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Published by Suomen Ortopedia ja Traumatologia -julkaisut, 2022-03-03 09:05:38

Suomen Ortopedia ja traumatologia - 45. julkaisu 1/2022

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Keilektomia
Keilektomia tarkoittaa nivelen liikelaajuuden paran- tamiseen ja kivun vähentämiseen tähtäävää osteo- fyyttien poistoa. Leikkaus kohdistuu etenkin dor- saalisesti ja MT I luun distaalipään dorsaalista osaa voi poistaa 30% asti, jotta nivelen stabiliteetti ei vaa- rannu. Samalla poistetaan muut osteofyytit nivelen ympäriltä ja mahdolliset irtokappaleet. Kiristäviä kapselirakenteita vapautetaan nivelen ympäriltä. Keilektomia on relatiivisen yksinkertainen toimenpide, josta toipuminen on nopeaa ja komplikaatiot harvinaisia. (22) Keilektomian on todettu auttavan hyvin gradus 1-2 hallux rigidus, jopa gradus 3 potilaille. (23) Keilektomia ei kuitenkaan estä taudin progressiota. Uusiin leikkauksiin kuten artrodeesiin ei toisaalta ole esteitä.
Osteotomiat
Osteotomialla pyritään kivun hoitoon muuttamalla nivelpintojen suhdetta toisiinsa. Osteotomioita on kuvattu tehtävän sekä proksimaali- että distaalipuo- lelle niveltä. Ehkä tunnetuin osteotomia on Mober- gin osteotomia, jossa proksimaaliphalangiin tehdään sulkevan kiilan dorsaalinen osteotomia kääntäen proksimaaliphalangin tyven nivelpintaa dorsaali- suuntaan parantaen dorsifleksiota. Samalla saadaan yleensä paremmin säilynyt plantaarinen nivelpinta esiin ja tehtyä dekompressiota nivelpintojen välille. Toisaalta plantaarifleksio heikkenee. Kun 81 gradus 3 hallux rigidus -potilaalle tehtiin Mobergin osteotomia liitettynä keilektomiaan, 4,3 vuoden seurannassa tyytyväisyysaste oli 85,2% ja 4,9% päätyi artrodeesiin seuranta-aikana. (24)
Artrodeesi
Artrodeesiä pidetään pitkälle edenneen hallux rigidus taudin ”gold standard” hoitona. Luudutuksessa osteofyytit ja kaikki rustopinnat poistetaan ja MT I luu liitetään proksimaaliphalangiin. Parhaasta luita yhteen liittävästä fiksaatiomenetelmästä ei ole tason 1 tai 2 näyttöä. Kadaaverimalleilla vahvimmaksi fiksaatioksi on osoittautunut vetoruuvin ja dorsaa- lisen levytyksen yhdistelmä. (25) Artrodeeseistä on raportoitu alle 5% komplikaatioita. Toisaalta luu- tumattomuutta on raportoitu jopa 20 %:lla. (20) Suurimmalle osalle potilaista artrodeesi auttaa hyvin
kivun hoitoon, mutta operaation huonoja puolia ovat jäykkyys, kenkäongelmat, pitkä toipumisaika ja metatarsalgia. (14-16) Artrodeesi on kirjallisuu- dessa osoittautunut artroplastiaa paremmaksi kivun hoidossa, komplikaatioiden vähyydessä, funktionaa- lisissa tuloksissa, lyhyenä sairaalahoitona ja lyhyenä paluuna normaali aktiviteetteihin. (15) MTP I artrodeesi on yleinen leikkaus ja niitä tehdään Suomes- sa vuosittain n. 20/100 000 (Finnish National Hos- pital Discharge Registry).
Artroplastia
Jotta kuluneen nivelen liike säilyisi tai jopa paranisi, isovarpaaseenkin on kehitetty tekoniveliä. Teko- niveliä on kehitetty MTP I niveleen sekä kokote- konivelenä että puolitekonivelenä. Puolitekoniveliä on kehitetty sekä phalangin proksimaalipäähän että metatarsaaliluun distaalipäähän. Kokotekoniveliä on verrattu RCT työssä artrodeesin kanssa ja artrodee- siryhmällä oli paremmat kliiniset tulokset, vähem- män kipua, vähemmän komplikaatiota ja vähem- män uusintaleikkauksia. (31) Tekonivelratkaisuja on vaivannut implanttien irtoaminen ja osteolyysi. Tekonivelleikkauksiin liittyvä luun reilu resektio aiheuttaa ongelman mahdollisessa myöhäisemmässä konversioleikkauksessa luudutukseen. Kun isovar- paan tyvinivelen kokotekoniveliä verrattiin puoli- tekoniveliin, kokotekonivelien tulokset olivat huo- nompia sekä liikelaajuudessa että postoperatiivisissa AOFAS pisteissä. (26)
Resektio artroplastia
Klassinen resektio artroplastia on Kellerin artroplastia, jossa resekoidaan proksimaaliphalngin tyviosa laajasti, jotta kuluneet nivelpinnat eivät enää koskisi toisiaan ja liike paranisi. Ongelmaksi on muodostunut nivelen epästabiilisuus, isovarpaaseen kehit- tyvä cock-up virheasento ja metatarsalgia muussa päkiässä. Keller artroplastiaa voidaan suositella vain matalan vaatimustason potilaille. (27)
Interpositio artroplastia
Resektio artroplastian resektion pienentämiseksi on kehitetty erilaisia biologisia spacereita nivelraon täyttämiseksi. Uutena implanttina on markkinoil- la metatarsaaliluun päähän asetettava synteettisen
Suomen Ortopedia ja Traumatologia Vol. 45
1 • 2022 SOT 49

ruston implantti, joka tulee kuluneen nivelen nivel- rakoon spaceriksi. Etuna on vähäinen luun resektio ajatellen tulevia mahdollisia luudutusleikkauksia. 202 potilaan RCT työssä verrattiin tätä implanttia artrodeesiin 2 vuoden seurannassa ja tulos oli lähes yhtä hyvä. (13)
Pohdinta
Hallux rigiduksen hoitoa käsittelevissä tutki- muksissa löytyy vain kaksi randomisoitua työtä, joissa kummassakin artrodeesi oli hoitomuotona parempi kuin tekonivel tai interpositio artroplastia. Suuri osa töistä on tehty pienillä potilasmää- rillä ja tutkimusten taso on heikkoa. Konservatii- vinen hoito on ensisijainen hoitomuoto. Luokkien 1-2 hallux rigidus potilailla keilektomia tai osteotomia ovat konservatiivisen hoidon epäonnistuttua vaihtoehtoja. Luokkien 3-4 potilailla artrodeesi on muodostunut perustellusti gold standard hoidoksi, mutta artrodeesinkaan tehoa ei ole vielä osoitettu randomisoidussa kokeessa. HYKS ortopedian kli- nikassa on vastikään aloitettu prospektiivinen ran- domisoitu tutkimus, jossa hallux rigiduksen gold standard -hoitoa eli artrodeesiä verrataan konserva- tiiviseen hoitoon vuoden seurannassa. (28)
Lähdeluettelo
1. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2003 Oct;24(10):731–43.
2. Brage ME, Ball ST. Surgical options for salvage of end-stage hallux rigidus. Foot Ankle Clin. 2002;7(1):49-73.
3. Giannini S, Ceccarelli F, Faldini C, et al. What’s new in surgical options for hallux rigidus? J Bone Joint Surg Am. 2004;86-A Suppl 2:72–83.
4. Lucas DE, Hunt KJ. Hallux Rigidus Relevant Anatomy and Pathophysiology. Foot Ankle Clin. 2015;20(3):381–89.
5. Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev. 2017;2(1):13–20.
6. Grady JF, Axe TM, Zager EJ, et al. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc. 2002;92(2):102–8.
7. Kunnasegaran R, Thevendran G. Hallux Rigidus Nonoperative Treatment and Orthotics. Foot Ankle Clin. 2015;20(3):401–12.
8. Zammit G V., Menz HB, Munteanu SE, et al. Inter- ventions for treating osteoarthritis of the big toe joint. Cochrane Database Syst Rev. 2009;(2).
9. Zammit G V, Menz HB, Munteanu SE, et al. Interventions for treating osteoarthritis of the big toe joint. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007809.
10. Smith RW, Katchis SD, Ayson LC. Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int. 2000;21(11):906–13.
11. Munteanu SE, Zammit G V., Menz HB, et al. Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: A randomised placebo-controlled trial. Ann Rheum Dis. 2011;70(10):1838–41.
12. Gibson JNA, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: A randomized controlled trial. Foot Ankle Int. 2005;26(9):680–90.
13. Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus. Foot Ankle Int. 2016;37(5):457–69.
14. McNeil DS, Baumhauer JF, Glazebrook MA. Evi- dence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013;34(1):15–32.
15. Yee G, Lau J. Current concepts review: Hallux rigidus. Foot Ankle Int. 2008;29(6):637–46.
16. Fitzgerald JA, Wilkinson JM. Arthrodesis of the metatarsophalangeal joint of the great toe. Clin Orthop Relat Res. 1981;(157):70–7.
17. Gould N, Schneider W, Ashikaga T. Epidemiological survey of foot problems in the continental United States: 1978-1979. Foot Ankle. 1980;1:8–10.
18. Coughlin MJ, Shurnas PS. Hallux Rigidus - Grading and Long-Term Results of Operative Treatment. J Bone Joint Surg Am. 2003;83(11):2072-2088.
19. Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br. 2001;83:706–708.
20. Pons M, Alvarez F, Solana J, Viladot R, Varela L. Sodium hyaluronate in the treatment of hallux rigidus. A single-blind, randomized study. Foot Ankle Int 2007;28:38-42.
21. Lam A, Chan JJ, Surace MF, Vulcano E. Hallux rigidus: How do I approach it? World J Orthop. 2017 May 18; 8(5): 364–371
22. Bussewitz BW, Dyment MM, Hyer CF. Intermedi- ate-term results following first metatarsal cheilectomy. Foot Ankle Spec. 2013;6:191–195.
23. Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg Am. 2004;86 A Suppl 1(Pt 2):119–30.
24. O'Malley MJ, Basran HS, Gu Y, Sayres S, Deland JT. Treatment of advanced stages of hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am. 2013;95:606–610.
25. Politi J, Hayes J, Njus G, et al. First metatarsal-phalangeal joint arthrodesis: A biomechanical assessment of stability. Foot Ankle Int. 2003;24(4):332–7.
26. Stibolt RD, Harshadkumar AP, Lehtonen EJ et al. Hemi- arthroplasty versus total joint arthroplasty for hallux rigidus:
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A systematic review and meta-analysis. Foot Ankle Spec. 2019;12:181-193.
27. Schneider W, Kadnar G, Kranzl A, Knahr K. Long-term results following Keller resection arthroplasty for hallux rigidus. Foot Ankle Int. 2011;32:933–939.
28. Miettinen M et al. Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint. BMJ Open 2021;11:e049298. doi: 10.1136/ bmjopen-2021-04929.
29. Shereff MJ, Bejjani FJ, Kummer FJ. Kinematics of the first metatarsophalangeal joint. J Bone Joint Surg [Am] 1986;68- A:392-398.
30. Hamid KS, Parekh SG. Clinical Presentation and Management of Hallux Rigidus. Foot Ankle Clin. 2015;20:391–399.
31. Stevens J, de Bot R, Hermus JP, van Rhijn LW, Witloks AM. Clinical Outcome Following Total Joint Replacement and Arthrodesis for Hallux Rigidus A Systematic Review. J Bone Joint Surg Reviews 2017;5(11):e2
32. Beeson P et al. Classification systems for hallux rigidus: a review of the literature. Foot and Ankle Int 2008;29(4):407- 14.
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The role of primary hip arthroplasty in acetabular fracture surgery
A. Gänsslen
Wolfsburg General Hospital, Department of Traumatology, Orthopedics and Hand Surgery. email: dr.gaensslen@gmx.de
Acetabular fractures in elderly patients are of up-co- ming relevance. For example, Ferguson et al. observed an increase of the proportion of these patients from 10% during 1980-1993 to 25% between 1994 and 2007 [12]. Treatment decision can be difficult in this age group as the reduced bone quality makes operative procedures more demanding.
Fracture Characteristics
The fracture characteristics in the elderly patient differs from younger patients [1,10,12,13,17,24,25]. In the elderly, a higher variability of the fracture pattern is present [14,24].
Due to the age-related restricted bone quality, the integrity of the main load zone at the superior acetabulum and the quadrilateral surface is of major importance to avoid relevant subluxation or protrusion of the femoral head [1,9,19]. Consequently, in elderly patients, marginal impactions are frequently observed involving the acetabular roof. Anglen et al. defined the radiological visible "gull sign" corresponding to superior marginal impactions [1]. It was identified as a relevant risk factor for rapidly progredient development of posttraumatic osteoarthritis [1,18,30]. Anglen stated that the presence of a „gull sign“ was 100% predictive for a secondary displacement [1].
Additional injury to the femoral head was observed in up to 30% of acetabular fractures in the elderly, with 4% of the cases showing an accompanying femoral head fracture (Pipkin fracture) [6].
Fractures involving the anterior column (especially associated anterior column plus posterior hemit- ransverse fractures) are typical fracture types in the elderly population. A reduced bone quality leads to a higher proportion of superior-medial marginal im-
pactions and of quadrilateral surface fractures.
Treatment Indications
Especially in elderly patients, comorbidities play an important role for treatment decision. There is a large variety between active "best-agers" to immobile high-aged patients. The "biological age" and the activity level before the injury form the basis for treatment decision. Many patients are in a reduced general condition. Comorbidities such as metabolic diseases, cardiovascular diseases, obesity and the presence of osteoporosis significantly influences the choice of treatment [12,22,24,30].
Treatment options include conservative treatment, percutaneous screw osteosynthesis, open reduction and internal fixation with screws and plates as well as prosthetic joint replacement with and without additional osteosynthesis [6,13,14,22,24].
In the presence of relevant primary cartilage injury to the femoral head or pre-existing, symptomatic co- xarthrosis, joint reconstructions are associated with poorer outcome. Thus, primary joint replacement is recommended in these patients [30,31].
The "biological age" of the patient plays a crucial role in treatment decision. The primary aim also in elderly patients is the anatomic acetabular reconstruction. Indications for a conservative treatment protocol and primary prosthetic replacement should be considered.
Operative Treatment
Surgical joint reconstruction should be favored in all unstable or displaced fractures with involvement of the weight bearing acetabular roof.
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The primary aim of surgery is the anatomical reconstruction of the joint surface and stabilization of the main weight bearing areas of the acetabulum. Especially the stable connection between the anterior and posterior column is the prerequisite of adequate weight bearing.
ORIF in the elderly is accompanied with up to 20% severe and 40% mild complications. Posttrau- matic degenerative joint changes occur in 6-31%.
Fractures with femoral head cartilage damage or a comminution at the superior-medial acetabular dome constitute a special treatment challenge [7,11,16,20,27]. Patients with preexisting degenerative joint changes can benefit from primary joint replacement [2-4,7,15,16]. Timing and tactical operative procedure can be difficult. Recommendations from the literature are inconsistent. Especially in older patients, limited mobility is associated with a significant risk of morbidity. A 2-step procedure doubles the time interval of restricted daily activities compared to an increased morbidity and mortality risk one-time procedure with primary hip replacement.
Primary Endoprosthetic Replacement
Primary endoprosthetic replacement in acetabular fractures is a complex procedure [11]. The integrity or stable connection between both, the anterior and posterior column, is the prerequisite for optimal results [4]. Fixation of the anterior column against the posterior column is required to allow stable cup fixation and ensure adequate weight bearing. The chosen approach is based on fracture morphology. The Kocher-Langenbeck approiach offers an optimal approach for primary endoprosthetic replacement together with plate fixation ofthe posterior column, whereas fracture treatment and prosthetic replacement via a pure anterior approach is more challenging.
Chakravarty et al. reported results using a combination of percutaneous screw osteosynthesis and primary total hip arthroplasty (THA) via a posterior approach. A lower blood loss of about 700ml (220- 1800 ml) was observed compared to a combined anterior-posterior stabilization with endoprosthetic replacement [7].
In the presence of acetabular comminution zones, without sufficient bony support for an- choring of a standard cup, tri-flanged system, e.g. a
Suomen Ortopedia ja Traumatologia Vol. 45
Burch-Schneider ring, should be considered [27]. An autologous or homologous bone graft can be necessary to support the implant [11,27,28]. Additional- ly, the use of "trabecular metal" implants for filling bone defects in primary THA is reported [8]. A recent analysis observed promising short-term results using porous metal acetabular components [29].
The main advantage of primary THA is the pos- sibility of immediate full weight [25]. A comparative study by Sermon et al. reported only 58% patients with a good to excellent functional result after primary THA analyzed using the Harris Hip Score, whereas pateints with secondary THA had 76% good to excellent results [26]. Accordingly, the indication for primary THA should be in narrow limits [11].
Overall, recent results of primary THA are encouraging. Tidermark et al. reported 60% good results after primary implantation of a Burch-Schnei- der ring in combination with autologous bone tran- splantation [27], despite a dislocation rate of 30%. The functional result, based on the Harris Hip Score, was good to excellent with an average of 84.6 points.
Results of combined osteosynthesis with THA show high rates of good and excellent results. Mears et al. reported 79% good functional results, becoming worse with increasing age [21]. Moush- ine et al. observed 87% cup migrations without other signs of loosening and reported 94% good clinical results [23]. Boraiah et al. reported 81% good clinical results without radiological signs of cup loosening [5].
Primary THA with combined osteosynthesis offer a acceptable complication rates and low cup loosening rate in selected patients. The main indication for primary THA is based on acetabular comminution zones involving the weight bearing area and concomitant femoral head injury.
References
1. Anglen JO, Burd TA, Hendricks KJ and Harrison P. The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures. J Orthop Trauma, 2003. 17: 625-34.
2. Beaule PE, Griffin DB and Matta JM. The Levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture. J Orthop Trauma, 2004. 18: 623-9.
3. Bellabarba C, Berger RA, Bentley CD, Quigley LR, Jacobs 1 • 2022 SOT 53

JJ, Rosenberg AG, Sheinkop MB and Galante JO. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am, 2001. 83-A: 868-76.
4. Berry DJ. Total hip arthroplasty following acetabular fracture. Orthopedics, 1999. 22: 837-9.
5. Boraiah S, Ragsdale M, Achor T, Zelicof S and Asprinio DE. Open reduction internal fixation and primary total hip arthroplasty of selected acetabular fractures. J Orthop Trauma, 2009. 23: 243-8.
6. Carroll EA, Huber FG, Goldman AT, Virkus WW, Pagenkopf E, Lorich DG and Helfet DL. Treatment of acetabular fractures in an older population. J Orthop Trauma, 2010. 24: 637-44.
7. Chakravarty R, Toossi N, Katsman A, Cerynik DL, Harding SP and Johanson NA. Percutaneous column fixation and total hip arthroplasty for the treatment of acute acetabular fracture in the elderly. J Arthroplasty, 2014. 29: 817-21.
8. Chana-Rodriguez F, Villanueva-Martinez M, Ro- jo-Manaute J, Sanz-Ruiz P and Vaquero-Martin J. Cup-cage construct for acute fractures of the acetabulum, re-defining indications. Injury, 2012. 43 Suppl 2: S28-32.
9. Culemann U, Holstein JH, Kohler D, Tzioupis CC, Pizanis A, Tosounidis G, Burkhardt M and Pohlemann T. Different stabilisation techniques for typical acetabular fractures in the elderly--a biomechanical assessment. Injury, 2010. 41: 405-10.
10. Daurka JS, Pastides PS, Lewis A, Rickman M and Bircher MD. Acetabular fractures in patients aged > 55 years: a systematic review of the literature. Bone Joint J, 2014. 96-B: 157-63.
11. De Bellis UG, Legnani C and Calori GM. Acute total hip replacement for acetabular fractures: a systematic review of the literature. Injury, 2014. 45: 356-61.
12. Ferguson TA, Patel R, Bhandari M and Matta JM. Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. J Bone Joint Surg Br, 2010. 92: 250-7.
13. Gänsslen A. [Biomechanical principles for treatment of osteoporotic fractures of the pelvis]. Unfallchirurg, 2010. 113: 272-80.
14. Guerado E, Cano JR and Cruz E. Fractures of the acetabulum in elderly patients: an update. Injury, 2012. 43 Suppl 2: S33-41.
15. Henry PD, Kreder HJ and Jenkinson RJ. The osteoporotic acetabular fracture. Orthop Clin North Am, 2013. 44: 201-15.
16. Herscovici D, Jr., Lindvall E, Bolhofner B and Scaduto JM. The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly. J Orthop Trauma, 2010. 24: 291-6.
17. Hill BW, Switzer JA and Cole PA. Management of high-energy acetabular fractures in the elderly individuals: a current review. Geriatr Orthop Surg Rehabil, 2012. 3: 95-106.
18. Laflamme GY and Hebert-Davies J. Direct reduction technique for superomedial dome impaction in geriatric acetabular fractures. J Orthop Trauma, 2014. 28: e39-43.
19. Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B and Leduc S. Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate. Injury, 2011. 42: 1130-4.
20. Malhotra R, Singh DP, Jain V, Kumar V and Singh R. Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System: mid term to long term follow-up. J Arthroplasty, 2013. 28: 1005-9.
21. Mears D and Velyvis J. Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results. J Bone Joint Surg, 2002. 84-A: 1-9.
22. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg, 1999. 7: 128-41.
23. Mouhsine E, Garofalo R, Borens O, Blanc C, Wettstein M and Leyvraz P. Cable fixation and early total hip arthroplasty in the treatment of acetabular fractures in elderly patients. J Arthroplasty, 2004. 19: 344-348.
24. Pagenkopf E, Grose A, Partal G and Helfet DL. Acetabular fractures in the elderly: treatment recommendations. HSS J, 2006. 2: 161-71.
25. Rickman M, Young J, Trompeter A, Pearce R and Hamilton M. Managing acetabular fractures in the elderly with fixation and primary arthroplasty: aiming for early weightbearing. Clin Orthop Relat Res, 2014. 472: 3375-82.
26. Sermon A, Broos P and Vanderschot P. Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003. Injury, 2008. 39: 914-21.
27. Tidermark J, Blomfeldt R, Ponzer S, Soderqvist A and Tornkvist H. Primary total hip arthroplasty with a Burch-Sch- neider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients. J Orthop Trauma, 2003. 17: 193-7.
28. Wang ZM, Sun HZ, Wang AM, Du QY, Wu SY, Zhao YF and Tang Y. Primary total hip arthroplasty for acetabular fracture. Chin J Traumatol, 2006. 9: 341-4.
29. Yuan B, Lewallen D and Hanssen A. Porous Metal Acetabular Components Have a Low Rate of Mechanical Failure in THA After Operatively Treated Acetabular Fracture. Clin Orthop, 2015. 473: 536–542.
30. Zha GC, Sun JY and Dong SJ. Predictors of clinical outcomes after surgical treatment of displaced acetabular fractures in the elderly. J Orthop Res, 2013. 31: 588-95.
31. Zhang L, Zhou Y, Li Y, Xu H, Guo X and Zhou Y. Total hip arthroplasty for failed treatment of acetabular fractures: a 5-year follow-up study. J Arthroplasty, 2011. 26: 1189-93.
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Long-term Outcome of Slipped Capital Femoral Epiphysis
Thomas Schlenzka, MD. Department of Orthopaedics and Traumatology. Helsinki University Hospital, Helsinki, Finland
Introduction
Slipped capital femoral epiphysis (SCFE) is a well-known hip disorder in children. Typically the capital femoral epiphysis displaces posteroin- feriorily. The incidence of SCFE is approximately 10 / 100 000 in children aged 8 to 15 years and boys are more often affected (65% vs. 35%)(1). Also a higher body mass index is associated with a higher risk for SCFE (2). The etiology of SCFE still remains unknown.
Common symptoms for SCFE are limping and pain in the groin, thigh, or knee. Decreased internal rotation of the hip is found in the physical examination. A frog-leg lateral radiograph of the pelvis confirms the diagnosis. For radiographical classification the Slip angle (SA) is measured (Figure 1). A slip angle below 30° is considered mild, whereas a SA between 30° and 50° is moderate. Slip angles above 50° are classified as severe (3, 4). Clinically a diffe- rentiation between stable and unstable slips is made (5). Stable slips allow the patients to bear weight, whereas with unstable slips weightbearing even with crutches is not tolerated.
The gold standard treatment for SCFE is in situ fixation with one or two cannulated screws. For severe slips also open reduction and fixation of the epiphysis is an option (6). Closed reduction may increase the risk for avascular necrosis of the femoral head (7).
Impingement
The slip of the epiphysis leads to deformation of the proximal articular femur, which leads to a cam-type femoroacetabular impingement. This can lead to mechanical damage of the chondrolabral part of the acetabulum and increase the risk for osteoarthritis. After in situ fixation of SCFE some remodeling of the head-neck-junction has been described (8). Arthrosco-
pic osteochondroplasty of the femoral neck after fixation has been used to treat the deformity. Besomi et al reported significant improvement of hip motion, pain and the alpha angle with osteochondroplasty performed at 2 years after initial surgery. However, 91% of patients presented with at least some intra-articular damage (9). As with idiopathic cam lesions, there is no evidence of osteochondroplasty reducing later risk for osteoarthritis.
Avascular Necrosis and Osteoarthritis
Avascular necrosis (AVN) of the femoral head is the most serious early complication in SCFE patients. Unstable SCFE is associated with a significantly higher risk for AVN. Delay of surgery and closed reduction maneuvers may increase this risk. The risk for AVN in stable slips is close to 0% (5, 10).
There are some studies on the long-term risk total hip replacement (THR) after in situ faixtion of SCFE. After mean follow-up times from 16 to 38 years, the incidence for THR has been between 5% and 28% (11, 12, 13, 14). Unpublished data suggests an incidence for THR of 50% after 50 years of follow-up. Female patients seem to carry a two-fold risk for total hip replacement after in situ fixation of SCFE. The risk for THR is strongly associated with the severity of the slip.
The long-term risk for THR after open reduction and fixation methods is not known.
Open surgeries as primary treatment of the more severe slips has been increasingly adopted. In the modified Dunn procedure the epiphysis is anatomically aligned and fixed. The technical diffi- culty of the procedure carries a high rate for AVN. In two-year follow-up studies AVN rates of 0% to 26% have been reported (15). There is no data on THR risk.
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Figure 1 The head-shaft angle (HSA): the angle between femoral axis and a line perpendicular to a line between anterior and posterior lips of the physis. The slip angle (SA) is measured by subtracting the healthy hip HSA (HSAh) from the affected side HSA (HSAs)
Summary
The elevated risk for later osteoarthritis after in situ fixation of SCFE has been shown. Treatment methods especially for severe and unstable slipped capital femoral epiphysis have evolved over the years and realignment procedures are routinely used in some centers. Also the use of arthroscopic osteochondroplasty for cam deformities has been introduced. The effect on the long-term prognosis has to be investigated on in the future.
References
1. Loder RT & Skopelja EN. The Epidemiology and Demographics of Slipped Capital Femoral Epiphysis. ISRN Orthopedics 2011 2011 1–19. (doi:10.5402/2011/486512)
2. Poussa M, Schlenzka D, & Yrjönen T. Body mass index and slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics Part B 2003 12 369–371. (doi:10.1097/00009957-200311000-00003)
3. Loder RT. Slipped capital femoral epiphysis. American family physician 1998 57 2135–2142, 2148–2150.
4. Boyer DW, Mickelson MR, & Ponseti I v. Slipped capital femoral epiphysis. Long-term follow-up study of one hundred and twenty-one patients. The Journal of bone and joint surgery. American volume 1981 63 85–95.
5. Loder RT, Richards BS, Shapiro PS, Reznick LR, & Aronson DD. Acute slipped capital femoral epiphysis: the importance of physeal stability. The Journal of bone and joint surgery. American volume 1993 75 1134–1140. (doi:10.2106/00004623-199308000-00002)
6. Otani T, Kawaguchi Y, & Marumo K. Diagnosis and treatment of slipped capital femoral epiphysis: Recent trends to note. Journal of Orthopaedic Science 2018 23 220–228. (doi:10.1016/j.jos.2017.12.009)
7. Davey S, Fisher T, & Schrader T. Controversies in
the Management of Unstable Slipped Capital Femoral Epiphysis. Orthopedic Clinics of North America 2022 53 51–56. (doi:10.1016/j.ocl.2021.09.003)
8. Reinhardt M, Stauner K, Schuh A, Steger W, & Schraml A. Slipped capital femoral epiphysis: Long-term outcome and remodelling after in situ fixation. HIP International 2016 26 25–30. (doi:10.5301/hipint.5000298)
9. Besomi J, Escobar V, Alvarez S, Valderrama J, Lopez J, Mella C, Lara J, & Meneses C. Hip arthroscopy following slipped capital femoral epiphysis fixation: Chondral damage
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and labral tears findings. Journal of Children’s Orthopaedics 2021 15 24–34. (doi:10.1302/1863-2548.15.200178)
10. Aronsson DD, Loder RT, Breur GJ, & Weinstein SL. Slipped capital femoral epiphysis: Current concepts. Journal of the American Academy of Orthopaedic Surgeons 2006 14 666–679. (doi:10.5435/00124635-200611000-00010)
11. Wensaas A, Svenningsen S, & Terjesen T. Long-term outcome of slipped capital femoral epiphysis: A 38-year follow-up of 66 patients. Journal of Children’s Orthopaedics 2011 5 75–82. (doi:10.1007/s11832-010-0308-0)
12. Castañeda P, Ponce C, Villareal G, & Vidal C. The natural history of osteoarthritis after a slipped capital femoral epiphysis/the pistol grip deformity. Journal of Pediatric Or- thopaedics 2013 33 . (doi:10.1097/BPO.0b013e318277174c)
13. Larson AN, Sierra RJ, Yu EM, Trousdale RT, & Stans AA. Outcomes of Slipped Capital Femoral Epiphysis Treated With In Situ Pinning. Journal of Pediatric Orthopaedics 2012 32 125–130. (doi:10.1097/BPO.0b013e318246efcb)
14. Poorter JJ de, Beunder TJ, Gareb B, Oostenbroek HJ, Bessems GHJM, Lugt JCT van der, Maathuis PGM, & Sande MAJ van der. Long-term outcomes of slipped capital femoral epiphysis treated with in situ pinning. Journal of Children’s Orthopaedics 2016 10 371–379. (doi:10.1007/ s11832-016-0759-z)
15. Mathew SE & Larson AN. Natural History of Slipped Capital Femoral Epiphysis. Journal of Pediatric Orthopaedics 2019 39 S23–S27. (doi:10.1097/BPO.0000000000001369)
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Treatment of Distal Femur Fractures : Retrospective analysis of 299 patients treated with lateral locking plate
Heini Sainio, Lasse Rämö, Jan Lindahl
Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
Distal femur fractures account for 0.4% of all fractures in adults (1). The overall incidence is around 8.7/100,000 person-years (2). The majority of distal femur fractures are fragility fractures occur- ring in women with increasing incidence with age (1,2). In younger patients these fractures occur due to high-energy trauma such as traffic or sport accidents, but even a simple fall causes similar fractures in elderly people (3). A high one-year mortality rate of 25–38% in over 60-year-old patients with distal femur fractures is comparable to the mortality of proximal femur fractures (4-9). The modern operative treatment options for distal femur fractures consist of lateral locking plates and retrograde nailing and sometimes a distal femoral replacement can be a relevant option (10,11).
Modern operative treatment
The best treatment option for distal femur fractures remains unknown. Although lateral locking plates are widely used, there has been concerns for high nonunion risk and associated plate failures (12-15). Several studies report high non-union rates (10– 22%) with modern lateral locking plates (13,14,16- 23). Delayed distal femur fracture healing can lead to mechanical failure of the plate (13,15,24). In a literature review, 75% of implant failures occurred three months after operation due to the plate fatigue secondary to delayed union and continuous movement of the fracture site (15). Two retrospective studies reported the failure rates of 22% and 9% with the variable angle locking distal femur plate (12,13). The plate failures occurred on average 5–6 months after operation in these studies reflecting the probability of nonunion of these fractures 12,13).
The literature shows no differences in healing or nonunion rates between retrograde intramedullary nailing (RIMN) and lateral locked plating of distal femur fractures (25-27). Retrograde nailing is a viable option in extra-articular or simple intra-articular fractures (10). However, lateral locked plating is the only viable option in comminuted or very distal femur fractures not amenable to nailing, or in periprosthetic fractures where the nail does not fit to passage through a knee prosthesis, or the entry point for the nail would be too posterior causing problems with fracture reduction (10). A recent article re- viewed and listed all the knee prosthesis models which allow the nail to passage through the prosthesis (28). To overcome these issues with the retrograde nailing, an advanced retrograde nail (RFN-Ad- vanced, DePuy Synthes) has been developed with more locking options, a greater distal bend in the nail to allow the more posterior entry point with the knee prostheses, and a washer plate for lateral condyle to allow more distal fixation possibilities through the plate and nail. However, clinical studies regarding this new implant are still lacking.
Because of the problems with delayed healing, plate failures, and often osteoporotic bone stock in fragility fractures, most surgeons do not allow early full weight-bearing after the lateral locking plate fixation despite increased immobilization-related morbidity and mortality among elderly. There is some evidence suggesting that the early full weight-bearing should be safe after lateral locked plating (29-30). Because of these immobilization-related concerns, more stable methods allowing full weight-bearing after operation have been described. A combined femoral nail and plate fixation has been reported to have a higher
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union-rate compared with lateral plating only and the technique has enabled full weight-bearing with promising results (31,32). Also, a double plating method has been described to gain a stable fixation in distal femur fractures (33,34).
Distal femoral replacement (DFR) can be a viable option in very distal and severely comminuted fractures, in very osteoporotic bone or fractures with a loose knee prosthesis – especially with elderly patients (10,11). Distal femoral replacement allows early full weight-bearing. Some evidence suggests earlier mobilization after DFR compared with ORIF, and the reoperation rates have been equal (35,36). However, the prosthesis implants have high costs which may exceed the other hospital costs of osteosynthesis of these fractures (37,38). There is still a limited amount of data available in the literature to estimate the right indications for this operation (10).
The recent literature lacks randomized controlled studies comparing lateral locked plating with other modern methods. Two feasibility studies report problems with implementing randomized controlled studies: The first one with plating versus intramedullary nailin (39) and the other one with plating versus distal femoral replacement (37). The goal with the treatment of distal femur fractures should be a stable fixation which–especially among elderly–allows free mobilization with full weight bearing. The patients with high risk for nonunion and plate failure after lateral locked plating may also benefit from other more stable fixation strategies or even distal femoral replacement.
Study methods
of distal femur was defined with a square-method as proposed by Urs Heim (40,41).
We defined a fracture as nonunited, when a patient had a surgical intervention to promote bony union in the fracture site. In addition, a reoperation done for a plate failure at least 3 months after operation and without a new trauma was assumed to occur due to nonunion of the fracture. Fractures were followed up until the radiological or clinical healing.
Preliminary Results
There were totally 619 distal femur fractures treated in Töölö hospital during the study period. The flowchart of all fractures is shown in Table 1. The total amount of AO/OTA A and C-type fractures treated with a lateral locking plate was 380, and 299 of these fractures fulfilled the inclusion criteria. The rate of nonunion was 10% (31/299) and 68% (21/31) of these patients with nonunion had an associated plate failure. The amount of plate failures in this study cohort was 7% (21/299). Plate failures occurred on average 9 months after operation (range 4–36). 75% of the fractures were operated with a monoaxial locking compression plate (LCP) and 25% with a polyaxial LCP. The most used plate was a monoaxial LCP plate with 11 holes (n=93). 73% of the patients were females (217/299) and 59% (176/299) were over 65 years old.
The one-year mortality in the whole patient population treated with lateral locking plates was 17% (66/380), and the one-year mortality in patients over 60 years old was 23% (64/273). The baseline characteristics of the patients treated with a lateral locking plate are in Table 2.
Discussion
The nonunion rate of 10% in patients with distal femur fracture treated with lateral locking plate in Töölö hospital is in line with the reported nonunion rates. Two thirds of patients with nonunion had also a plate failure. The one-year mortality and patient demographics are comparable with the previous literature. Almost half of the patients had a previous implant in the same femur and 1/4 of the patients had a periprosthetic fracture above a knee replacement, which reflects the complexity of the operative treatment. Without any statistical methods used, it
This study is a retrospective cohort study conducted in the Helsinki University Hospital (Töölö Hospi- tal). We identified all patients with a distal femur fracture treated at our institution between 2009 and 2018 using the electronic patient record system.
We included patients aged 16 years or older with traumatic AO/OTA type A or C distal femur fractures treated with a lateral locking plate. Patients with a stress fracture, a pathological fracture, epicondylar or subchondral fracture, or ligament sprains such as ACL, PCL, MCL or LCL avulsion injuries, were excluded. A fracture was classified as a distal femur fracture if a part of the fracture site was located on a metaphyseal area of distal femur. Metaphyseal area
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Table 1. The flowchart of all distal femur fractures
BMI (range) mean
192/268 (72%) 76/268 (28%)
(16.3–47.7) 25.4
Lateral locking plate N=380
Included in the study N=299
Exclusion:
1)No follow-up visits, N=17
2) Death before healing of the fracture, N=57 3) Double plating method, N= 2
4) Atypical plate, N= 4
5) Delay to the operation >1 month, N=1
Distal femur fractures
N=619
AO/OTA A -and C-type fractures N=531
AO/OTA B-type fractures N=88
Operative treatment N=428
Nonoperative treatment N=103
Operative treatment N=59
Cast N=29
Nail Retrograde N=31 Antegrade N=3
Femoral replacement N=5
Femoral amputation N=8
External fixator and later knee arthrodesis N=1
Cast N=93
Death before the final treatment N=10
Table 2. Baseline characteristics of patients treated with a lateral locking plate
Sex
Females Males
25/31 (81%) 6/31 (19%) (22.0–46.7) 30.1
Reoperation due to nonunion Healed fractures N=268 (N=31)
Age (range) mean
(16–106) 68
(26–87) 64
High-energy trauma 9/31 (29%) 6/31 (19%)
55/268 (21%)
Open fractures
26/268 (10%)
AO/OTA classification A1
A2
A3
C1 C2 C3
3 (10%) 12 (39%) 9 (29%) 0 (0%)
1 (3%)
6 (19%) 10/31 (32%)
Knee periprosthetic fracture
67 (25%) 63 (23.5%) 58 (22%) 11 (4%)
30 (11%) 39 (14.5%)
66/268 (25%)
Any previous femur implant 13/31 (42%)
126/268 (47%)
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seems that the patients with nonunion were slightly younger, had more high-energy traumas and open fractures, and their BMI was slightly higher compared to the healed patients.
Our future goal is to evaluate how accurately the previously identified patient-, treatment- and injury-related risk factors predict a distal femur fracture nonunion in this population. This way we can identify patients who are at risk for distal femur fracture nonunion after lateral locked plating.
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2. Elsoe R, Ceccotti AA, Larsen P. Population-based epidemiology and incidence of distal femur fractures. Int Orthop. Published online 2018. doi:10.1007/s00264-017-3665-1
3. Martinet O, Cordey J, Harder Y, Maier A, Bühler M, Barraud GE. The epidemiology of fractures of the distal femur. Injury. 2000;31(SUPPL.3). doi:10.1016/s0020- 1383(00)80034-0
4. Larsen P, Ceccotti AA, Elsoe R. High mortality following distal femur fractures: a cohort study including three hundred and two distal femur fractures. Int Orthop. 2020;44(1):173-177. doi:10.1007/s00264-019-04343-9
5. Moloney GB, Pan T, Van Eck CF, Patel D, Tarkin I. Geriatric distal femur fracture: Are we underestimating the rate of local and systemic complications? Injury. Published online 2016. doi:10.1016/j.injury.2016.05.024
6. Streubel PN, Ricci WM, Wong A, Gardner MJ. Mortality after distal femur fractures in elderly patients. Clin Orthop Relat Res. Published online 2011. doi:10.1007/s11999-010- 1530-2
7. Tsai SHL, Lin T-Y, Tischler EH, et al. Distal femur fractures have a higher mortality rate compared to hip fractures among the elderly: Insights from the National Trauma
Data Bank. Injury. 2021;52(7):1903-1907. doi:10.1016/j. injury.2021.04.023
8. Jennison T, Divekar M. Geriatric distal femoral fractures: A retrospective study of 30 day mortality. Injury. 2019;50(2):444-447. doi:10.1016/j.injury.2018.10.035
9. Loosen A, Fritz Y, Dietrich M. Surgical Treatment of Distal Femur Fractures in Geriatric Patients. Geriatr Orthop Surg Rehabil. 2019;10:2151459319860723. doi:10.1177/2151459319860723
10. Hake ME, Davis ME, Perdue AM, Goulet JA. Modern Implant Options for the Treatment of Distal Femur Fractures. J Am Acad Orthop Surg. 2019;27(19):e867-e875. doi:10.5435/JAAOS-D-17-00706
11. Gwathmey FWJ, Jones-Quaidoo SM, Kahler D, Hurwitz S, Suomen Ortopedia ja Traumatologia Vol. 45
Cui Q. Distal femoral fractures: current concepts. J Am Acad Orthop Surg. 2010;18(10):597-607. doi:10.5435/00124635- 201010000-00003
12. Tank JC, Schneider PS, Davis E, et al. Early Mechanical Failures of the Synthes Variable Angle Locking Distal Femur Plate. J Orthop Trauma. 2016;30(1):e7-e11. doi:10.1097/ BOT.0000000000000391
13. McDonald TC, Lambert JJ, Hulick RM, et al. Treatment of Distal Femur Fractures With the DePuy-Synthes Variable Angle Locking Compression Plate. J Orthop Trauma. 2019;33(9):432-437. doi:10.1097/BOT.0000000000001510
14. Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL. 2010 Mid-America Orthopaedic Association Physician in Training Award: Healing complications are common after locked plating for distal femur fractures.
Clin Orthop Relat Res. Published online 2011. doi:10.1007/ s11999-011-1870-6
15. Henderson CE, Kuhl LL, Fitzpatrick DC, Marsh JL. Locking plates for distal femur fractures: Is there a problem with fracture healing? J Orthop Trauma. Published online 2011. doi:10.1097/BOT.0b013e3182070127
16. Are Locking Constructs in Distal Femoral Fractures Always Best? A Prospective Multicenter Randomized Controlled Trial Comparing the Less Invasive Stabili- zation System With the Minimally Invasive Dynamic Condylar Screw System. J Orthop Trauma. 2016;30(1):e1-6. doi:10.1097/BOT.0000000000000450
17. Ricci WM, Streubel PN, Morshed S, Collinge CA, Nork SE, Gardner MJ. Risk factors for failure of locked plate fixation of distal femur fractures: An analysis of 335 cases. J Orthop Trauma. Published online 2014. doi:10.1097/BOT. 0b013e31829e6dd0
18. Rodriguez EK, Zurakowski D, Herder L, et al. Mechanical construct characteristics predisposing to non-union
after locked lateral plating of distal femur fractures. J Orthop Trauma. Published online 2016. doi:10.1097/ BOT.0000000000000593
19. Consortium SF. LCP Versus LISS in the Treatment of Open and Closed Distal Femur Fractures: Does it Make a Difference? J Orthop Trauma. Published online 2016. doi:10.1097/00005131-201606000-00015
20. Kiyono M, Noda T, Nagano H, et al. Clinical outcomes
of treatment with locking compression plates for distal femoral fractures in a retrospective cohort. J Orthop Surg Res. Published online 2019. doi:10.1186/s13018-019-1401-9
21. Karam J, Campbell P, David M, Hunter M. Comparison of outcomes and analysis of risk factors for non-union in locked plating of closed periprosthetic and non-periprosthetic distal femoral fractures in a retrospective cohort study. J Orthop Surg Res. 2019;14(1):150. doi:10.1186/ s13018-019-1204-z
22. Rodriguez EK, Boulton C, Weaver MJ, et al. Predictive factors of distal femoral fracture nonunion after lateral locked plating: A retrospective multicenter case-control study of 283 fractures. Injury. Published online 2014. doi:10.1016/j.injury.2013.10.042
23. Campbell ST, Lim PK, Kantor AH, et al. Complica- tion Rates after Lateral Plate Fixation of Periprosthetic
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Distal Femur Fractures: A Multicenter Study. Injury. 2020;51(8):1858-1862. doi:10.1016/j.injury.2020.05.009
24. Hoffmann MF, Jones CB, Sietsema DL, Tornetta P, Koenig SJ. Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort. J Orthop Surg Res. Published online 2013. doi:10.1186/1749-799X-8-43
25. Koso RE, Terhoeve C, Steen RG, Zura R. Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis. Int Orthop. 2018;42(11):2675-2683. doi:10.1007/s00264-018-3864-4
26. Shah JK, Szukics P, Gianakos AL, Liporace FA, Yoon RS. Equivalent union rates between intramedullary nail and locked plate fixation for distal femur periprosthetic fractures – a systematic review. Injury. 2020;51(4):1062-1068. doi:10.1016/j.injury.2020.02.043
27. Ristevski B, Nauth A, Williams DS, et al. Systematic review of the treatment of periprosthetic distal femur fractures. J Orthop Trauma. 2014;28(5):307-312. doi:10.1097/ BOT.0000000000000002
28. Thompson SM, Lindisfarne EAO, Bradley N, Solan M. Periprosthetic supracondylar femoral fractures above a total knee replacement: compatibility guide for fixation with a retrograde intramedullary nail. J Arthroplasty. 2014;29(8):1639-1641. doi:10.1016/j.arth.2013.07.027
29. Poole WEC, Wilson DGG, Guthrie HC, et al. “Modern” distal femoral locking plates allow safe, early weight-bearing with a high rate of union and low rate of failure. Bone Jt J. Published online 2017. doi:10.1302/0301-620X.99B7. BJJ-2016-0585.R1
30. Smith JRA, Halliday R, Aquilina AL, et al. Distal femoral fractures: The need to review the standard of care. Injury. 2015;46(6):1084-1088. doi:10.1016/j.injury.2015.02.016
31. Garala K, Ramoutar D, Li J, et al. Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation. Injury. Published online November 2021. doi:10.1016/j.injury.2021.11.011
32. Yoon RS, Patel JN, Liporace FA. Nail and Plate Combination Fixation for Periprosthetic and Interpros- thetic Fractures. J Orthop Trauma. 2019;33(9):S18-S20. doi:10.1097/BOT.0000000000001571
33. Liporace FA, Aneja A, Carroll EA, Yoon RS. Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How? J Orthop Trauma. 2021;35(Suppl 5):S38-S40. doi:10.1097/BOT.0000000000002235
34. Steinberg EL, Elis J, Steinberg Y, Salai M, Ben-Tov T.
A double-plating approach to distal femur fracture: A clinical study. Injury. 2017;48(10):2260-2265. doi:10.1016/j. injury.2017.07.025
35. Upfill-Brown A, Arshi A, Sekimura T, Lee C, Stavrakis
A, Sassoon A. Short-term outcomes of periprosthetic compared to native distal femur fractures, a national database study. Arch Orthop Trauma Surg. Published online June 2021. doi:10.1007/s00402-021-04000-0
36. Hart GP, Kneisl JS, Springer BD, Patt JC, Karunakar MA. Open Reduction vs Distal Femoral Replacement Arthroplas-
ty for Comminuted Distal Femur Fractures in the Patients 70 Years and Older. J Arthroplasty. 2017;32(1):202-206. doi:10.1016/j.arth.2016.06.006
37. Hull PD, Chou DTS, Lewis S, et al. Knee Fix or Replace Trial (KFORT): a randomized controlled feasibility study. Bone Joint J. 2019;101-B(11):1408-1415. doi:10.1302/0301- 620X.101B11.BJJ-2019-0370.R2
38. Brodke DJ, Devana SK, Upfill-Brown A, Lee C. Cost-effectiveness of fixation versus arthroplasty for geriatric distal femur fractures. Injury. Published online November 2021. doi:10.1016/j.injury.2021.11.054
39. Griffin XL, Costa ML, Phelps E, et al. Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT. Health Technol Assess. 2019;23(51):1-132. doi:10.3310/hta23510
40. Müller ME, Nazarian S, Koch P et al. The Comprehensive Classification of Fractures of Long Bones. Springer-Verlag; 1990.
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Is primary knee arthroplasty an option for proximal tibial fractures?
A. Gänsslen
Wolfsburg General Hospital, Department of Traumatology, Orthopedics and Hand Surgery email: dr.gaensslen@gmx.de
Fractures in many anatomical regions are sufficiently treated by primary joint replacement, especially in elderly patients.
The most common areas include the proximal femur (predominantly displaced femoral neck fractures and less common trochanteric fractures in degenerative joints), proximal humerus (displaced fractures with egg-shell type humeral head frag- ments), elbow fractures (displaced or low fractures with severe osteoporosis or in cases with rheumatoid arthritis) and less common distal femur fractures.
In fractures of the lower extremities the primary aim of any treatment in elderly patients is to allow early/immediate weight bearing, to restore function and avoid complications due to immobilization.
ORIF of displaced tibial plateau fractures is the standard of care in younger patients but in older, osteoporotic patients these results are often difficult to reproduce [1,2,3,10,16].
In many studies no correlation between fixation failure and clinical outcome was observed after ORIF, but if worse results were observed, age at presentation was the most significant source of variati- on in functional outcome [4].
AGE is a relevant FACTOR of a worse outcome after ORIF of proximal tibial fractures.
A decade ago, Bohm et al. performed a literature review analyzing the operative management of osteoporotic fractures around the knee, focusing on tibial head fractures [4].
A negative correlation was found with increasing age regarding radiological outcome with a 30-79% failure rate and loss of reduction with incongruency and axis deviation.
Interestingly the conversion rate ORIF to TKR was maximum 7.9% after approximately 4 years [4]. Despite an overall good to excellent outcome rate of 70-80%, revision rates of 8-20% and complication rates of 24-48% were reported.
ORIF of proximal tibia fractures (in elderly patients) is associated with worse radiological outcome and a high complication and revision rate.
Overall, there is a 3.5-fold long-lasting increased risk of TKR after ORIF after a mean of 13.9 years [6]. This analysis found a maximum risk during the first 5 years after fracture occurrence.
A present analysis found that age > 60 years was not associated with treatment failure, defined as post-traumatic arthritis grade III and IV or nonunion, after ORIF. The fracture type (C2 or C3 according to AO/OTA) and malreduction were found to be significant risk factors for fixation failure [9].
If we are not able to anatomically reduce the proximal tibia fracture, primary TKR should be considered.
During the last decade, even in some proximal tibia fractures primary total knee replacement (TKR) was performed.
Some encouraging results were reported performing primary TKR. Huang et al. stated TKR to be a suitable solution in elderly patients with complex tibial plateau fractures [7]. These results were confirmed by others showing TKR to be a suitable option in elderly patients with pre-existing osteoarthritis and poor bone quality to allow immediate weight-bearing and a faster recovery. But it was stated that primary TKR is a demanding surgery with a significant complication rate [15]. A recent analysis from Finland in 22 elderly patients reported good functional results with mean flexion of 109°, with the majority of patient being satisfied or highly satisfied [19]. Overall, a 9.1% complication rate was observed.
A recent analysis compared primary TKR and ORIF [1]. Range of motion and the KSS knee and function scores were significantly better in the TKA patients and TKR patients were associated with a lower complication rate.
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Accepted indications for primary TKR
There are some indications in complex proximal tibia fractures [3,17]:
–preexisting symptomatic (endstage) osteoarthritis in elderly patients
–articular involvement making internal fixation ha- zardous
–elderly patients, who cannot perform non-weight bearing
–substantial bone destruction
–pathological fractures
–young patients with complete destruction of the
proximal tibia
Preoperative planning
It is essential in elderly/geriatric patients to address several factors, which can influence the treatment [13,17]:
–multidisciplinary ortho-geriatric co-management addressing comorbidities
–blood management to control of anemia –cardiac and pulmonary evaluation –analysis of the soft-tissue envelope –analysis of the overall vascular condition –availability of different TKR-types –availability of an experienced knee surgeon
The Surgeon
When planning primary an expert knee surgeon, who is extensively familiar with revision TKR surgery is mandatory.
–Depending on fracture type, fracture comminution, bone loss, osteoporosis etc. even familiarities of reconstruction following tumor resection is sometimes necessary. Thus,
–planning of joint-line restoration, component rotation, bone defect management and implant fixation should be considered [8,11].
Choice of implants and constraints
As already mentioned, the implant choice depends on the fracture personality and the amount of metaphyseal involvement. According to Parratte et al., the following recommendations my be helpful [13]:
–involvement of collateral ligament insertions
favors a rotating-hinge implant
–in severe metaphyseal destruction a segmental me-
ga-prosthesis should be considered
Overall, four different prostheses types are used [18]:
– hinge
–total stabilized
–surfacing (cruciate retaining) –surfacing (posterior stabilized)
Implant selection
The primary surgical goal is a stable tibial base-plate associated with appropriate prosthetic fixation [4, 5,12,14].
Especially in comminuted fractures, the true joint-line level and tibial rotation are difficult to determine [13]. Parratte et al., recommended some principles [13]:
–comminuted lateral condyle fracture: the joint-line level is easily determined by the anatomical medial plateau; lateral defect filling is crucial for achieving stability
–bicondylar tibial fractures: the fractures are associated with instability of the tibial base, making joint-line reconstruction and tibial rotation analysis most difficult; a cone or other filling device, stabilized by a cemented stem is recommended
–anterior tibial tubercle involvement: often, appropriate internal fixation is necessary for reconstruction of the extensor mechanism
Present Evidence - Systematic Reviews
Recently two systematic reviews were published [18,20]. Wong et al. analyzed seven studies, inclu- ding105 patients. They reported on primary data and reported a mortality rate of 4.75%, a total complication rate of 15.2% and a good overall outcome with an average range of motion of 107.5° [20].
Tapper et al. recently analyzed 16 studies including 197 patients with primary TKR after tibial head fractures [18]. An overall low-quality evidence was reported. At a maximum 4-year follow-up an overall complication rate of 6.1% and a revision rate of 3.6% was found. These rates were lower than for seconda- ryTKR(20–48%vs.8–20%,respectively)buthigher
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compared to elective primary TKR surgery.
Many different fracture types and therefore many different prosthesis types were used, making clear individual conclusions based on fracture types impossible.
Conclusion
Primary TKR is a valid alternative, especially in elderly, osteoporotic patients, but is presently rarely performed. If indicated, modular implants are favored [3].
Primary TKA is indicated for select tibial plateau fractures to reduce the need for reoperation. The outcome does not appear to be superior to ORIF [20].
References
1. Abdelbadie A, El-Hennawy A and Sallam A. Primary Total knee Arthroplasty: A Viable Surgical Option for Complex Tibial Plateau Fractures in Elderly. J Knee Surg, 2020. 33: 496-503.
2. Ali A, El-Shafie M and Willett K. Failure of fixation of tibial plateau fractures. J Orthop Trauma, 2002. 16: 323-329.
3. Aurich M, Koenig V and Hofmann G. Comminuted intraar- ticular fractures of the tibial plateau lead to posttraumatic osteoarthritis of the knee: Current treatment review. Asian J Surg, 2018. 41: 99-105.
4. Bohm E, Tufescu T and Marsh J. The operative management of osteoporotic fractures of the knee: to fix or replace? J Bone Joint Surg Br, 2012. 94: 1160-1169.
5. Boureau F, Benad K, Putman S, Dereudre G and Kern G. Does primary total knee arthroplasty for acute knee joint fracture maintain autonomy in the elderly? A retrospective study of 21 cases. Orthop Traumatol Surg Res, 2015. 101: 947-951.
6. Elsoe R, Johansen M and Larsen P. Tibial plateau fractures are associated with a long-lasting increased risk of total knee arthroplasty a matched cohort study of 7,950 tibial plateau fractures. Osteoarthritis Cartilage, 2019. 27: 805-809.
7. Huang J, Shen J, Chen J and Tong P. Primary total knee arthroplasty for elderly complex tibial plateau fractures. Acta Orthop Traumatol Turc, 2016. 50: 702-705.
8. Huten D. Femorotibial bone loss during revision total knee arthroplasty. Orthop Traumatol Surg Res, 2013. 99: S22-33.
9. Kim J, Hwang K, Soh H, Shon O and Park K. Comparison of tibial plateau fracture surgical outcomes between young and elderly patients: are outcomes really poorer in the elderly? Arch Orthop Trauma Surg, 2021. doi: 10.1007/ s00402-021-03855-7:
10. Krupp R, Malkani A and Roberts C. Treatment of bicondylar tibia plateau fractures using locked plating versus external fixation. Orthopaedics, 2009. 32:
11. Morgan-Jones R, Oussedik S, Graichen H and Haddad F. Zonal fixation in revision total knee arthroplasty. Bone Joint J, 2015. 97-B: 147-149.
12. Parratte S, Bonnevialle P, Pietu G, Saragaglia D, Cherrier B and Lafosse J. Primary total knee arthroplasty in the management of epiphyseal fracture around the knee. Orthop Traumatol Surg Res, 2011. 97: S87-94.
13. Parratte S, Ollivier M and Argenson J. Primary total knee arthroplasty for acute fracture around the knee. Orthop Traumatol Surg Res, 2018. 104: S71-S80.
14. Ries M. Primary arthroplasty for management of osteoporotic fractures about the knee. Curr Osteoporos Rep, 2012. 10: 322-327.
15. Sabatini L, Aprato A, Camazzola D, Bistolfi A, Capella M and Massè A. Primary total knee arthroplasty in tibial plateau fractures: Literature review and our institutional experience. Injury, 2021. S0020-1383(21)00104-2. doi: 10.1016/j.injury.2021.02.006:
16. Stevens D, Beharry R, McKee M, Waddell J and Schemitsch E. The longterm functional outcome of operatively treated tibial plateau fractures. J Orthop Trauma, 2001. 15: 312-320.
17. Tampere T, Ollivie M, Jacquet C, Fabre-Aubrespy M and Parratte S. Knee arthroplasty for acute fractures around the knee. EFORT Open Rev, 2020. 5: 713-723.
18. Tapper V, Toom A, Pamilo K, Niinimäki T, Nieminen J, Nurmi S, Kortekangas T and Paloneva J. Primary total knee replacement for tibial plateau fractures in older patients: a systematic review of 197 patients. Arch Orthop Trauma Surg, 2021. doi: 10.1007/s00402-021-04150-1:
19. Tapper V, Toom A, Pesola M, Pamilo K and Paloneva J. Knee joint replacement as primary treatment for proximal tibial fractures: analysis of clinical results of twenty-two patients with mean follow-up of nineteen months. Int Orthop 2020. 44: 85-93.
20. Wong M, Bourget-Murray J, Johnston K and Desy N. Un- derstanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review
of the literature. J Orthop Traumatol, 2020. 21(1):7. doi: 10.1186/s10195-020-00546-8.
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Is routine removal of syndesmotic screw needed? (RODEO trial)
Fay R K Sanders1, Merel F Birnie1, Siem A Dingemans1, Michel P J van Bekerom2, Markus Parkkinen3, Ruben van Veen2, RODEO collaborator group, J Carel Goslings2, Tim Schepers1
1 Trauma Unit, Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands 2 Department of Orthopaedic and Trauma Surgery, OLVG, the Netherlands
3 Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Finland
Introduction
Syndesmotic injuries are present in 15-20 % of surgically treated ankle fractures (1,2). Most commonly syndesmotic rupture is treated with syndesmotic screw fixation (3). Traditionally, the screw has been removed after 3 months because it is thought to cause pain during weight bearing and obstruct the normal ankle function (4,5). Some has also argued that removal is necessary to attain the final anatomic reduction (6). Yet, there are other studies showing that removal of syndesmotic screw does not improve the functional outcome or range of motion (7-11). It is thought that if the screw breaks or loosens it will return the normal movement of the ankle (8,10,11). Removal of syndesmotic screw is complicated by surgical site infection (SSI) up to 9% of cases (11- 14). Because of the high complication rate, it would be beneficial to remove the screw only if patient experience difficulties. The present study aimed to in- vestigate the effect of on-demand removal (ODR) of syndesmotic screw on functional outcome. The hypothesis was that there would be no difference in functional outcome at 12 months compared patients with ODR and routine removal (RR).
Materials and methods
The ROutine vs on DEmand removal Of the syndesmotic screw (RODEO) trial was international multicentre randomized controlled trial and was conducted in 17 European centres (14 teaching hospitals and 3 academic, level 1 trauma centres). The study was carried out between January 2017 and
April 2019. Adult patients (>17 years) with traumatic syndesmotic injury, which was treated surgically within 2 weeks from injury, using 1-2 syndesmotic screw were included. Exclusion criteria were: concomitant injury of lower extremity or other medical condition hampering rehabilitation, Injury Severi- ty Score >15 and possible language barrier. A total of 197 patients were randomized for on-demand removal (only in case of complaints) and routine removal (at 12 weeks) study groups and 152 of these completed the study. The primary outcome was functional outcome measured by the Olerud-Mo- lander Ankle Score (OMAS) at 12 months after screw placement. Secondary outcomes were Amer- ican Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), pain using 10-point visual analogue scale (VAS), active range of motion and complications. Patients were seen at outpatient clinic at 3, 6 and 12 months from operation.
Results
The final analysis included 152 patients, 73 routine removal (RR) and 79 on-demand removal (ODR).
The mean age of the patients was 46.9 years, and 59% were male. In the RR group the screw removal was performed in 67 of 73 cases; there were five crossovers and one revision surgery. At the time of removal of the screw it was found to be broken in nine cases. In the ODR group 18 out of 79 (23%) patients had screw removal at a mean of 33 weeks from initial surgery. Reasons for removal were pain (n=7), limited ROM or stiffness (n=6), revision surgery with syndesmotic fixation (n=2), skin reac-
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tion to implants and screw backing out (n=2) and not described (n=1). Out of 18 ODR patients with screw removal, the screw was already broken in ten cases. None of the five crossovers from RR group to ODR had their screw removed.
The primary outcome: The median OMAS at 12 months after fixation was 85 for the RR group and 80 for the ODR group. The non-inferiority test indicated that the observed effect size was significantly within equivalent bounds for both the inten- tion-to-treat and per-protocol, meaning that ODR was not inferior to RR. OMAS scores were comparable between the groups also at 3 and 6 months after surgery. Functional outcome AOFAS hindfoot score did not differ between groups at any time- point. ROM and VAS pain scores showed no statistical difference at any time point.
Complications were significantly more common in the the RR group (12/73) than in the ODR group (1/79) (p=0.007). Complications in the RR group comprised of wound dehiscence (n=5), superficial SSI (n=2), deep SSI (n=2), diastasis after removal (n=1), synovitis (n=1), and increase in stiffness after screw removal (n=1). In the ODR group one patient had superficial SSI after removal of all implants.
Conclusions
The current study found that on-demand screw removal was non-inferior to routine removal regard to functional outcome. Moreover, no differences were found in the pain or ROM at any time point between the two groups. Since routine removal group had significantly higher complication rate, on-demand removal can be suggested to standard practice of care after syndesmotic fixation.
References
1. Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma. 2010;24(1):7– 11.
2. van den Bekerom MPJ, Lamme B, Hogervorst M, Bolhuis HW. Which ankle fractures require syndesmotic stabilization? J FootAnkle Surg. 2007;46(6):456–463.
3. Schepers T, van Zuuren WJ, Vogels LMM, van Lieshout EM. The management of acute distal tibio-fibular
syndesmotic injuries: results f a nationwide survey. Injury Netherlands. 2012;43(10):1718–1723.
4. Bell DP, Wong MK. Syndesmotic screw fixation in Weber C ankle injuries- -should the screw be removed before weight bearing. Injuy Netherlands. 2006;37(9):891–898.
5. Miller AN, Paul O, Boraiah S, Parker RJ, Helfet DL, Lorich DG. Functional outcomes after syndesmotic screw fixation and removal. J Orthop Trauma. 2010;24(1):12–16.
6. Amouzadeh Omrani F, Kazemian G, Salimi S. Evaluation of syndesmosis reduction after removal syndesmosis screw in anklefracture with syndesmosis injury. Adv Biomed Res. 2019;8:50.
7. Briceno J, Wusu T, Kaiser P, et al. Effect of syndesmotic implant removal on dorsiflexion. Foot Ankle Int. 2019;40(5):499–505.
8. Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma United States. 2010;24(1):2–6.
9. Pogliacomi F, Artoni C, Riccoboni S, Calderazzi F, Vaienti E, Ceccarelli F. The management of syndesmotic screw in ankle fractures. Acta Biomed. 2019;90(1):146–149.
10. Kaftandziev I, Spasov M, Trpeski S, Zafirova-Ivanovs- ka B, Bakota B. Fate of the syndesmotic screw: search for a prudent solution. Injury Netherlands. 2015;46(Suppl 6):S125-9.
11. Boyle MJ, Gao R, Frampton CMA, Coleman B. Removal of the syndesmotic screw after the surgical treatment of
a fracture of theankle in adult patients does not affect one-year outcomes: A randomised controlled trial. Bone Joint J. 2014;96-B(12):1699–1705.
12. Andersen MR, Frihagen F, Madsen JE, Figved W. High complication rate after syndesmotic screw removal. Injury. 2015;46(11):2283–2287.
13. Juarez-Jimenez HG, Garibay-Cervantes A, Rosas-Medina JA, Salas-Morales GA, Rodriguez-Reyes EJ. Prevalence of complications related to the removal of the syndesmotic screw. Acta Ortop Mex. 2018;32(2):76–81.
14. Schepers T, Van LE, de VM, der EM. Complica- tions of syndesmotic screw removal. Foot Ankle Int. 2011;32(11):1040–1044.
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Title: Biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome: protocol for a prospective multinational, multi-centre study involving patients with tibial fractures
First and last author: Abraham Nilsson and Jörg Schilcher
Department of Orthopaedic Surgery and Department of Biomedical and Clinical Sciences, University Hospital Linköping, Linköping University, Sweden.
Department of Orthopaedics, Eksjö, Region Jönköping County, Sweden.
Department of Orthopaedic surgery in Norrköping, Sweden.
Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Finland
Introduction
The ischemic pain of acute compartment syndrome (ACS) can be difficult to discriminate from the pain linked to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is based on clinical findings and performed at a low level of suspicion(1). Biomarkers of muscle cell damage may help to identify and monitor patients at risk, similar to current routines for patients with acute myocardi- al infarction(2,3). This study will test the hypothesis that biomarkers of muscle cell damage can predict ACS in patients with tibial fractures.
Methods
Patients aged 15–65 years who have suffered a tibial fracture will be included (Table). Plasma (P)- myoglobin and P-creatine phosphokinase (P-CK) will be analysed at 6-hourly intervals after admission to the hospital and – if applicable – after surgical fixation or fasciotomy. In addition, if ACS is suspected, blood samples will be collected at 6-hourly intervals. An independent expert panel will assess retrospec- tively the study data and will classify those patients who had undergone fasciotomy into those with ACS and those without ACS. The area under the receiver operator characteristics curves will be used to identify the success of the biomarkers in discriminating
between patients who develop ACS and those who do not. Logistic regression analyses will be used to assess the discriminative abilities of the biomarkers to predict ACS corrected for pre-specified covaria- tes. Blood samples will be collected from patients with ACS but without tibial fractures, to serve as a positive control group of ACS.
Results
Our study is still including patients. In a retrospective pilot study on patients with tibial fractures and patients with tibial fractures complicated by suspected ACS, the mean pre-operative values for myoglobin were 289 μg/L (SD 249) and 1449 μg/L (SD 1044) (Figure). These values were used for sample size calculations. Assuming an area under the curve of 0.7, alpha 0.05, power of 80 % and a
prevalence of ACS of 5 %, we require 16 patients with suspected ACS and 311 without.
Discussion and conclusion
If we are able to define threshold values of P-myoglobin and P-CK for the detection of ACS with good diagnostic accuracy, these values could be implemented in clinical practice without delay. Spe- cifically, these threshold values would support the individual surgeons decision to abstain from fascio-
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tomy when deemed feasible and follow biomarker dynamics and clinical status instead.
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References
1. Schmidt AH. Acute compartment syndrome. Injury. 2017;48 Suppl 1:S22-S5.
2. Valdez C, Schroeder E, Amdur R, Pascual J, Sarani B. Serum creatine kinase levels are associated with extremity compartment syndrome. J Trauma Acute Care Surg. 2013;74(2):441-5; discussion 5-7.
3. Hefler F. Compartment syndrome after gynecologic laparoscopy: systematic review of the literature and establishment of normal values for postoperative serum creatine kinase and myoglobin levels. Arch Gynecol Obstet. 2017;296.2:285-93.
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Ocular traumatology for orthopaedic surgeons
Anna Schlenzka, Ophthalmologist, FEBO, Oculoplastic and cataract surgeon, HUCH Eye Hospital
An orthopaedic surgeon typically encounters an ocular trauma patient in the setting of other, often more serious injuries. 7,5%-16% of polytrauma patients have ocular/orbital injury, most commonly related to road traffic accidents and falls (1). Facial and orbital trauma are risk factors for vision threatening ocular injury in polytrauma patients (2). Iden- tification of eye injuries is challenging in many cases of polytrauma patients primarily due to the presence of life-threatening injuries which receive higher pri- ority. Furthermore, undetected or missed injuries are not uncommon, even during the secondary evaluation of polytrauma patients. Periorbital swelling makes examination of the eye difficult and therefore injuries such as globe perforations can be missed. Furthermore, if the patient is unconscious or para- lyzed, visual acuity and other symptoms cannot be assessed. Early suspicion and detection, first aid and consulting with an ophthalmologist is crucial to prevent unnecessary permanent visual loss and other ocular symptoms affecting the quality of life in these patients.
Classification
Ocular trauma to the globe can be classified into mechanical injury, chemical injury and physical non-mechanical injuries as represented in Figure 1 (3). Damage to periocular structures such as the orbit, optic nerve (via direct or indirect mechanism), eyelids, lacrimal system and extraocular muscles should also be recognized, warranting an ocular examination and ophthalmologist consultation.
Encountering an ocular trauma patient
Patient history, when possible, should include previous ocular diseases and surgeries and precise mechanism of injury. Blunt objects are more likely to cause rupture of the globe whereas sharp objects are
likely to cause lacerations. The eye can be insidious- ly calm initially after a small penetrating injury (eg. sharp end of nail that entered and exited the eye) or small intraocular foreign object. Therefore, it is crucial to suspect a penetrating ocular injury based on the mechanism of trauma. Symptoms related to ocular and periocular injuries are typically straight- forward; visual loss, other visual symptoms, pain and double vision.
The basic examination of an ocular trauma patient includes visual acuity, intraocular pressure (IOP), inspection of the periocular area, position of the globe, pupillary responses, an ocular motility test and inspection of the anterior segment of the globe. Gauzes or cotton buds may be used to gently open swollen eyelids. Care should be taken to pull and press the eyelids towards the orbital rim and not apply pressure on the globe.
Blunt ocular trauma
Blunt ocular trauma occurs via a direct blow to the eyeball eg. with fist, ball or blunt instrument. The eyeball compresses and decompresses sudden- ly causing an intraocular compression wave and reflected and rebound compression waves in addition to the direct impact from trauma. Thus, a blunt injury can damage the eye/periocular area at a variety of locations causing one or more of the following: corneal abrasion, subconjunctival hemorrhage, hyphema, damage to the iris/pupillary sphincter, immediate rise in IOP or later glau- coma, traumatic iritis, dislocation of lens, vitreous hemorrhage, retinal tear or detachment, choroidal tear or damage to the optic nerve. The IOP may even rise during the impact sufficiently to cause a scleral rupture at the weakest part of the sclera, typically behind extraocular muscle insertions or at a previous surgery site.
A blunt trauma to the eye can also result in
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Figure 1
Mechanical injury
Chemical injury
Physical non- mechanical injury
Closed globe
Open globe
Acid
Alkali
Tear/pepper gas
Radiation (welding, ultraviolet)
Burns Frost injury
Contusion
Lamellar laceration
Superficial foreign body
Rupture (blunt trauma, inside-out mechanism)
Laceration
Penetrating (entrance wound only)
Perforating (seperate entrance and exit wounds)
Intraocular foreign body
Ocular trauma
pressure rise in the orbit and a subsequent orbital fracture. Most typically the floor of the orbit is damaged. An extraorbital muscle entrapment at the fracture site causes restriction in ocular movement and diplopia. This may also cause a vasovagal reflex resulting in bradycardia and nausea which are relieved after successful surgical repositioning of orbital contents. (4) Periorbital edema, hematoma and subconjunctival hemorrhage are typical even without accompanying ocular injury. CT scanning of the orbits is indicated for any head trauma patient who presents with change in the position of the globe, reduced visual acuity, subconjunctival haemorrhage, change in sensation in the maxillary division of the trigeminal nerve or blepharohematoma. (5)
Possible ocular findings that can point serious injury of the globe and warrant ophthalmologist consultation are clearly deteriorated vision, low/high IOP (normal IOP with iCare tonometer 10-22), ex- tensive conjunctival hemorrhage, hyphema, missing
red reflex and abnormal pupillary response.
The threshold for permanent damage caused by high IOP to the optic nerve depends on individual factors. The higher the pressure, the faster and more likely damage occurs. IOP >30 should be treated promptly. When high IOP is caused by blocked outflow of aqueous due to eg intraocular hemorrhage or other damage to intraocular structures, primary treatment is to medically lower the
intraocular pressure.
High IOP accompanied by exophthalmos, tight
eyelids and restricted ocular motility is a sign of orbital compartment syndrome (caused by eg a ret- robulbar hematoma). If the optic nerve is already severely compressed the pupil is nonresponsive and visual acuity is impaired. Elevation of intra-orbital pressure exceeding the vascular perfusion pressure of the ophthalmic artery can result in ischemia and ir- reversible vision loss if not corrected emergently. An immediate lateral cantholysis is necessary to relieve the pressure behind the globe.
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Open globe injury
An open globe injury can be unambiguous with findings including a deformed eye, visible wound on the cornea/sclera, protruding intraocular contents, no anterior chamber and low intraocular pressure. Other clues pointing toward this serious injury can be markedly deteriorated vision, abnormal/misshaped pupil, missing red reflex and exten- sive subconjunctival hemorrhage. IOP may be be normal or even high. An open globe injury cannot be ruled out by imaging (6), hence clinical examination of visual function and ocular structures is necessary.
In the occasion of suspected open globe injury, further inspection of the eye should be discontin- ued to prevent further damage. The affected eye should be covered with a shield without instill- ing any drops or ointments. An upright position if possible and treating pain and possible nausea pre- vents the unnecessary rise of orbital pressure and expulsion of intraocular content. The visual acuity prognosis of an open globe injury patients depends on presenting visual acuity, location of injury, time delay to primary surgical repair and timely pre- vention of infection with systemic and local anti- biotics. (7) Surgical repair by an ophthalmologist (ideally within 12-24 hours) should be organized without delay.
Eyelid and lacrimal injuries
The eyelids are a complex structure that needs to be repaired with expertise to ensure future opening and closure of the eye and comfort of the patient. Any wound extending to the eyelid margin or missing tissue should be evaluated and/or sutured by an ophthalmologist. Due to the anatomical proximity of the eye and eyelid, a laceration of the latter is a risk factor for serious injury to the eye. Injuries to the eyelid/skin near the medial canthal area should evoke suspicion of lacrimal outflow system damage, which is ideally repaired within 48 hours to ensure a good postoperative result. Failure to repair the damaged canaliculi will most probably result in a permanently constantly watering eye. Lacrimal outflow system injuries are associated with head trauma, orbital and facial fractures, lacerations of face/eyelids and vision threatening ocular injuries. (8)
Associated injuries
Associated injuries in the head, face, eye and periocular area are common. A few percent of orbital fractures are associated with ophthalmological emergencies, the majority of which will present with diminished visual acuity, other visual changes or abnormal pupillary re- activity. A blunt injury mechanism, subconjunctival hemorrhage, fracture of the roof of the orbit, distinct loss of vision and double vision are factors predicting the risk of serious ocular injury. (10)
Summary
Suspect serious ocular injury/open globe injury especially in polytrauma patients with head/facial trauma. Measure IOP & inspect eyes and periocular area sys- tematically to find all significant injuries. Don’t hesi- tate to contact your nearest ophthalmologist.
References
1. T. Georgouli, I. Pountos, B. Y. P. Chang & P. V. Giannoudis. Prevalence of ocular and orbital injuries in polytrauma patients. European Journal of Trauma and Emergency Surgery volume 37, pages135–140 (2011)
2. Poon, Alexander, McCluskey, Peter J. Hill, David A. MS, Eye Injuries in Patients with Major Trauma. The Journal of Trauma: Injury, Infection, and Critical Care: March 1999 - Volume 46 - Issue 3 - p 494-49
3. DJ. Pieramici, P Sternberg Jr, TM. Aaberg. A System for Classifying Mechanical Injuries of the Eye (Globe). American Journal of Ophthalmology. Volume 123, Issue 6, June 1997, s. 820-831
4. Tobin JR, Grey Weaver R, Chapter 34 - Ophthalmology, A Practice of Anesthesia for Infants and Children (Sixth Edition), Elsevier, 2019, s. 790-803
5. Exadaktylos A K, Sclabas G M, Smolka K, et al. The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma center. J Trauma. 2005;58:336–341.
6. James R. Allison, Andrew Kearns and Robert J. Banks. Predicting orbital fractures in head injury: a preliminary study of clinical findings. Emerg Radiol. 2020; 27(1): 31–36.
7. Edward K Sung , Rohini N Nadgir, Akifumi Fujita, Cory Siegel, Roya H Ghafouri, Anastasia Traband, Osamu Sakai: Injuries of the globe: what can the radiologist offer? Radio- graphics May-Jun 2014;34(3):764-76.
8. Richard J Blanch, Jonathan Bishop , Hedayat
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Javidi , Philip Ian Murray: Effect of time to primary repair on final visual outcome after open globe injury. Br J Ophthalmol. 2019 Oct;103(10):1491-1494.
9. Jordan David R, Ziai Setareh, Gilberg Steven M, Mawn Louise A. Pathogenesis of Canalicular Lacerations. Ophthalmic Plastic & Reconstructive Surgery: September 2008 - Volume 24 - Issue 5 - p 394-398
10. Elizabeth J. Rossin, Colleen Szypko, Isaiah Giese et al: Factors Associated With Increased Risk of Serious Ocular Injury in the Setting of Orbital Fracture. JAMA Ophthalmol. 2021;139(1):77-83
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The effect of the Covid-19 pandemic on paediatric trauma
Arimatias Raitio, MD, PhD
University of Turku and Turku University Hospital
The outbreak of coronavirus disease first emerged in Wuhan, China in December 2019. Alarming numbers of hospitalizations and deaths were reported first in China and a few months later in northern Italy. The COVID-19 outbreak of 2019 was declared a pandemic by the WHO in March 2020. Significant restriction measures were implemented by the governments worldwide aiming to control the spread of the disease and to “flatten the curve”. This included closures of schools, day-care centres, restaurants, and cessation of organized sports.
The effects of these lock-down measures on the healthcare system were first reported in New Zealand by Christey et al. where significant reduction of all trauma patients was observed in March 2020. A month later Bram et al. reported 2.5-fold decrease in paediatric fractures in Philadelphia, US compared to pre-pandemic cohort. Since then, several countries worldwide including Finland, UK, Italy, Greece, and Indonesia have reported similar reductions in the number of paediatric trauma patients. Publications and their main findings are summarized in the table below.
The exceptions to this observation have been Sweden and Austria. Interesting- ly, nationwide register data in Sweden and a single centre study from Vienna demonstrated no change in fracture incidence and trauma operations during the first wave of the COVID-19 pandemic. During the first wave Sweden chose different strategy aiming for herd immunity instead of lock-down measures. This likely explains the unchanged incidence of paediatric trauma in their country.
In conclusion, limitations of children’s activities and especially closure of playgrounds and cessation of organized sports appears to reduce the number of injuries. It also seems that the number of paediatric injuries agrees with regional differences in the strictness restrictions.
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Author / doi
Time frame
Setting
Location
Main findings
Bram et al. / 10.1097/ BPO.0000000000001600
March – April 2020
Single centre
Philadelphia, US
2.5-fold reduction in paediatric fractures
Raitio et al. / 10.1177/1457496920968014
March - May 2020
Multicentre, nationwide
Finland
Significant reduction (31%) in Fx requiring operative treatment (esp school, day- care, and organized sports)
Ibrahim et al. / 10.1302/2633- 1462.22.BJO-2020-0152.R1
March - June 2020
Single centre
UK
Reduction in absolute number of Fx but increase in trampoline related injuries and operative treatment
Kambouri et al. / 10.7759/cureus.17543
March - May 2020
Single centre
Greece
Over 40 % reduction in emergency visits in general
Kelly et al.
March - August 2020
Single centre
Rhode Island, US
Decreased A&E visits, injuries decreased non-significantly
Kuorikoski et al. / 10.1136/ wjps-2021-000304
March - December 2020
Multicentre (three)
Finland
Marked decrease in injuries among older children (13 - 17 years) during lockdown (March 2020)
Melander et al. / 10.1111/ pan.14203
Year 2020
Nationwide register
Sweden
Dramatic reduction in trauma operations during the 1st wave (levels normalized shortly after)
Payr et al. / 10.3390/ijer- ph18115829
March - May 2020
Single centre
Austria
No change in Fx incidence and proportional increase in mild head injuries
Pelletier et al. / 10.1001/jama- networkopen.2020.37227
January - June 2020
Multicentre (49)
US
No typical increase in trauma for springtime (i.e. decrease compared to normal levels)
Raffaldi et al. / 10.1016/j. lanepe.2021.100081
March - May 2020
Multicentre (23)
Italy
Over 70% reduction in trauma-related admissions
Utomo et al. / https:// doi.org/10.3889/oam- jms.2021.6720
Year 2020
Single centre
Indonesia
Significant reduction in Fx rate among older children (11 - 18 years)
Table 1. Summary of publications
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Spinal endoscopy: Helsinki and Turku experience so far and what’s the future?
Jari Siironen
Helsinki University Hospital jari.siironen@hus.fi
Do we need endoscopic spine surgery?
A typical goal of most spine procedures for degenerative pathologies involves addressing and relieving extrinsic neural compression. As the tools and techniques to perform these procedures have evolved, surgeons have been able to perform these procedures with more limited operative exposures. Thus, spine surgery has evolved from traditional open spine surgery to minimally invasive spine surgery, and quite logically to endoscopic spine surgery.
Principles of endoscopy are similar to minimally invasive surgery, to decrease pressure on soft tissue crushing from prolonged retraction, avoid soft tissue stripping and dissection, and bone and ligamentous preservation for optimal decompression without excessive destruction and post-operative instability. This may provide patients with decreased post-operative pain and disability.
The aging population around the world leads to increasing incidence of degenerative spinal conditions. Therefore there is a need for a minimally invasive technique in treatment for spinal conditions to meet the medical complexity of the elderly. Endoscop- ic spine surgery may play a role in this. Furthermore, endoscopic spine surgery can play important role for example in the treatment of disc herniations especially for the persons who engage in the competitive sports and early functional recovery is especially important.
If it is effective, why aren’t we all using it
already?
For a variety of reasons, mainly because there is a learning curve and we already have had effective and time-tested means to treat “simple” spine surgery,
spine surgery has lagged behind other specialties in the adoption of endoscopical surgery. However, technical evolution, better optics and endoscopes, patient demand for less invasive spine procedures and surgeon drive to proceed technically and to minimize surgical dissection have caused the present global rapid growth of endoscopical spine operations.
What’s good and bad about endoscopic
spine surgery?
In theory, advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmetic result.
Endoscopical operation unarguably creates the least amount of collateral tissue damage. Disad- vantages rise primarily from the single working channel that precludes multiple concurrent instrument use and independence between the camera and instrument movements, thus limiting the vis- ualisation of the working field and the possibilities the surgeon can do.
What are the results of endoscopic spine
surgery?
There is a growing body of scientific evidence that not only confirms the efficacy of these procedures but also points out the advantages these procedures offer with respect to less morbidity. At the moment, however, we can safely say that the endoscopic spine surgery gives at least equally good result as open or “normal” minimally invasive spine surgery.
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Full endoscopy system (in Helsinki by Riwo Spine)
Full endoscopy, the system in use in Helsinki and Turku University Hospitals typically involves a single working channel, which houses the endoscope and one surgical instrument. The working channel only allows for the use of one instrument at a time. The operator can change the instrument, for example switch- ing from a bone removal device or a drill to a cautery device, but the size of the working channel does not allow for the concurrent use of two instruments.
Beveled working channel designs allow surgeons to use the working channel itself as a retractor, by dis- placing structures outside the working and visual field.
For visibility, there is a consistent irrigation through the endoscope and its tip with saline.
Interlaminar vs. transforaminal approach
The two most commonly utilized approaches for endoscopic surgery in the lumbar spine are the posterolateral (or interlaminar) approach and the extraforaminal (or transforaminal) approach. The interlaminar approach (Figure 1) is similar to the “normal” one used in conventional discectomy. A paramedian incision is used to access the lamina and interlaminar space, where the surgeon has direct access to the spinal structures within the central canal and lateral recesses. This approach has the broadest application, as the majority of spinal disorders involve neural compression in the central and/or lateral recess zones. The usual limiting factor is the size of the facet joint, as the endoscope is a straight device. However, different burrs can be used to overcome this, as well as to treat even spinal stenosis.
In the extraforaminal approach (Fig 2), a far lateral incision is used to allow instruments to access the extraforaminal and lateral foraminal zones avoiding the existing nerve root. This approach pro- vides direct access to the foramen and can be used for isolated unilateral foraminal conditions or neural compression in the lateral recess or central canal secondary to ventral disc herniation.
Typically, for disc herniations in L5/S1 the interlaminar is used for easy access without bone removal, if the interlaminar window if big enough. Disc herniation levels from L4/5 cranially can usually be
reached easier by transforaminal approach, whereas the iliac crest often make this approach impossible for the level L5/S1.
Finnish experience
With less than 100 lumbar disc herniations done endoscopically, the Helsinki (Helsinki University Hos- pital) experience so far:
1. There is a learning curve of 20-30-40 cases.
2. In the beginning slower than microdiscectomy (positioning, irrigation, X-rays, surgical skills).
3. It is probably a good idea to gather enough cases for the same team (and a surgeon/s) within a short period of time in order to accumulate enough experience
4. The team experience is mandatory.
5. In the beginning conversions to microdiscecto-
my (10%).
6. In the beginning more residuals/residives
(20%).
7. The author has had one clear complication:
new, clear sensory and mild motor S1 - paresis. It’s mandatory not to try “too much” when you’re on the learning curve.
8. The transforaminal route in the beginning more difficult (because it’s not the “usual” route)
9. Previous experience in endoscopy/lumbar injec-
tions may help
10. Easier (to gain ”n”, ie. experience) if you already
see high flow of cases in your institue
11. Infections or hematomas extremely rare
12. Excellent visibility, optics at the target
13. As with microdiscectomy, the vast majority
benefit clearly
14. Extremely mini-invasive, “true MISS”
15. Fast recovery
16. In suitable cases the best way to decompress the
nerve
What’s next in Helsinki:
1. Simple root bony decompressions 2. Cervical foraminotomies
Meanwhile, in Turku University Hospital: close to 20 lumbar discs operated on by 3 neurosurgeons.
Moreover, 35 cases of thoracic disc herniations
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operated endoscopically by a neurosurgeon + thoracic surgeon. One lung anaesthesia. 3D endoscope. 85% of patients reported good outcome 2 months postoperatively.
What’s next?
In short, setting up a system for spinal endoscopy requires money and effort. There is a learning curve for the whole team. It seems, however, that endoscopy is the next logical step of MISS, demanded also more and more by the patients and supported by minimal tissue damage, possibly a shorter recovery time and excellent results.
It thus comes as no surprise that globally endoscopic decompressions are increasing in number and have been utilized in the settings of degenerative spinal stenosis in lumbar, cervical and thoracic spine, but even in spondylolisthesis, scoliosis, previous fusion, tumor and infection. Furthermore, endoscopic lumbar interbody fusion has also been routinely utilized even under local anaesthesia.
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Figure 1. Translaminar approach.
Figure 1. Translaminar approach.
Figure 2. Transforaminal approach
Figure 2. Transforaminal approach
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The evidence of HTO versus UKA for the treatment of medial knee osteoarthritis
Juuso Siren, MD1; Lasse Rämö, MD, PhD1; Jussi Kosola, MD, PhD2; Jan Lindahl, MD, PhD1
1 Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospi- tal, Helsinki, Finland
2 Department of Orthopaedics and Traumatology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
The knee osteoarthritis (OA) is a common medical condition negatively affecting patients’ everyday lives and creating economic burden to societies.(1-3) Knee OA is often related to varus deformity and has various treatment options.(4) After failed nonsurgical treatment, total knee arthroplasty (TKA) has been performed traditionally. Although TKA has been shown to be superior to nonsurgical treatment,(5) around 20% of patients are not satisfied with TKA.(6-8) In addition to TKA, various surgical approaches to knee OA have been described. In isolated medial unicompartmental knee OA, high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are widely used.(9)
In UKA, the damaged medial cartilage surfac- es are replaced by intra-articular implants. UKA has been shown to result in a faster recovery after surgery, to be cost-effective, with no difference in patient reported outcomes, re-operations, or complications compared with TKA.(10, 11) However, TKA is still widely used as the gold standard for treating medial knee OA. It has been speculated that UKA could be a suitable treatment option up to 25–48% of patients suffering from knee OA.(4)
HTO is a joint sparing operation for medial knee OA. The aim of HTO is to shift weight towards the healthy lateral compartment of the knee using an extra-articular valgus osteotomy. Though HTO has traditionally been used in early OA, it has also been performed in patients with late-stage OA with good long-term outcomes.(12, 13) HTO can be performed with an open- or closing wedge technique and it does not seem to influence clinical outcomes.(14) In 2014, Cochrane analysis concluded that HTO reduces pain and improves knee function
after failed conservative treatment but there are no studies comparing HTO with nonoperative treatment.(15) However, there is an RCT comparing HTO with valgus bracing showing better outcomes in pain reduction with HTO. There was no difference in knee function scores between the groups. (16) The survivorship of HTO in literature is reported to be between 75–95% in 5 years and 51–98% in 10 years, when conversion to TKA is used as an end point.(17-22)
Despite there are no proper RCTs comparing HTO with UKA, several meta-analyses have compared these treatment options for medial knee OA. UKA showed a slightly better patient related outcomes and slightly better results in pain reduction whereas HTO resulted in better range of motion. Also, UKA resulted in less complications compared with HTO. There were no differences in the conversion rate to TKA.(23-25) Based on registry data, the survival of TKA after previous UKA is reduced compared to previous HTO.(26, 27)
Currently, there is no high-quality evidence to answer the question whether HTO or UKA leads to superior outcomes in the surgical treatment of medial knee OA.
References
1. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis. 2014;73(7):1323-30.
2. Sharma L. Osteoarthritis of the Knee. N Engl J Med. 2021;384(1):51-9.
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3. Katz JN, Arant KR, Loeser RF. Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review. JAMA. 2021;325(6):568-78.
4. Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. Knee. 2009;16(6):473-8.
5. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015;373(17):1597-606.
6. Shannak O, Palan J, Esler C. A regional registry study of 216 patients investigating if patient satisfaction after total knee arthroplasty changes over a time period of five to 20years. Knee. 2017;24(4):824-8.
7. Baker PN, van der Meulen JH, Lewsey J, Gregg PJ, National Joint Registry for E, Wales. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007;89(7):893- 900.
8. Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand. 2000;71(3):262-7.
9. McCormack DJ, Puttock D, Godsiff SP. Medial compartment osteoarthritis of the knee: a review of surgical options. EFORT Open Rev. 2021;6(2):113-7.
10. Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, et al. The clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (TOPKAT): 5-year outcomes of a randomised controlled trial. Lancet. 2019;394(10200):746- 56.
11. Knifsund J, Niinimaki T, Nurmi H, Toom A, Keemu
H, Laaksonen I, et al. Functional results of total-knee arthroplasty versus medial unicompartmental arthroplasty: two-year results of a randomised, assessor-blinded multicentre trial. BMJ Open. 2021;11(6):e046731.
12. Jin QH, Lee WG, Song EK, Jin C, Seon JK. Comparison of Long-Term Survival Analysis Between Open-Wedge High Tibial Osteotomy and Unicompartmental Knee Arthroplasty. J Arthroplasty. 2021;36(5):1562-7 e1.
13. Shon OJ, Park SJ, Shim BJ, Lee DY. Comparative Study of Clinical and Radiographic Outcomes of High Tibial Osteotomy in Patients with Kissing Lesions and Non-Kissing Lesions. Knee Surg Relat Res. 2017;29(4):288-94.
14. Nerhus TK, Ekeland A, Solberg G, Olsen BH, Madsen JE, Heir S. No difference in time-dependent improvement in functional outcome following closing wedge versus opening wedge high tibial osteotomy: a randomised controlled trial with two-year follow-up. Bone Joint J. 2017;99-B(9):1157-66.
15. Brouwer RW, Huizinga MR, Duivenvoorden T, van Raaij TM, Verhagen AP, Bierma-Zeinstra SM, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2014(12):CD004019.
16. van Outeren MV, Waarsing JH, Brouwer RW, Verhaar JAN, Reijman M, Bierma-Zeinstra SMA. Is a high tibial osteotomy (HTO) superior to non-surgical treatment in patients with varus malaligned medial knee osteoarthritis (OA)? A propensity matched study using 2 randomized controlled trial (RCT) datasets. Osteoarthritis Cartilage. 2017;25(12):1988-93.
17. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to -22-year followup study. Clin Orthop Relat Res. 1999(367):18-27.
18. Niinimaki TT, Eskelinen A, Mann BS, Junnila M, Ohtonen P, Leppilahti J. Survivorship of high tibial osteotomy
in the treatment of osteoarthritis of the knee: Finnish registry-based study of 3195 knees. J Bone Joint Surg Br. 2012;94(11):1517-21.
19. Billings A, Scott DF, Camargo MP, Hofmann AA. High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am. 2000;82(1):70-9.
20. Gstottner M, Pedross F, Liebensteiner M, Bach C. Long-term outcome after high tibial osteotomy. Arch Orthop Trauma Surg. 2008;128(1):111-5.
21. Hui C, Salmon LJ, Kok A, Williams HA, Hockers N, van der Tempel WM, et al. Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am J Sports Med. 2011;39(1):64-70.
22. Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003;85(3):469- 74.
23. Fu D, Li G, Chen K, Zhao Y, Hua Y, Cai Z. Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis. J Arthroplasty. 2013;28(5):759-65.
24. Cao Z, Mai X, Wang J, Feng E, Huang Y. Unicompartmen- tal Knee Arthroplasty vs High Tibial Osteotomy for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. J Arthroplasty. 2018;33(3):952-9.
25. Santoso MB, Wu L. Unicompartmental knee arthroplasty, is it superior to high tibial osteotomy in treating unicompartmental osteoarthritis? A meta-analysis and systemic review. J Orthop Surg Res. 2017;12(1):50.
26. Robertsson O, A WD. The risk of revision after TKA is affected by previous HTO or UKA. Clin Orthop Relat Res. 2015;473(1):90-3.
27. El-Galaly A, Nielsen PT, Kappel A, Jensen SL. Reduced survival of total knee arthroplasty after previous unicompartmental knee arthroplasty compared with previous high tibial osteotomy: a propensity-score weighted mid-term cohort study based on 2,133 observations from the Danish Knee Arthroplasty Registry. Acta Orthop. 2020;91(2):177-83.
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Evaluation of chondral injuries and cartilage repair
Jani Puhakka
Schulthess Klinik, Zürich, Switzerland
Introduction
Articular cartilage is a highly specialized connec- tive tissue in diarthrodial joints, allowing skeletal load transfer during motion due to its sophisticat- ed composition. The chondrocytes in the articular cartilage are embedded in a hydrated extracellular matrix (ECM), including collagen fibers and pro- teoglycans. Hyaline chondrocytes' unique viscoelas- tic and mechanical properties are possible because of the ECM's organized structure.
Degeneration and injuries to the joint can cause structural changes in the hyaline cartilage, which leads to dysfunction and pain. Cartilage repair can be used to treat these conditions. It aims to fill the defect and to create a biomechanical function that is similar to that of the original articular cartilage. (1,2) The lack of blood vessels and lymphatic supply makes repair of cartilage lesions in hyaline cartilage difficult.(3) Surgical therapies ranging from bone-marrow stimulation to osteochondral grafting and autologous chondrocyte implantation have been used to overcome this challenge.(4,5) As well as developing the cartilage repair techniques, it is essential to evaluate the outcomes of these procedures. Different methods, including imaging techniques, arthroscopy, and histology, have been used for assessing the tissue morphology to assess cartilage repair success.(6-9)
As the higher quality of repair tissue correlates with better clinical outcomes, repair quality may be an objective measure to evaluate the repair technique.(10-12) Using both histological or arthroscopic methods, you can evaluate the structural outcome of cartilage repair and cartilage pathologies.(1,13-17) Additionally, repair tissue quality may serve as a primary outcome measure in studies without achievable clinical outcomes (e.g., feasibility studies and animal studies).(8)
The histological analysis of articular cartilage pro- vides detailed information about the tissue structure. However, it is an invasive procedure that requires a cartilage biopsy, leading to additional tissue morbidity. An arthroscopic evaluation, which does not require a tissue sample and correlates with histological findings, could reduce the need to use more invasive methods for assessing cartilage repair results in a clinical setting.
Arthroscopic evaluation of cartilage lesions and cartilage repair
Arthroscopy is considered the gold standard for grading cartilage lesions and cartilage repair. The In- ternational Cartilage Repair Society (ICRS) score is often used to describe cartilage lesions.(10) This score distinguishes four grades of cartilage lesions: grade 0 (normal), grade 1 lesions (superficial softening and/ or superficial fissures and cracks, grade 2 lesions (lesions extending down to \50% of cartilage depth), grade 3 lesions (severely abnormal with an extension of the lesions to the subchondral bone) and finally the complete defect (severely abnormal) (Figure 1). Spahn et al. studied the reliability of this arthroscopic grading and concluded that the arthroscopic grading of cartilage lesions is poor, and more objective measurement methods should be developed. (18)
In a novel cartilage repair animal model, we studied the inter-rater and intra-rater reliability of arthroscopic ICRS grading (Table 1). We concluded that the ICRS grading system has only poor to moderate reliability for evaluating cartilage repair in the porcine cartilage repair model. We also highlighted the need for novel objective methods to evaluate cartilage repair.(19)
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F
E
T
(
Figure 1. The ICRS cartilage injury classification. (Reprinted from the ICRS Cartilage Injury Evaluation Package [www.cartilage.org]
Table 1. Arthroscopic evaluation of cartilage repair with International Cartilage Repair Society (ICRS) scoring system.(10)
Cartilage repair assessment ICRS
Points
Degree of defect repair
In level with surrounding cartilage
4
75% repair of defect depth
3
50% repair of defect depth
2
25% repair of defect depth
1
0% repair of defect depth
0
Integration to the border zone
Complete integration with surrounding cartilage
4
Demarcating border < 1 mm
3
3/4th of graft integrated, 1/4th with a notable border > 1 mm width
2
1/2 of graft integrated with surrounding cartilage, 1/2 with a notable
border > 1 mm
1
From no contact to 1/4th of graft integrated with surrounding cartilage
0
Macroscopic appearance
Intact smooth surface
4
Fibrillated surface
3
Small, scattered fissures or cracks
2
Several, small or few but large fissures
1
Total degeneration of the grafted area
0
Overall repair assessment
Grade I: normal
12
Grade II: nearly normal
11–8
Grade III: abnormal
7–4
Grade IV: severely abnormal
3-1
igure 1. The ICRS cartilage injury classification. (Reprinted from the ICRS Cartilage Injury
valuation Package [www.cartilage.org]
Comparison Between Arthroscopic and Discussion Histologic International Cartilage Repair
Society Scoring systems
What makes this arthroscopic assessment unrelia-
able 1. Arthroscopic evaluation of cartilage repair with International Cartilage Repair Society
To understand how arthroscopy can inform us about
ble? Arthroscopic classifications are mainly designed
to evaluate a single point on the cartilage surface.
CRS) scoring system.(10)
the cartilage repair's histological quality, we evaluated CthaertairltahgroescroeppicaiIrCaRsSseinssamn eanitmIaClRmSodel correlat- ed it against histological ICRS gradings. Arthroscop-
Unfortunately, the defect and cartilage repair tissue
ic and histologic ICRS scoring methods for repaired
a cartilage repair or cartilage defect with arthrosco-
py, you see a gradient of different repair results or
cartilage defects. In contrast, histological ICRS as-
sessment is done from a preselected single stained
from the selected section.
We tested this in our animal model by develop-
Degree of defect repair
articular cartilage showed a moderate correlation
(r=0.49 and r=0.5). In this study, the arthroscopic
In level with surrounding cartilage
4
ICRS grading system showed good inter-rater reliabil-
section showing a more detailed structure but only
ity, and the histologic ICRS grading system showed excellent inter-rater reliability.(20)
3
75% repair of defect depth
are often heterogeneous. Therefore, while evaPluoaitnintsg
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50% repair of defect depth
2
I

ing a simplified scoring method (AREA) that also considers heterogeneity. In a reliability study setup, we cave binomial results (good/bad) for each quad- rant of the cartilage repair. AREA grading produced a score from 0 (zero quadrants were good) to 4 (4 quadrants were good). With this method, the inter-rater reliability showed moderate to good reliability and intra-rater reliability poor to good reliability. This method also showed better reliability than ICRS grading. (Puhakka et al. 2022, unpublished)
The unreliability of subjective methods based on visual assessment of 2D vision is not ideal for cartilage studies and clinical use. More advanced and objective methods should be developed and used for cartilage evaluation. Several novel arthroscopic methods have been introduced to assess the severity of damage in hyaline cartilage, e.g., mechanical testing of cartilage stiffness, high-frequency ultrasound, mechano-acoustical testing, optical coherence tomography, and optical coherence tomography electro-mechanical testing.(21-30) These methods might make performing arthroscopic as- sessments of cartilage defects and repair easier and more reliable. However, none have been validated to determine the quality and quantity of repaired tissue. Their validity has only been studied to assess the damage done to native hyaline cartilage. It is unclear if their excellent ability to detect damage in hyaline cartilage makes them useful for determining the quality and quantity of repair tissue.
References
1.Ahsan T, Sah RL. Biomechanics of integrative cartilage repair. Osteoarthritis Cartilage. 1999;7(1):29-40.
2.Fahy N, Alini M, Stoddart MJ. Mechanical stimulation of mesenchymal stem cells: Implications for cartilage tissue engineering. J Orthop Res. 2018;36(1):52-63.
3.Widuchowski W, Widuchowski J, Trzaska T. Articular cartilage defects: study of 25,124 knee arthroscopies. Knee. 2007;14(3):177-82.
4.Brittberg M. Autologous chondrocyte implantation--technique and long-term follow-up. Injury. 2008;39 Suppl 1:S40-9.
5.Hunziker EB. Articular cartilage repair: basic science and clinical progress. A review of the current status and prospects. Osteoarthritis Cartilage. 2002;10(6):432-63.
6.Chang G, Sherman O, Madelin G, Recht M, Regatte R. MR
imaging assessment of articular cartilage repair procedures. Magn Reson Imaging Clin N Am. 2011;19(2):323-37.
7.Rutgers M, van Pelt MJ, Dhert WJ, Creemers LB, Saris DB. Evaluation of histological scoring systems for tissue-engineered, repaired and osteoarthritic cartilage. Osteoarthritis Cartilage. 2010;18(1):12-23.
8.Smith GD, Taylor J, Almqvist KF, Erggelet C, Knutsen G, Garcia Portabella M, et al. Arthroscopic assessment of cartilage repair: a validation study of 2 scoring systems. Arthroscopy. 2005;21(12):1462-7.
9.van den Borne MP, Raijmakers NJ, Vanlauwe J, Victor
J, de Jong SN, Bellemans J, et al. International Cartilage Repair Society (ICRS) and Oswestry macroscopic cartilage evaluation scores validated for use in Autologous Chondrocyte Implantation (ACI) and microfracture. Osteoar- thritis Cartilage. 2007;15(12):1397-402.
10.Brittberg M, Winalski CS. Evaluation of cartilage injuries and repair. J Bone Joint Surg Am. 2003;85-A Suppl 2:58-69.
11.Brun P, Dickinson SC, Zavan B, Cortivo R, Hollander AP, Abatangelo G. Characteristics of repair tissue in second-look and third-look biopsies from patients treated with engineered cartilage: relationship to symptomatology and time after implantation. Arthritis Res Ther. 2008;10(6):R132.
12.Riyami M, Rolf C. Evaluation of microfracture of traumatic chondral injuries to the knee in professional football and rugby players. J Orthop Surg Res. 2009;4:13.
13.Dzioba RB. The classification and treatment of acute articular cartilage lesions. Arthroscopy. 1988;4(2):72-80.
14.Oakley SP, Lassere MN. A critical appraisal of quantitative arthroscopy as an outcome measure in osteoarthritis of the knee. Semin Arthritis Rheum. 2003;33(2):83-105.
15.Oakley SP, Portek I, Szomor Z, Appleyard RC, Ghosh P, Kirkham BW, et al. Arthroscopy -- a potential "gold standard" for the diagnosis of the chondropathy of early osteoarthritis. Osteoarthritis Cartilage. 2005;13(5):368-78.
16.Olesen ML, Christensen BB, Foldager CB, Hede KC, Jorgensen NL, Lind M. No Effect of Platelet-Rich Plasma Injections as an Adjuvant to Autologous Cartilage Chips Im- plantation for the Treatment of Chondral Defects. Cartilage. 2019:1947603519865318.
17.Schuttler KF, Gotschenberg A, Klasan A, Stein T, Pehl A, Roessler PP, et al. Cell-free cartilage repair in large defects of the knee: increased failure rate 5 years after implantation of a collagen type I scaffold. Arch Orthop Trauma Surg. 2019;139(1):99-106.
18.Spahn G, Klinger HM, Baums M, Pinkepank U, Hofmann GO. Reliability in arthroscopic grading of cartilage lesions: results of a prospective blinded study for evaluation
of inter-observer reliability. Arch Orthop Trauma Surg. 2011;131(3):377-81.
19.Puhakka J, Paatela T, Salonius E, Muhonen V, Meller A, Vasara A, et al. Arthroscopic International Cartilage Repair Society Classification System Has Only Moderate Reliability in a Porcine Cartilage Repair Model. Am J Sports Med. 2021;49(6):1524-9.
20.Puhakka J, Salonius E, Paatela T, Muhonen V, Meller A, Vasara A, et al. Comparison Between Arthroscopic and
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Histological International Cartilage Repair Society Scoring Systems in Porcine Cartilage Repair Model. Cartilage. 2022;13(1):19476035211069246.
21.Kaleva E, Viren T, Saarakkala S, Sahlman J, Sirola J, Puhakka J, et al. Arthroscopic Ultrasound Assessment of Articular Cartilage in the Human Knee Joint: A Potential Diagnostic Method. Cartilage. 2011;2(3):246-53.
22.Puhakka J, Afara IO, Paatela T, Sormaala MJ, Timonen MA, Viren T, et al. In Vivo Evaluation of the Potential of High-Fre- quency Ultrasound for Arthroscopic Examination of the Shoulder Joint. Cartilage. 2016;7(3):248-55.
23.Lyyra T, Jurvelin J, Pitkanen P, Vaatainen U, Kiviranta I. Indentation instrument for the measurement of cartilage stiffness under arthroscopic control. Med Eng Phys. 1995;17(5):395-9.
24.Lyyra T, Arokoski JP, Oksala N, Vihko A, Hyttinen M, Jurvelin JS, et al. Experimental validation of arthroscop-
ic cartilage stiffness measurement using enzymatically degraded cartilage samples. Phys Med Biol. 1999;44(2):525- 35.
25.Kiviranta P, Lammentausta E, Toyras J, Nieminen HJ, Julkunen P, Kiviranta I, et al. Differences in acoustic properties of intact and degenerated human patellar cartilage during compression. Ultrasound Med Biol. 2009;35(8):1367-75.
26.Kiviranta P, Lammentausta E, Toyras J, Kiviranta I, Jurvelin JS. Indentation diagnostics of cartilage degeneration. Oste- oarthritis Cartilage. 2008;16(7):796-804.
27.Niemela T, Viren T, Liukkonen J, Arguelles D, te Moller NC, Puhakka PH, et al. Application of optical coherence tomography enhances reproducibility of arthroscopic evaluation of equine joints. Acta Vet Scand. 2014;56:3.
28.Becher C, Ricklefs M, Willbold E, Hurschler C, Abedian R. Electromechanical Assessment of Human Knee Articular Cartilage with Compression-Induced Streaming Potentials. Cartilage. 2016;7(1):62-9.
29.Sim S, Hadjab I, Garon M, Quenneville E, Lavigne P, Buschmann MD. Development of an Electromechanical Grade to Assess Human Knee Articular Cartilage Quality. Ann Biomed Eng. 2017;45(10):2410-21.
30.Sim S, Chevrier A, Garon M, Quenneville E, Yaroshinsky A, Hoemann CD, et al. Non-destructive electromechanical assessment (Arthro-BST) of human articular cartilage correlates with histological scores and biomechanical properties. Osteoarthritis Cartilage. 2014;22(11):1926-35.
Suomen Ortopedia ja Traumatologia Vol. 45
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Malpractice and Patient Injuries in Orthopedic and Trauma Treatment
Eero Hirvensalo
Helsinki University Hospital and Patient Insurance Centre
Introduction
The Act for Patient Insurance came into force on May 1, 1987. All persons working in the health care with patients must be insured. A corresponding patient insurance organization is present in each Nordic Country but is not seen in this level in other countries. All patient claims are analyzed by the Centre by using a large group of specialists. Patients suffering of maltreatment, severe infection, accident during treatment or some unexpected serious complication can lead to compensation from an insurance company after the decision made by lawyers in Patient Insur- ance Centre. This evaluation is based on non – guilt principle, which gives a legal support for each health care worker. Since 1987 the civil trials because of maltreatment have diminished dramatically. Operative injuries make the largest subgroup of compensated injuries. Orthopedics and Traumatology, including hand surgery and in the spine region also neurosur- gery, covers nearly half of the annual cases. The injuries are concentrated in specific regions and operative procedures. Therefore, the compensated cases in the past years deserve to be discussed in the clinical forum. Data from the Patient Insurance Centre has been used for this analysis (1).
Patient Injuries in 2021
Finnish Patient Insurance Center solved 8.700 claims in 2021 sent by patients suspecting a potential patient injury in their treatment. Of these, around 2.300 cases (23%) were considered as patient injuries and were compensated. The majority of these were treatment injuries (80%). Because of severe postoperative infection compensation was given in 108 (4.6%) cases.
Injuries in operative treatment or false decision making and treatment in orthopedic and trauma-field are constantly proportionally high covering about one fourth of all cases (360 operation injuries and about 250 other treatment injuries). These number, however, cover all trauma, e.g., conservative trauma treatment done by non-specialized phy- sicians in primary health care.
The proportion of injuries in the private clinics is growing, being 23% of all injuries in the operative surgery in 2021 (Table 1).
Patient Injuries compensated in 2019 - 2021
Hip and knee arthroplasties have become the leading operative procedure in orthopedics. They are also associated with numerous patient injuries (Table 2 and 3). The most frequent technical errors in hip arthroplasties are inadequate acetabular cup positioning, wrong femoral component size selection and positioning, ne- glected iatrogenic fracture of the femur, unattended lengthening of the extremity over 1.5 cm and ischial nerve injuries. In total knee arthroplasties wrong implant positioning (rotation, varus-valgus) and implant size are year by year the most often seen problems. Vascular and neural injuries in the knee region as a rare complication have also been recognized. Infec- tion injuries in both major endoprosthesis groups are compensatedinmostseverecases,whenevertheindi- vidual risks for infection were not evaluated too high.
Operative injuries are frequent also in ankle fractures. Malreduction, malposition of the screws and in- sufficient fixation have been the main causes for compensation. Cases of missed diagnoses and instability of the ankle injury have been almost as numerous as operative errors.
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Table 1. Compensated patient injuries in 2021 categorized in five subgroups.
Table 1. Compensated patient injuries in 2021 categorized in five subgroups.
In fractures of the distal antebrachium insuffi- cient evaluation of the fracture type, delayed consultation of hand surgeons or orthopedic surgeons and poor results after conservative treatment cover most of the compensated cases. Missed diagnosis and thereby maltreatment is also frequently seen in carpal (scaphoid), metacarpal and digital fractures, as well as false diagnosis and decision making in ligamentous, tendon, vascular and neural injuries in the hand region (Table 2).
In elective hand surgery, suboptimal treatment (e.g. neural injuries) is seen in neurolysis (canalis carpi). Compensated injuries are frequent also in arthrodesis and in ligamentous repair in the hand region (arthroscopic hand surgery).
Technical errors are relatively numerous in operative treatment of humeral, femoral and tibial fractures. Malreduction, rotational and angular var- iation, neural injuries and malposition of the implants and screws are the usual reasons for compensation.
In elderly patients missed diagnosis of fractures
of the proximal hip, pelvis and spine is a special subgroup to be mentioned. Compensated operative claims are in the same numeral level compared to the diagnostic error- subgroup.
Repair of ligamentous injuries of the knee leads to complications especially in ACL- surgery. Most of these patient injuries occurred in the private clinics (Table 3). The main reason for compensation is incorrect positioning of the graft. Similar- ly, compensated surgical claims in shoulder surgery are concentrated in the private clinics where a growing number of cases have been operated in the past years.
Technical errors in spinal surgery were seen most often in decompressive and spinal fusion surgery. Direct intradural lesion and root injuries because of false positioning of the screws are still frequent, seen even in computer assisted surgery. Injuries associated with intervertebral disc surgery are less frequent compared to the decompressive surgery. The total amount of operations is also smaller. However, in herniated disc -subgroup (M51) delayed treat-
Vuonna 2021 ratkaistut korvattavat potilasvahingot Vahinkojen lukumäärä
0 100 200 300 400
500 600
700 800 900
Tuki- ja liikuntaelinten leikkaustoimenpiteet
Muut leikkaus- tai anestesiatoimenpi- teet
Kliiniset tutkimus- tai hoitotoimenpiteet
Hammashoito Muut toimenpiteet
Julkinen sektori
Yksityinen sektori
Suomen Ortopedia ja Traumatologia Vol. 45
1 • 2022 SOT 89
134
229
276
346
184
498
52
84
97
102

Table 2. Compensated patient injuries, 30 most frequent diagnoses categorized in three
Table 2. Compensated patient injuries, 30 most frequent diagnoses categorized in three subgroups.
subgroups.
YLEISIMMÄT PERUSSAIRAUDET VUOSINA 2019-2021 RATKAISTUISSA KORVATTAVISSA POTILASVAHINGOISSA
PERUSSAIRAUS
TOIMENPIDE
LEIKKAUS TAI ANESTESIA
KLIININEN TUTKIMUS- TAI HOITO
MUU TOIMEN- PIDE
LUKU- MÄÄRÄ YHTEENSÄ
1.
K04
Hammasytimen ja hampaanjuuren kärkeä ympäröivien kudosten sairaudet
14
0
367
381
2.
K08
Muut hampaiden ja tukikudosten sairaudet
112
0
177
289
3.
M16
Lonkan nivelrikko
188
10
4
202
4.
M17
Polven nivelrikko
171
12
13
196
5.
S82
Polven ja/tai säären murtuma
94
66
20
180
6.
K02
Hammaskaries
6
1
161
168
7.
S52
Kyynärvarren murtuma
57
93
12
162
8.
S62
Ranteen tai käden murtuma
18
89
12
119
9.
M48
Muut nikamasairaudet
93
18
6
117
10.
S72
Reisiluun murtuma
46
47
17
110
10 YLEISIMMÄN PERUSSAIRAUDEN OSUUS
28 %
11.
S83
Polven alueen nivelten ja siteiden sijoiltaanmeno, nyrjähdys ja/tai venähdys
68
17
7
92
12.
S42
Hartianseudun tai olkavarren murtuma
44
34
12
90
13.
M51
Muut nikamavälilevyjen sairaudet
53
32
3
88
14.
M20
Sormien ja varpaiden hankinnaiset epämuotoisuudet
79
1
0
80
15.
K05
Hampaan kiinnityskudosten sairaudet
35
1
40
76
16.
H25
Vanhuudenkaihi
67
6
1
74
17.
C50
Rintasyöpä
23
20
31
74
18.
K80
Sappikivitauti
58
10
4
72
19.
S63
Ranteen tai käden nivelten ja siteiden sijoiltaanmenot, nyrjähdykset ja/tai venähdykset
20
41
3
64
20.
S66
Ranteen ja käden lihas- ja jännevamma
5
47
6
58
20 YLEISIMMÄN PERUSSAIRAUDEN OSUUS
40 %
21.
K35
Äkillinen umpilisäketulehdus
38
16
4
58
22.
S92
Nilkan/jalkaterän murtuma
8
39
10
57
23.
M19
Muut nivelrikot
52
0
1
53
24.
I63
Aivoinfarkti
3
43
7
53
25.
G56
Yläraajan yhden hermon sairaudet
44
5
2
51
26.
R10
Vatsa- ja lantiokipu
9
31
10
50
27.
M54
Selkäsärky
1
40
9
50
28.
S76
Lonkan/reiden lihas/jännevamma
14
34
2
50
29.
K40
Nivustyrä
43
5
1
49
30.
S02
Pääkopan ja /tai kasvojen luiden murtuma
7
2
35
44
30 YLEISIMMÄN PERUSSAIRAUDEN OSUUS
47 %
ment is more often seen. Severe neural complications result because of wrong diagnostic and treatment pathways. The role of conservative treatment seems to be overestimated even in severe cases with neural impairment symptoms. This tendency is seen also in the degenerative spine - patient group (M48) with neural disorders (registered in addition together with the herniated disc subgroup as ischial or lumbar pain in the diagnosis group M54).
In foot and ankle surgery operative errors are prominent in arthrodesis subgroup (Table 3). Es- pecially wrong positioning and poor fixation of the toe in MTP-arthrodesis are common. Less frequent are the compensated cases in distal osteotomy-procedures of the first metatarsal bone.
Discussion
Operative patient injuries are still quite common in orthopedic and trauma care. Cumulative information of the compensated patient injuries should be discussed thoroughly in each health care unit. Especially recurrent and numerous injuries should promote evaluation of possible preventive acts and possible correction measures of the treatment pro- cesses. This is especially important when analyzing how to avoid delayed diagnosis and treatment. It is also important when finding solutions for more safe and accurate operative techniques. In cases, where the primary indication of surgery is relative, more attention should be given to alternative
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Table 3. Cumulative 3-year-data of the most frequent compensated surgical injuries (2019-2021)
Table 3. Cumulative 3-year-data of the most frequent compensated surgical injuries (2019-2021)
TOIMENPIDE
JULKINEN SEKTORI
YKSITYINEN SEKTORI
YHTEENSÄ
YKSITYISEN SEKTORIN OSUUS
1.
NFB
Lonkan tekonivelleikkaukset
206
4
210
2%
2.
NGB
Polven tekonivelleikkaukset
149
7
156
4%
3.
EBB
Hampaiden kiruginen korjaaminen tai korvaaminen
5
121
126
96 %
4.
ABC
Selkäytimen ja hermojuurien vapautus rappeuman yhteydessä
104
16
120
13 %
5.
NAG
Selkärangan luudutusleikkaukset ja vastaavat
92
6
98
6%
6.
NHG
Nilkan ja jalkaterän nivelien muovausleikkaukset ja luudutukset
79
14
93
15 %
7.
EBA
Hampaiden poistot
54
23
77
30 %
8.
CJE
Kaihileikkaukset ultraäänitekniikalla ja niihin liittyvät toimenpiteet
47
25
72
35 %
9.
LCD
Kohdunpoistot
62
5
67
7%
10.
NGE
Polven nivelside- ja kapselileikkaukset
12
53
65
82 %
10 YLEISIMMÄN TOIMENPITEEN OSUUS
39 %
11.
NHJ
Nilkan, jalkaterän ja varpaiden murtumaleikkaukset
48
4
52
8%
12.
NCJ
Kyynärvarren murtumaleikkaukset
48
3
51
6%
13.
ACC
Ääreishermojen toimintahäiriökorjaukset
41
8
49
16 %
14.
JKA
Sappirakon leikkaukset
45
2
47
4%
15.
JAB
Nivustyrän leikkaukset
40
6
46
13 %
16.
JFB
Ohut- ja paksusuolen typistysleikkaukset
43
2
45
4%
17.
NBJ
Olkapään ja olkavarren murtumaleikkaukset
35
3
38
8%
18.
JEA
Umpilisäkkeen poistot
37
0
37
0%
19.
NGJ
Säären ja polvilumpion murtumaleikkaukset
36
1
37
3%
20.
BAA
Kilpirauhasen leikkaukset
35
0
35
0%
20 YLEISIMMÄN TOIMENPITEEN OSUUS
55 %
21.
NHK
Jalkaterän luuleikkaukset
25
10
35
29 %
22.
UJF
Ohut- ja paksusuolen tähystykset
23
5
28
18 %
23.
NDJ
Ranne/kämmen/sormimurtumien leikkaukset
17
7
24
29 %
24.
NFC
Lonkan tekonivelien uusintaleikkaukset
23
1
24
4%
25.
NFJ
Reisiluun murtumaleikkaukset
23
0
23
0%
26.
NDG
Ranne-/käsinivelien muovaukset/luudutuks
20
3
23
13 %
27.
NBL
Olkapään ja olkavarren lihas- ja jänneleikkaukset
7
16
23
70 %
28.
NDE
Ranne- ja käsinivelien kapselien ja nivelsiteiden leikkaukset
6
17
23
74 %
29.
HAD
Rintarauhasen muotoa korjaavat leikkaukset
12
10
22
45 %
30.
CKD
Silmän sisällä tehtävät lasiais- ja verkkokalvotoimenpiteet
21
1
22
5%
30 YLEISIMMÄN TOIMENPITEEN OSUUS
64 %
treatment choices instead of operative treatment, especially if the data shows increased number of patient injuries associated with this specific technique.
Infection injuries are compensated only in the most severe cases. This does not mean, that this problem could be ignored. Meticulous surgical technique and proper implant selection and position without excessive soft tissue damage should be preferred whenever possible. The vascular status of the operation area should be sufficient for any intervention. Postoperative infection causes always delay of the healing and in several cases a suboptimal end-result.
References
Annual public data, Patient Insurance Centre (2019 - 2021)
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Treatment of lateral clavicle fractures
Karl Wieser, MD, Balgrist University Hospital, University of Zurich
Fractures of the distal third of the clavicle account for approximately 15% of all clavicle fractures. Those with coracoclavicular instability corresponding to Neer type IIB and V represent up to 50% and are particularly prone to the development of nonunion. Thus, the treatment of displaced distal clavicle fractures remains challenging, as they are associated with rupture or avulsion of the coracoclavicular ligaments and a small lateral fragment with limited screw purchase. Conservative treatment of distal clavicle fractures is associated with up to 30% nonunions, which are no less challenging to treat. If treated surgically, clavicle hook plates are broadly used owing to their easy applicability and good union rates. However, these implants almost always need to be removed after bony consolidation and are associated with a number of complications such as acromial osteolysis, degenerative changes of the acromioclavicular joint, subacromial bursitis, and if used without arthroscopic assistance iatrogenic rotator cuff lesions.
Indirect reduction and stand-alone coracoclavicular fixation using a coracoclavicular screw has been introduced into clinical practice in 1991. In a recent biomechanical study, supplementary or stand-alone coracoclavicular fixations have outperformed fixation using a distal clavicle locking plate with a 75% higher construct strength.
We present the clinical and radiologic outcome of a consecutive series of patients treated by a stand- alone coracoclavicular and interfragmentary stabilization using a so-called cow-hitch technique with a suture anchor. It is a minimally invasive fixation technique without prominent hardware that allows for a well- controlled anatomic reduction and stable fixation of difficult-to-treat, comminuted fractures.
Nineteen patients were treated with a specific surgical technique for distal clavicle fractures with either rupture or bony avulsion of the coracoclavicular ligaments. All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of 1.8 mm. Sports activities were fully resumed after an average of 4.7 months.
The stand-alone cow-hitch suture repair for unstable distal clavicular fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication rate. Both radiographic and patient- reported long-term results are very satisfactory.
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Radiograph of a right clavicle preoperatively and 1 year postoperatively after stand-alone cow-hitch suture repair for this unstable distal clavicular fracture with normal coracoclavicular alignment and bony consolidation.
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Bankart fractures: Conservative or operative treatment
Karl Wieser, MD, Balgrist University Hospital, University of Zurich
Primary traumatic anterior shoulder dislocation can be associated with displaced fractures of the anteri- or glenoid rim. Such fractures occur in up to 21% of traumatic shoulder dislocations and are classified as either Ideberg type IA if the fragment is 5 mm or type IB if it is >5 mm. Ideberg type-IA fractures, or so-called chip fractures, can be treated nonoperatively, although there is a growing trend toward surgical stabilization of these fractures in young and active first-time dislocators. Despite a lack of evidence of su- periority over nonoperative treatment, many believe that surgical treatment is necessary to regain anatomic reduction because it reduces the risk of recurrent instability and posttraumatic osteoarthritis (OA). At our clinic, anterior glenoid rim fractures are treated nonoperatively regardless of fragment size and degree of displacement as long as post-reduction computed tomography (CT) scans reveal antero-posterior cen- tering of the humeral head on the glenoid (i.e., the humeral head does not follow the displaced fragment). This abstract presents the medium- to longterm results of a consecutive series of patients following nonoperative treatment of an anterior glenoid rim fracture, with particular attention paid to recurrent instability and development. 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years)
Fracture-healing was documented in all patients. Complete reduction or remodeling of the fragment with no or little irregularity at the articular fracture zone was observed in 23 patients (79%), and partial reduction with a step-off of 5 mm was observed in the remaining 7 cases (24%). Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1
patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive appre- hension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work.
Compared with the published data on arthroscopically treated patients by Markus Scheibel et al (JSES 2016), the radiographic results of the present study are at least comparable, if not superior. In the largest published cohort, 7 (33%) of 21 arthroscopically treated rim fractures showed an average residual postoperative step-off of 2 mm, with an overall osteoarthritis rate of almost 30% and with 3 cases (14%) graded as severe OA. Interestingly, the authors reported that a non-per- fect anatomic reduction with a postoperative step-off was not associated with a significantly increased OA rate, which is in accordance with the results of the present study. Therefore, it seems that the risk of degenerative changes is associated with the traumatic event itself (i.e., fracture-dislocation) rather than with nonanatomic fracture consolidation, and might even be amplified by surgical refixation.
Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients.
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Figure 1 CT scan of a patient with a glenoid rim fracture immediately after traumatic shoulder dislocation.
Figure 2: After 10 years a complete reduction and remodeling of the fragment can be seen
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Polviproteesin instabiliteetti
Mikko Manninen Orton Oy
Instability of the knee joint after total knee arthroplasty (TKA) is the most common non-infectious reason for revision arthroplasty surgery. In the Finnish Arthroplasty Register (FAR) 28% of all the knee revisions made during 2021 were performed because of TF joint instability. Instability can be classified as symmetrical flexion, mid-flexion, extension or hyperextension (genu recurvatum) or global multiplanar type. In addition to this, asymmetrical instability can affect the medial or the lateral structures of the TKA joint.
To evaluate reason for ”bad TKA knee” accurate physical examination is needed as well good quality X-rays (AP, lateral, mechanical axis). Computed tomography (CT) helps to find rotational malalignment of the components.
Stepwise diagnostics gives good idea of the type of instability. If the symptoms are harmful and severe, revision surgery should be considered. There has to be full range of components available in the revision unit. In operation the type of instability is confirmed and the procedure is then headed to correct the instability and other mechanical problems of the TKA. If needed, as in global instability, a rotating hinge type implants is needed.
Johdanto
Tekonivelpolven instabiliteetti on varsin yleinen uusintaleikkauksen syy. Britannian rekisterissä (NJR) instabiliteetti on syynä uuusintaleikkauk- siin 17,4 %:ssa (1). Suomen rekisterissä osuus vuosittain on lisääntynyt vuosien 2014-21 välillä 12%:sta n. 28%:iin (2). Instabiliteetin tunnista- minen, hoidon suunnittelu ja asianmukainen leikkaushoidon toteutus voivat parantaa huonoksi koetun polvitekonivelen.
Instabiliteetin oireet ja diagnoosi
Instabiliteetti aiheuttaa subjektiivisia oireita kuten kipua, altapettämistunnetta ja turvotusta. Se voi vaurioittaa muovi-inserttiä ja johtaa lisääntyvään epävakausoireeseen ja jopa täyteen luksaatioon.
Kliininen tutkimus on helppo, mikäli instabiliteetti on selkeä. Suhteellisen vähäisen, mutta
oireita aiheuttavan fleksioinstabiliteetin löytämi- nen sen sijaan voi vaatia erityistä tarkkaavaisuutta. Fleksioinstabiliteettiin voivat viitata pes anserinuk- sen tai tractus iliotibialiksen ärtyminen ja tendi- niitti tai verinen nesteily polvessa (4,5). Posterior sag sign (PSS) voi olla positiivinen, etusuunta kou- kussa testattuna voi olla poikkeuksellisen väljä tai vapaasti polvesta riippuvaa säärtä ekstensorilla nos- taessa suoraksi nähdään ennen ojentumista tibia- komponentin nousu kontaktiin reisikomponentin kanssa (8). Liiketestauksissa kiinnitetään huomio- ta liikkeen suoraviivaisuuteen ja mahdollisiin poik- keavuuksiin liikeradoissa.
Kuvantamisessa hyvälaatuiset ja suorat seisten otetut natiivikuvat ovat tärkeät. Alaraajan mekaa- ninen akseli kuvataan ja näistä yhdessä arvioidaan komponenttien koko ja asemointi sekä linjaus raa- jassa. TT-kuvauksella voidaan selvittää komponenttien rotaatioasentoa luisiin maamerkkeihin nähden ja arvioida onko asennus teknisesti rotaati-
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oiden osalta onnistunut. Vääntökuvat voivat joskus auttaa tilanteen hahmottamisessa, mutta niissä ha- vaittuja asioita voi olla vaikea tulkita.
Instabiliteetin jaottelu
Aiemmin instabiliteetit jaoteltiin varus-valgus, recurvatum, antero-posterioriseen fleksio ja globaaliin tyyppiin (3). Nykyisin suositellaan käytettäväksi käy- tännöllisempää jaottelua ekstensio, genu recurvatum, fleksio, mid-fleksio ja globaali monen suunnan tyyp- pisiin instabiliteetteihin (5,6,7). Luokittelu auttaa revision suunnittelussa.
Instabiliteetin leikkaushoidon periaatteista
Al-Jabri (5) esittää viime vuonna julkaistussa review-artikkelissaan selkeän vuokaavion hoitoratkai- suista. Aina ei välttämättä tarvita komponenttien kytkentäasteen nostoa saranaratkaisusta puhumat- takaan. Toisaalta, jos luupuutteiden vuoksi metalli- augmentteja tarvitaan, useimmissa järjestelmissä on tarpeen valita järeämmät peruskomponentit, sillä niissä on augmenttipaikat valmiina. Jos ongelma on ainoastaan riittämätön posteriorinen offset flek- sioinstabiliteettipolvessa, se tulee korjata suurem- malla reisikomponentilla siten, että offset kasvaa taakse. Fleksioinstabliteetin syynä voi olla myös liiallinen säärikomponentin takakallistus, mikä tulee
tarvittaessa korjata. Mid-fleksioinstabiliteetissa tarkistetaan niveltaso, tasapainotetaan ekstensio- ja fleksioraot sekä arvioidaan tarvetta muuttaa femur- komponentin muotoa. Ekstensiotyyppisessä instabi- liteetissa reisikomponenttia siirretään augmenttien avulla distaalisesti siten, että ekstensio ja fleksioraot tasapainottuvat. Akselilinjaus, niveltaso ja peh- mytkudosten balansointi tarkistetaan ja korjataan tarpeen mukaan.
Nuoremmilla, fyysisesti aktiivisilla potilailla on tärkeää saavuttaa stabiliteetti riittävillä, mutta liial- lista kytkentäastetta varovilla ratkaisuilla. Mikäli esim. constrained-tyyppiseen vahvasti kampeavaan muoviin ei ole tarvetta, voidaan useissa järjestel- missä käyttää PS-tyyppistä muovia, mikä piden- tää luu-komponenttisaumojen kestoikää. Iäkkäillä, matalan liikunnallisen vaatimustason potilailla voi joskus olla parempi tehdä ”melko hyvä” ratkaisu täydellisen revision sijasta, esimerkiksi vaihtaa vain muovi paksumpaan. Toisaalta, jos luukomponent- tien revisiota tässä ryhmässä tarvitaan, ei lisääntyvää kytkentäastetta kannata kaihtaa. Jopa pienemmällä- kin aiheella yliojennuksen estävä saranaproteesirat- kaisu on usein hyvä vaihtoehto ja postoperatiivinen mobilisaatio helpottuu. Saranaratkaisu on käytän- nössä perusteltu genu recurvatum ja globaalissa ins- tabiliteetissa (kuva). Useimmiten saranaa tarvitaan myössilloin,kunMCLonpettänytjaekstensioins- tabiliteetin syynä on ligamenttivaurio.
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Lopuksi
Tunnistamaton tekonivelpolven (fleksio)instabiliteetti selittänee merkittävän osan epätyydyttävis- tä kirurgian lopputuloksista. Stabiliteetin kliinisiä oireita ja löydöksiä kannattaa etsiä ja suhteuttaa löy- döksiä potilaan oireisiin. Mikäli kirurgisiin ratkai- suihin edetään, on yksikössä oltava tarjolla erilaiset komponenttivaihtoehdot ja riittävä tietotaito pa- remman lopputuloksen saavuttamiseksi.
Kirjallisuutta
1. 17th annual report of the UK NJR. https://reports. njrcentre.org.uk/downloads
2. Suomen tekonivelrekisteri FAR. https://www.thl.fi/ far/#index
3. Vince KG, Abdeen A, Sugimori T. The unstable total knee arthroplasty: causes and cures. J Arthroplasty 2006;21(suppl1):44–49.
4. Hofmann S, Seitlinger G, Djahani O, Pietsch
M. The painful knee after TKA: a diagnostic algorithm for failure analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19:1442-52.
5. Al-Jabri T, Brivio A, Maffulli N, Barrett D. Management of instability after primary total knee arthroplasty: an evidence-based review. J Orthop Surg Res. 2021;16:729.
6. Rodriguez-Merchan EC. Instability following knee arthroplasty. HSS J. 2011;7: 273-8.
7. Petrie JR, Haidykewych GJ. Instability in total knee arthroplasty: assesment and solutions. BJJ 2016;98-B (1supplA):116-9.
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