlos Rodríguez-Merchán, Primitivo Gómez-Cardero, and Carlos A. Encinas-Ullán

  • The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic.

  • Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves).

  • A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years.

  • Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%.

  • The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively.

Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007

Marko Nabergoj, Patrick J. Denard, Philippe Collin, Rihard Trebše, and Alexandre Lädermann

  • The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.

  • The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.

  • Zumstein et al defined a ‘complication’ following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient’s final outcome.

  • High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.

  • Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture.

Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039

Pietro Feltri, Camilla Mondini Trissino da Lodi, Alberto Grassi, Stefano Zaffagnini, Christian Candrian, and Giuseppe Filardo

  • To compare one-stage vs. two-stage bilateral unicondylar knee arthroplasty (UKA) in terms of complications, mortality, reinterventions, transfusion rate, days to discharge, and outcomes for the treatment of bilateral mono-compartmental knee osteoarthritis.

  • A systematic review was performed in the PubMed, Web of Science, and Cochrane databases up to February 2021. Randomized controlled trials, case-control studies, and case series describing the use of bilateral UKA were retrieved. A meta-analysis was performed on complications, mortality, reinterventions, transfusion rate, and days to discharge comparing one-stage vs. two-stage replacement, and outcomes were also reported. Assessment of risk of bias and quality of evidence was performed with the Newcastle-Ottawa Scale.

  • Fifteen articles were included on 1451 patients who underwent bilateral UKA (44.9% men, 55.1% women, mean age 66 years). The systematic review documented, for bilateral one-stage UKA: 2.6% major and 5.4% minor complication rates, 0.5% mortality, 1.9% reintervention, 4.1% transfusion rates, and 4.5 mean days to discharge. No studies reported functional differences. The meta-analysis did not find differences for major complications, minor complications, mortality, reintervention, transfusion rates, or days to discharge versus two-stage bilateral procedures. The operative time was 112.3 vs. 125.4 minutes for one-stage and two-stage surgeries, respectively. The overall quality of the retrieved studies was high.

  • Bilateral single-stage UKA is a safe procedure, with a few complications, and overall positive clinical results. No differences were found in terms of complications, mortality, reinterventions, transfusion rate, and days to discharge in comparison with the two-stage approach.

Cite this article: EFORT Open Rev 2021;6:1063-1072. DOI: 10.1302/2058-5241.6.210047

Marko Nabergoj, Patrick J. Denard, Philippe Collin, Rihard Trebše, and Alexandre Lädermann

  • Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.

  • A ‘problem’ is defined as an intraoperative or postoperative event that is not likely to affect the patient’s final outcome, such as intraoperative cement extravasation and radiographic changes. A ‘complication’ is defined as an intraoperative or postoperative event that is likely to affect the patient’s final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.

  • Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.

  • High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.

  • The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient’s final outcome, and their prevalence has dramatically decreased.

  • With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications.

Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040