Publications by authors named "Carsten Perka"

304 Publications

Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement.

Arch Orthop Trauma Surg 2021 Jun 7. Epub 2021 Jun 7.

Department of Orthopaedic Surgery, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.

Introduction: The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion.

Materials And Methods: Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110).

Results: A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points.

Conclusion: Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients.
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http://dx.doi.org/10.1007/s00402-021-03981-2DOI Listing
June 2021

Unexpected low-grade infections in revision hip arthroplasty for aseptic loosening : a single-institution experience of 274 hips.

Bone Joint J 2021 Jun;103-B(6):1070-1077

Department of Orthopaedics, Universitaetsmedizin Greifswald, Greifswald, Germany.

Aims: The purpose of this study was to evaluate unexpected positive cultures in total hip arthroplasty (THA) revisions for presumed aseptic loosening, to assess the prevalence of low-grade infection using two definition criteria, and to analyze its impact on implant survival after revision.

Methods: A total of 274 THA revisions performed for presumed aseptic loosening from 2012 to 2016 were reviewed. In addition to obtaining intraoperative tissue cultures from all patients, synovial and sonication fluid samples of the removed implant were obtained in 215 cases (79%) and 101 cases (37%), respectively. Histopathological analysis was performed in 250 cases (91%). Patients were classified as having low-grade infections according to institutional criteria and Musculoskeletal Infection Society (MSIS) International Consensus Meeting (ICM) 2013 criteria. Low-grade infections according to institutional criteria were treated with targeted antibiotics for six weeks postoperatively. Implant failure was defined as the need for re-revision resulting from periprosthetic joint infection (PJI) and aseptic reasons. The mean follow-up was 68 months (26 to 95).

Results: Unexpected positive intraoperative samples were found in 77 revisions (28%). Low-grade infection was diagnosed in 36 cases (13%) using institutional criteria and in nine cases (3%) using MSIS ICM 2013 criteria. In all, 41 patients (15%) had single specimen growth of a low-virulent pathogen and were deemed contaminated. Coagulase-negative and anaerobes were the most commonly isolated bacteria. Implant failure for PJI was higher in revisions with presumed contaminants (5/41, 12%) compared to those with low-grade infections (2/36, 6%) and those with negative samples (5/197, 3%) (p = 0.021). The rate of all-cause re-revision was similar in patients diagnosed with low-grade infections (5/36, 14%) and those with presumed contaminants (6/41, 15%) and negative samples (21/197, 11%) (p = 0.699).

Conclusion: Our findings suggest that the presumption of culture contamination in aseptic revision hip arthroplasty may increase the detection of PJI. In this cohort, the presence of low-grade infection did not increase the risk of re-revision. Further studies are needed to assess the relevance of single specimen growth and the benefits of specific postoperative antibiotic regimens. Cite this article:  2021;103-B(6):1070-1077.
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http://dx.doi.org/10.1302/0301-620X.103B6.BJJ-2020-2002.R1DOI Listing
June 2021

Follow-up definitions in clinical orthopaedic research : a systematic review.

Bone Jt Open 2021 May;2(5):344-350

Department of Trauma and Reconstructive Surgery, BG Klinik, Eberhard Karls University Tübingen, Tubingen, Germany.

Aims: The follow-up interval of a study represents an important aspect that is frequently mentioned in the title of the manuscript. Authors arbitrarily define whether the follow-up of their study is short-, mid-, or long-term. There is no clear consensus in that regard and definitions show a large range of variation. It was therefore the aim of this study to systematically identify clinical research published in high-impact orthopaedic journals in the last five years and extract follow-up information to deduce corresponding evidence-based definitions of short-, mid-, and long-term follow-up.

Methods: A systematic literature search was performed to identify papers published in the six highest ranked orthopaedic journals during the years 2015 to 2019. Follow-up intervals were analyzed. Each article was assigned to a corresponding subspecialty field: sports traumatology, knee arthroplasty and reconstruction, hip-preserving surgery, hip arthroplasty, shoulder and elbow arthroplasty, hand and wrist, foot and ankle, paediatric orthopaedics, orthopaedic trauma, spine, and tumour. Mean follow-up data were tabulated for the corresponding subspecialty fields. Comparison between means was conducted using analysis of variance.

Results: Of 16,161 published articles, 590 met the inclusion criteria. Of these, 321 were of level IV evidence, 176 level III, 53 level II, and 40 level I. Considering all included articles, a long-term study published in the included high impact journals had a mean follow-up of 151.6 months, a mid-term study of 63.5 months, and a short-term study of 30.0 months.

Conclusion: The results of this study provide evidence-based definitions for orthopaedic follow-up intervals that should provide a citable standard for the planning of clinical studies. A minimum mean follow-up of a short-term study should be 30 months (2.5 years), while a mid-term study should aim for a mean follow-up of 60 months (five years), and a long-term study should aim for a mean of 150 months (12.5 years). Level of Evidence: Level I. Cite this article:  2021;2(5):344-350.
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http://dx.doi.org/10.1302/2633-1462.25.BJO-2021-0007.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168549PMC
May 2021

Dual-Energy Computed Tomography in Spine Fractures: A Systematic Review and Meta-Analysis.

Int J Spine Surg 2021 Jun 7;15(3):525-535. Epub 2021 May 7.

Department of Orthopaedic Surgery and Traumatology, Uszoki Hospital, Budapest, Hungary.

Background: The purpose of this study was to perform a systematic literature review and meta-analysis to evaluate the sensitivity, specificity, and accuracy of dual-energy computed tomography (DE-CT) of bone marrow edema and disc edema in spine injuries.In vertebral injuries, prompt diagnosis is essential to avoid any delays in treatment. Conventional radiography may only reveal indirect signs of fractures, such as when it is displaced. Therefore, to detect the presence of bone marrow or disc edemas, adjunctive tools are required, such as magnetic resonance imaging (MRI) or DE-CT.

Methods: Search terms included ((DECT) OR (DE-CT) OR (dual-energy CT) OR "Dual energy CT" OR (dual-energy computed tomography) OR (dual energy computed tomography)) AND ((spine) OR (vertebral)), and the PubMed, EMBASE, and MEDLINE databases and the Cochrane Library and Google were used. We found 1233 articles on our preliminary search, but only 13 articles met all criteria. Data were extracted to calculate the pooled sensitivity, specificity, and diagnostic odds ratio for analysis using R software.

Results: Within the 13 studies, 515 patients, 3335 vertebrae, and 926 acute fractures (27.8%) defined by MRI were included. The largest cohort included 76 patients with 774 vertebrae. In 12 publications, MRI was reported for comparison. For DE-CT, the overall sensitivity was 86.2% with a specificity of 91.2% and accuracy of 89.3%. Furthermore, 5 studies reported the accuracy of CT with an overall sensitivity of 81.3%, specificity of 80.7%, and accuracy with 80.9%. Significant differences were found for specificity ( < .001) and accuracy ( = .023). However, significant interobserver differences were reported.

Conclusions: DE-CT seems to be a promising diagnostic tool to detect bone marrow and disc edemas, which can potentially replace the current gold standard, the MRI.

Level Of Evidence: 2.

Clinical Relevance: This study shows that DE-CT seems to be a promising diagnostic tool with an accuracy of 89.3%.
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http://dx.doi.org/10.14444/8074DOI Listing
June 2021

Developmental Hip Dysplasia Treated with Cementless Total Hip Arthroplasty Using a Straight Stem and a Threaded Cup-A Concise Follow-Up, At a Mean of Twenty-Three Years.

J Clin Med 2021 Apr 28;10(9). Epub 2021 Apr 28.

Department for Orthopaedic Surgery, University of Greifswald, 17475 Greifswald, Germany.

We previously reported the 9-year follow-up results of 121 cementless total hip arthroplasties (THAs) from 1990 to 1994 in 93 patients with developmental dysplasia of the hip (DDH). The present study reports the updated long-term results after a mean follow-up of 23 years. Fifty-seven patients (72 hips) were alive and available for follow-up. Since our previous report, nine THAs had been revised. The cumulative implant survivorship of any component was 87% (95% CI, 78-92%). The cumulative probability of not having aseptic cup loosening was 87% (95% CI, 77-93%) and there was no revision surgery for aseptic stem loosening. In three hips (5%), an exchange of the ball and liner due to polyethylene wear was performed after a mean of 12 years. This study demonstrates that cementless THA for DDH with restoration of the hip joint center provides excellent long-term durability.
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http://dx.doi.org/10.3390/jcm10091912DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8124514PMC
April 2021

Significant increase in quantity and quality of knee arthroplasty related research in KSSTA over the past 15 years.

Knee Surg Sports Traumatol Arthrosc 2021 Apr 10. Epub 2021 Apr 10.

Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.

Purpose: This study aimed to evaluate both publication and authorship characteristics in Knee Surgery, Sports Traumatology, Arthroscopy journal (KSSTA) regarding knee arthroplasty over the past 15 years.

Methods: PubMed was searched for articles published in KSSTA between January 1, 2006, and December 31st, 2020, utilising the search term 'knee arthroplasty'. 1288 articles met the inclusion criteria. The articles were evaluated using the following criteria: type of article, type of study, main topic and special topic, use of patient-reported outcome scores, number of references and citations, level of evidence (LOE), number of authors, gender of the first author and continent of origin. Three time intervals were compared: 2006-2010, 2011-2015 and 2016-2020.

Results: Between 2016 and 2020, publications peaked at 670 articles (52%) compared with 465 (36%) published between 2011 and 2016 and 153 articles (12%) between 2006 and 2010. While percentage of reviews (2006-2010: 0% vs. 2011-2015: 5% vs. 2016-2020: 5%) and meta-analyses (1% vs. 6% vs. 5%) increased, fewer case reports were published (13% vs. 3% vs. 1%) (p < 0.001). Interest in navigation and computer-assisted surgery decreased, whereas interest in perioperative management, robotic and individualized surgery increased over time (p < 0.001). There was an increasing number of references [26 (2-73) vs. 30 (2-158) vs. 31 (1-143), p < 0.001] while number of citations decreased [30 (0-188) vs. 22 (0-264) vs. 6 (0-106), p < 0.001]. LOE showed no significant changes (p = 0.439). The number of authors increased between each time interval (p < 0.001), while the percentage of female authors was comparable between first and last interval (p = 0.252). Europe published significantly fewer articles over time (56% vs. 47% vs. 52%), whereas the number of articles from Asia increased (35% vs. 45% vs. 37%, p = 0.005).

Conclusion: Increasing interest in the field of knee arthroplasty-related surgery arose within the last 15 years in KSSTA. The investigated topics showed a significant trend towards the latest techniques at each time interval. With rising number of authors, the part of female first authors also increased-but not significantly. Furthermore, publishing characteristics showed an increasing number of publications from Asia and a slightly decreasing number in Europe.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06555-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035607PMC
April 2021

Ceramic-on-Ceramic Bearing in Total Hip Arthroplasty Reduces the Risk for Revision for Periprosthetic Joint Infection Compared to Ceramic-on-Polyethylene: A Matched Analysis of 118,753 Cementless THA Based on the German Arthroplasty Registry.

J Clin Med 2021 Mar 12;10(6). Epub 2021 Mar 12.

German Arthroplasty Registry (EPRD Deutsche Endoprothesenregister gGmbH), Straße des 17. Juni 106-108, 10623 Berlin, Germany.

Periprosthetic joint infection (PJI) is one of the most common complications in total hip arthroplasty (THA). The influence of bearing material on the risk of PJI remains unclear to date. This registry-based matched study investigates the role of bearing partners in primary cementless THA. Primary cementless THAs recorded in the German Arthroplasty Registry since 2012 with either a ceramic-on-ceramic (CoC) or ceramic-on-polyethylene (CoP) bearings were included in the analysis. Using propensity score matching (PSM) for age, sex, obesity, diabetes mellitus, Elixhauser comorbidity index, year of surgery and head size, we compared the risk for revision for PJI for CoC and CoP. Within the 115,538 THAs (87.1% CoP; 12.9% CoC), 977 revisions were performed due to PJI. There was a significantly higher risk for revision for PJI for CoP compared with CoC over the whole study period ( < 0.01) after 2:1 matching (CoP:CoC) with a hazard ratio of 1.41 (95% confidence interval (CI), 1.09 to 1.80) After 3 years, the risk for revision for PJI was 0.7% (CI 0.5-0.9%) for CoC and 0.9% (CI 0.8-1.1%) for CoP. The risk for revision for all other reasons except PJI did not significantly differ between the two groups over the whole study period ( = 0.4). Cementless THAs with CoC bearings were less likely to be revised because of infection in mid-term follow-up. In the future, registry-embedded studies focusing on long-term follow-up, including clinical data, as well as basic science studies, may give a deeper insight into the influence of the bearing partners.
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http://dx.doi.org/10.3390/jcm10061193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002089PMC
March 2021

Public Interest in Knee Pain and Knee Replacement during the SARS-CoV-2 Pandemic in Western Europe.

J Clin Med 2021 Mar 4;10(5). Epub 2021 Mar 4.

Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany.

Due to the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic, a large number of elective knee replacement procedures had to be postponed in both early and late 2020 in most western countries including Germany and the UK. It is unknown how public interest and demand for total knee arthroplasties was affected. Public interest in knee pain, knee osteoarthritis and knee arthroplasty in Germany and the UK was investigated using Google Trend Analysis. In addition, we monitored for changes in patient composition in our outpatient department. As of early March in Germany and of late March in the UK, until the lockdown measures, a 50 to 60% decrease in relative search frequency was observed in all categories investigated compared to the beginning of the year. While public interest for knee pain rapidly recovered, decreased interest for knee osteoarthritis and replacement lasted until the easing of measures. Shortly prior to and during the first lockdown mean search frequency for knee replacement was significantly decreased from 39.7% and 36.6 to 26.9% in Germany and from 47.7% and 50.9 to 23.7% in the UK (Germany: = 0.022 prior to lockdown, < 0.001 during lockdown; UK: < 0.0001 prior to and during lockdown). In contrast, mean search frequencies did not differ significantly from each other for any of the investigated time frames during the second half of 2020 in both countries. Similarly, during the first lockdown, the proportion of patients presenting themselves to receive primary knee arthroplasty compared to patients that had already undergone knee replacement declined markedly from 64.7% to 46.9%. In contrast, patient composition changed only marginally during the lockdown measures in late 2020 in both Germany and the UK. We observed a high level of public interest in knee arthroplasty despite the ongoing pandemic. The absence of a lasting decline in interest in primary knee arthroplasty suggests that sufficient symptom reduction cannot be achieved without surgical care for a substantial number of patients.
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http://dx.doi.org/10.3390/jcm10051067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961830PMC
March 2021

Two-Stage Revision Total Hip Arthroplasty Without Spacer Placement: A Viable Option to Manage Infection in Patients With Severe Bone Loss or Abductor Deficiency.

J Arthroplasty 2021 Jul 18;36(7):2575-2585. Epub 2021 Feb 18.

Department of Orthopaedics, Charité Universitaetsmedizin Berlin, Centre for Musculoskeletal Surgery, Berlin, Germany.

Background: High rates of spacer-related complications in two-stage exchange total hip arthroplasty (THA) have been reported. Patients with advanced bone defects and abductor deficiency may benefit from a nonspacer two-stage revision. This study reports on the clinical course of a contemporary two-stage exchange for periprosthetic hip infection without spacer insertion.

Methods: We reviewed 141 infected THAs with extensive bone loss or abductor damage who underwent two-stage exchange without spacer placement. The mean duration from resection arthroplasty to reimplantation was 9 weeks (2-29). Clinical outcomes included interim revision, reinfection, and aseptic revision rates. Restoration of leg-length and offset was assessed radiographically. Modified Harris hip scores were calculated. Mean follow-up was 5 years (3-7). Treatment success was defined using the modified Delphi consensus criteria.

Results: Thirty-four patients (24%) had treatment failure, including 13 reinfections, 16 interim redebridements for persistent infection, 2 antibiotic suppressive therapies, and 3 prosthetic joint infection-related deaths. Aseptic rerevision after reimplantation was necessary in 14 patients (10%). Dislocation accounted for most aseptic complications, with 20 dislocations occurring in 15 patients (11%). Leg-length and offset were restored to preoperative measures. Mean modified Harris hip scores significantly improved from 35 points to 67 points.

Conclusion: A nonspacer two-stage exchange is a viable option for managing chronically infected THA with severe bone loss or abductor deficiency, showing comparable rates of interim revision and recurrence of infection. Cementless reimplantation demonstrates good midterm survivorship with comparable functional outcomes and leg-length restoration. However, dislocation continues to be a major concern.
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http://dx.doi.org/10.1016/j.arth.2021.02.040DOI Listing
July 2021

Epidemiology of proximal femoral fractures.

J Clin Orthop Trauma 2021 Jan 20;12(1):161-165. Epub 2020 Jul 20.

Department of Orthopaedic Surgery and Traumatology, Charité Berlin, UniversityHospital Berlin, Berlin, Germany.

Introduction: With increasing age, the incidence of proximal femoral fractures increases steadily. Although the different treatments are investigated frequently, little is known about the seasonal variation and predisposing factors. The purpose of this study is to investigate the epidemiology, the impact of femoroacetabular impingement, as well as the presence of osteoarthritis.

Methods: We performed a retrospective review of all patients with pertrochanteric, lateral and medial femoral neck fractures between 2012 and 2019. Inclusion criteria consisted of patients older than 18 years old who presented with isolated proximal femoral fractures without any congenital or hereditary deformity. For analysis, we assessed the demographics, season at time of accident, Kellgren-Lawrence score and corner edge (CE) angle.

Results: In total, 187 patients were identified at a mean age of 75.1 ± 12.9 years old. Females consisted of 54.5% of this cohort. Most commonly, patients tend to present in winter with pertrochanteric fractures whereas no seasonal variation was found for medial femoral neck fractures. Significant correlations between season and age (regression coefficient -0.050 ± 0.021; p < 0.05) were identified. In medial neck fractures, the Gardner score was lower and Kellgren-Lawrence score higher for both female than males (p < 0.05). Patients with lateral neck fractures were significantly younger at 68.6 ± 12.5 years old (p < 0.05). In pertrochanteric fractures, the Kellgren-Lawrence score was significantly higher at 2.1 ± 0.8 (p < 0.05) with higher CE angle at 43.0 ± 7.6° (p = 0.14).

Conclusion: With increasing incidences of proximal femoral fractures, it is essential to recognize potential risk factors. This allows for development of new guidelines and algorithm that can aid in diagnosis, prevention, and education for patients.
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http://dx.doi.org/10.1016/j.jcot.2020.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920330PMC
January 2021

Invited reply to the letter to the editor by McNally et al., 2021.

BMC Musculoskelet Disord 2021 03 8;22(1):256. Epub 2021 Mar 8.

Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.

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http://dx.doi.org/10.1186/s12891-021-04118-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941972PMC
March 2021

The Pertinent Literature of Enhanced Recovery after Surgery Programs: A Bibliometric Approach.

Medicina (Kaunas) 2021 Feb 17;57(2). Epub 2021 Feb 17.

Center for Musculoskeletal Surgery (CMSC), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, 10117 Berlin, Germany.

The programs of enhanced recovery after surgery are the new revolution in surgical departments; however, features of this concept have not been systematically explored. Therefore, the purpose of this study was to explore Enhanced recovery after surgery (ERAS)-related research using bibliometric analysis. The search strategy of ERAS programs was conducted in the Web of Science database. Bibliometric analysis was further performed by Excel and Bibliometrix software. The relationship between citation counts and Mendeley readers was assessed by linear regression analysis. 8539 studies from 1994-2019 were included in the present research, with reporting studies originating from 91 countries using 18 languages. The United States (US) published the greatest number of articles. International cooperation was discovered in 82 countries, with the most cooperative country being the United Kingdom. Henrik Kehlet was found to have published the highest number of studies. The journal Anesthesia and Analgesia had the largest number of articles. Linear regression analysis presented a strong positive correlation between citations and Mendeley readers. Most research was related to gastrointestinal surgery in this field. This bibliometric analysis shows the current status of ERAS programs from multiple perspectives, and it provides reference and guidance to scholars for further research.
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http://dx.doi.org/10.3390/medicina57020172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922786PMC
February 2021

Human IgA-Expressing Bone Marrow Plasma Cells Characteristically Upregulate Programmed Cell Death Protein-1 Upon B Cell Receptor Stimulation.

Front Immunol 2020 12;11:628923. Epub 2021 Feb 12.

Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany.

The functions of bone marrow plasma cells (BMPC) beyond antibody production are not fully elucidated and distinct subsets of BMPC suggest potential different functions. Phenotypic differences were identified for human BMPC depending on CD19 expression. Since CD19 is a co-stimulatory molecule of the B-cell-receptor (BCR), and IgA and IgM BMPC express the BCR on their surface, we here studied whether CD19 expression affects cellular responses, such as BCR signaling and the expression of checkpoint molecules. We analyzed 132 BM samples from individuals undergoing routine total hip arthroplasty. We found that both CD19 and CD19 BMPC expressed BCR signaling molecules. Notably, the BCR-associated kinase spleen tyrosine kinase (SYK) including pSYK was higher expressed in CD19 BMPC compared to CD19 BMPC. BCR stimulation also resulted in increased kinase phosphorylation downstream of the BCR while expression of CD19 remained stable afterwards. Interestingly, the BCR response was restricted to IgA BMPC independently of CD19 expression. With regard to the expression of checkpoint molecules, CD19 BMPC expressed higher levels of co-inhibitory molecule programmed cell death protein-1 (PD-1) than CD19 BMPC. IgA BMPC characteristically upregulated PD-1 upon BCR stimulation in contrast to other PC subsets and inhibition of the kinase SYK abrogated PD-1 upregulation. In contrast, expression of PD-1 ligand, B and T lymphocyte attenuator (BTLA) and CD28 did not change upon BCR activation of IgA BMPC. Here, we identify a distinct characteristic of IgA BMPC that is independent of the phenotypic heterogeneity of the subsets according to their CD19 expression. The data suggest that IgA BMPC underlie different regulatory principles and/or exert distinct regulatory functions.
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http://dx.doi.org/10.3389/fimmu.2020.628923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907642PMC
February 2021

Impact of the COVID-19 shutdown on orthopedic trauma numbers and patterns in an academic Level I Trauma Center in Berlin, Germany.

PLoS One 2021 16;16(2):e0246956. Epub 2021 Feb 16.

Center for Musculoskeletal Surgery, Charité -Universitätsmedizin Berlin, Berlin, Germany.

Background: The COVID-19 pandemic led to the implementation of drastic shutdown measures worldwide. While quarantine, self-isolation and shutdown laws helped to effectively contain and control the spread of SARS-CoV-2, the impact of COVID-19 shutdowns on trauma care in emergency departments (EDs) remains elusive.

Methods: All ED patient records from the 35-day COVID-19 shutdown (SHUTDOWN) period were retrospectively compared to a calendar-matched control period in 2019 (CTRL) as well as to a pre (PRE)- and post (POST)-shutdown period in an academic Level I Trauma Center in Berlin, Germany. Total patient and orthopedic trauma cases and contacts as well as trauma causes and injury patterns were evaluated during respective periods regarding absolute numbers, incidence rate ratios (IRRs) and risk ratios (RRs).

Findings: Daily total patient cases (SHUTDOWN vs. CTRL, 106.94 vs. 167.54) and orthopedic trauma cases (SHUTDOWN vs. CTRL, 30.91 vs. 52.06) decreased during the SHUTDOWN compared to the CTRL period with IRRs of 0.64 and 0.59. While absolute numbers decreased for most trauma causes during the SHUTDOWN period, we observed increased incidence proportions of household injuries and bicycle accidents with RRs of 1.31 and 1.68 respectively. An RR of 2.41 was observed for injuries due to domestic violence. We further recorded increased incidence proportions of acute and regular substance abuse during the SHUTDOWN period with RRs of 1.63 and 3.22, respectively.

Conclusions: While we observed a relevant decrease in total patient cases, relative proportions of specific trauma causes and injury patterns increased during the COVID-19 shutdown in Berlin, Germany. As government programs offered prompt financial aid during the pandemic to individuals and businesses, additional social support may be considered for vulnerable domestic environments.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246956PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886210PMC
February 2021

Bacterial contamination of irrigation fluid and suture material during ACL reconstruction and meniscus surgery : Low infection rate despite increasing contamination over surgery time.

Knee Surg Sports Traumatol Arthrosc 2021 Feb 10. Epub 2021 Feb 10.

Center for Musculoskeletal Surgery, Charitéplatz 1, 10117, Berlin, Germany.

Purpose: During knee arthroscopy, irrigation fluid from the surgical site accumulates in the sterile reservoir. Whether these fluid collections and also suture material used during the arthroscopic surgical processes show bacterial contamination over time during surgery remains unclear. The purpose of this study was to determine this contamination rate and to analyze its possible influence on postoperative infection.

Materials And Methods: In this study, 155 patients were included. Fifty-eight underwent reconstruction of the anterior cruciate ligament (ACL), 63 meniscal surgery and 34 patients combined ACL reconstruction and meniscus repair. We collected pooled samples of irrigation fluid from the reservoir on the sterile drape every 15 min during the surgery. In addition, we evaluated suture material of ACL graft and meniscus repair for bacterial contamination. Samples were sent for microbiological analysis, incubation time was 14 days. All patients were seen in the outpatient department 6, 12 weeks and 12 months postoperatively and examined for clinical signs of infection.

Results: A strong statistical correlation (R = 0.81, p = 0.015) was found between an advanced duration of surgery and the number of positive microbiological findings in the accumulated fluid. Suture and fixation material showed a contamination rate of 28.4% (29 cases). Despite the high contamination rate, only one infection was found in the follow-up examinations, caused by Staphylococcus lugdunensis.

Conclusion: Since bacterial contamination of accumulated fluid increases over time the contact with the fluid reservoirs should be avoided.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-021-06481-3DOI Listing
February 2021

A New Rectus and Sartorius Sparing Approach for Periacetabular Osteotomy in Patients with Developmental Dysplasia of the Hip.

J Clin Med 2021 Feb 5;10(4). Epub 2021 Feb 5.

Department for Orthopaedic Surgery, University of Greifswald, Ferdinand-Sauerbruch-Straße, D-17475 Greifswald, Germany.

Background: periacetabular osteotomy (PAO) is known as the gold standard surgical treatment in young adults with symptomatic hip dysplasia. With the aim of reducing soft tissue trauma, we developed a new rectus and sartorius sparing (RASS) approach. We hypothesized that this new PAO technique was equal regarding acetabular reorientation, complication rate, and short-term clinical outcome parameters, compared to our conventional, rectus sparing (RS) approach.

Patients And Methods: we retrospectively assessed all PAO procedures performed by a single surgeon between 2016 and 2019 (n = 239 hips in 217 patients). The cases in which the new RASS technique were used (n = 48) were compared to the RS cases for acetabular orientation parameters, surgical time, perioperative reduction of hemoglobin level, and length of hospital stay (LOHS). Inclusion criteria were a lateral center-edge angle (LCEA) <25° and osteoarthritis Tönnis grade ≤1. Patients with acetabular retroversion or additional femoral osteotomy were excluded.

Results: the mean patient age at the time of surgery was 29 years (14 to 50, SD ± 8.5). Females accounted for 79.5% in this series. The mean preoperative LCEA were 16° (7 to 24°, SD ± 4.4) and 15° (0 to 23°, SD ± 6) in the RASS and the RS group, respectively ( = 0.96). The mean preoperative acetabular index (AI) angles were 14° (2 to 25°, SD ± 4) and 14° (7 to 29°, SD ± 4.3), respectively ( = 0.67). The mean postoperative LCEA were significantly improved to 31° (25 to 37°, SD ± 3.5, < 0.001) and 30.2° (20 to 38°, SD ± 4, < 0.001), respectively. The mean postoperative AI angles improved to 2.8° (-3 to 13°, SD ± 3.3, < 0.001) and 3° (-2 to 15°, SD ± 3.3, < 0.001), respectively. There were no significant differences between the RASS and the RS group for surgical time, perioperative reduction in hemoglobin level, and LOHS. No blood transfusions were necessary perioperatively in either group. No major perioperative complication occurred in either group. We observed one surgical site infection (SSI) requiring superficial debridement in the RS group.

Conclusion: the RASS approach for PAO showed to be a safe procedure with equivalent acetabular reorientation and equivalent clinical outcome parameters compared to the RS approach. Additionally, patients have fewer postoperative restrictions in mobilization with the RASS approach.
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http://dx.doi.org/10.3390/jcm10040601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915261PMC
February 2021

App-based rehabilitation program after total knee arthroplasty: a randomized controlled trial.

Arch Orthop Trauma Surg 2021 Feb 6. Epub 2021 Feb 6.

Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117, Berlin, Germany.

Introduction: New app-based programs for postoperative rehabilitation have been developed, but no long-term study has been published to date. Thus, a prospective randomized control trial with 2-year follow-up was performed to evaluate the effectiveness of app-based rehabilitation (GenuSport) compared to a control group after total knee arthroplasty (TKA).

Methods: Between April and October 2016, 60 patients were enrolled in the study. Twenty-five patients were lost to follow-up, leaving 35 patients undergoing TKA for inclusion. In this group, twenty patients received app-based exercise program and 15 were randomized to the control group. The mean age was 64.37 ± 9.32 years with a mean follow-up of 23.51 ± 1.63 months. Patients in the app group underwent an app-based knee training starting on the day of surgery; whereas, patients in the control group underwent regular physiotherapy. Functional outcome scores using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and VAS of pain were analyzed.

Results: In the short term, significant differences between the app group and control group in time of 10-m walk (19.66 ± 7.80 vs. 27.08 ± 15.46 s; p = 0.029), VAS pain at rest and activity (2.65 ± 0.82 vs. 3.57 ± 1.58, respectively 4.03 ± 1.26 vs. 5.05 ± 1.21; p < 0.05) were observed. In the long term, a variety of different tendencies was found, highest in KSS Function with 76.32 ± 16.49 (app group) vs. 67.67 ± 16.57 (control group) (p = 0.130). Additionally, patients in the app group required less painkillers (10.0% vs. 26.7%) and more likely to participate in sports (65.0% vs. 53.3%).

Conclusions: An app-based knee trainer is a promising tool in improving functional outcomes such as KSS function score and VAS after TKA.

Level Of Evidence: Level II, prospective randomized control trial.
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http://dx.doi.org/10.1007/s00402-021-03789-0DOI Listing
February 2021

The subjective knee value is a valid single-item survey to assess knee function in common knee disorders.

Arch Orthop Trauma Surg 2021 Feb 1. Epub 2021 Feb 1.

Center for Musculoskeletal Surgery, Campus Mitte, Charité-Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.

Introduction: The patient's perspective plays a key role in judging the effect of knee disorders on physical function. We have introduced the Subjective Knee Value (SKV) to simplify the evaluation of individual's knee function by providing one simple question. The purpose of this prospective study was to validate the SKV with accepted multiple-item knee surveys across patients with orthopaedic knee disorders.

Materials And Methods: Between January through March 2020, consecutive patients (n = 160; mean age 51 ± 18 years, range from 18 to 85 years, 54% women) attending the outpatient clinic for knee complaints caused by osteoarthritis (n = 69), meniscal lesion (n = 45), tear of the anterior cruciate ligament (n = 23) and focal chondral defect (n = 23) were invited to complete a knee-specific survey including the SKV along with the Knee Injury Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee subjective knee form (IKDC-S). The Pearson correlation coefficient was used to evaluate external validity between the SKV and each patient-reported outcome measure (PROM) separately. Furthermore, patient's compliance was assessed by comparing responding rates.

Results: Overall, the SKV highly correlated with both the KOOS (R = 0.758, p < 0.05) and the IKDC-S (R = 0.802, p < 0.05). This was also demonstrated across all investigated diagnosis- and demographic-specific (gender, age) subgroups (range 0.509-0.936). No relevant floor/ceiling effects were noticed. The responding rate for the SKV (96%) was significantly higher when compared with those for the KOOS (81%) and the IKDC-S (83%) (p < 0.05).

Conclusion: At baseline, the SKV exhibits acceptable validity across all investigated knee-specific PROMs in a broad patient population with a wide array of knee disorders. The simplified survey format without compromising the precision to evaluate individual's knee function justifies implementation in daily clinical practice.

Level Of Evidence: II, cohort study (diagnosis).
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http://dx.doi.org/10.1007/s00402-021-03794-3DOI Listing
February 2021

Implications for diagnosis and treatment of peri-spinal implant infections from experiences in periprosthetic joint infections-a literature comparison and review.

J Spine Surg 2020 Dec;6(4):800-813

Center for Musculoskeletal Surgery, Charité - Universitaetsmedizin Berlin, Berlin, Germany.

Both, periprosthetic joint infection (PJI) and peri-spinal implant infection (PSII) are serious complications occurring in arthroplasty and spine instrumentation with absolute numbers expected to rise in the next years. The currently existing literature data describing the characteristics of PSII are limited when compared to PJI studies. However, both PJI and PSII exhibit similarities concerning pathogenesis, symptoms, diagnosis, treatment and prognosis. This literature review aims at comparing PJI and PSII and to develop implications for diagnosis and treatment of PSII from existing studies about PJI. The review was performed on the basis of a structured PubMed, Cochrane Library, and Medline analysis and existing guidelines, with 99 references being included. The results indicate that specific terms like re-infection should be defined in the context of PSII based on existing definitions of PJI, that biofilm studies and studies analyzing different prosthesis surfaces in arthroplasty could be used for PSII, and that histopathology as an additional standard tool in PSII diagnosis might be helpful. In addition, the development of a standardized algorithm-based treatment system with antibiotic protocols, including long term suppression, for PSII similar to the ones existing for PJI is necessary.
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http://dx.doi.org/10.21037/jss-20-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797793PMC
December 2020

Facing metaphyseal bone stock defects: Mid- and longterm results of cones.

J Orthop 2021 Jan-Feb;23:31-36. Epub 2020 Dec 23.

Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Germany.

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http://dx.doi.org/10.1016/j.jor.2020.12.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779840PMC
December 2020

Recommendations for Patients with High Return to Sports Expectations after TKA Remain Controversial.

J Clin Med 2020 Dec 26;10(1). Epub 2020 Dec 26.

Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Chariteplatz 1, 10117 Berlin, Germany.

(1) Background: Improved surgical techniques and implants in total knee arthroplasty (TKA) have led to broader indications for surgical interventions of osteoarthritis of the knee. There is a growing young and active patient subgroup with high return to sports (RTS) expectations after TKA. The current lack of evidence regarding RTS capacity in this patient cohort, requires the consolidation of experts' opinions and experiences to address the special needs among these patients. The aim of this study was to assess current expert opinions in regard to preoperative patient assessment, surgical technique and decision-making and patient counseling for these patients. (2) Methods: We performed a survey among surgeons specialized in arthroplasty with a questionnaire designed to assess current recommendations, surgical techniques, and implant preferences as well as patient counseling in patients with high expectations for RTS after TKA. (3) Results: The majority of surgeons are in favor of return to low-impact sports after TKA within 3 to 6 months. Some even recommend return to high-impact sports. Despite improvement of surgical techniques and implants, we observed no clear preference for a single surgical technique or implant specification in active patients. (4) Conclusions: Current evidence for sports-associated complications after TKA is scarce. Despite a growing array of surgical techniques and implants, the available literature is still controversial with no single surgical technique or TKA design distinguishing itself clearly from others. Surgeons' recommendations are mostly based on their experience and training. Nonetheless, we observed growing faith in modern implants with some surgeons even recommending high-impact sports after TKA.
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http://dx.doi.org/10.3390/jcm10010054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796219PMC
December 2020

Taper corrosion: a complication of total hip arthroplasty.

EFORT Open Rev 2020 Nov 13;5(11):776-784. Epub 2020 Nov 13.

Center for Musculoskeletal Surgery, Orthopedic Department, Charité - Universitätsmedizin Berlin, Berlin, Germany.

The focus on taper corrosion in modular hip arthroplasty increased around 2007 as a result of clinical problems with large-head metal-on-metal (MoM) bearings on standard stems. Corrosion problems with bi-modular primary hip stems focused attention on this issue even more.Factors increasing the risk of taper corrosion were identified in laboratory and retrieval studies: stiffness of the stem neck, taper diameter and design, head diameter, offset, assembly force, head and stem material and loading.The high variability of the occurrence of corrosion in the clinical application highlights its multi-factorial nature, identifying the implantation procedure and patient-related factors as important additional factors for taper corrosion.Discontinuing the use of MoM has reduced the revisions due to metal-related pathologies dramatically from 49.7% (MoM > 32 mm), over 9.2% (MoM ⩽ 32 mm) to 0.8% (excluding all MoM).Further reduction can be achieved by omitting less stiff Ti-alloys and large metal heads (36 mm and above) against polyethylene (PE).Standardized taper assembly of smaller and ceramic heads will reduce the clinical occurrence of taper corrosion even further. If 36 mm heads are clinically indicated, only ceramic heads should be used.Taper-related problems will not comprise a major clinical problem anymore if the mentioned factors are respected. Cite this article: 2020;5:776-784. DOI: 10.1302/2058-5241.5.200013.
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http://dx.doi.org/10.1302/2058-5241.5.200013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722945PMC
November 2020

Diclofenac for prophylaxis of heterotopic ossification after hip arthroplasty: a systematic review.

Hip Int 2020 Dec 3:1120700020978194. Epub 2020 Dec 3.

Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Germany.

Background: Heterotopic ossification (HO) is defined as the formation of lamellar bone in extraskeletal soft tissues. HO can be a severe complication after hip arthroplasty but can possibly be prevented by postoperative treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or radiotherapy. Diclofenac is 1 of the most used drugs in HO prophylaxis because it is effective and long established. However, there is still no uniform therapy regimen in terms of duration, dose and side effect profile regarding the application of diclofenac in HO prevention. We have, therefore, conducted the first systematic review investigating diclofenac for HO prophylaxis after hip arthroplasty. The aim of this study is to assess the efficacy, dose and duration of diclofenac therapy in preventing HO after total hip arthroplasty (THA).

Methods: According to the PRISMA Guidelines we performed a systematic literature search in EMBASE via Ovid, in MEDLINE via PubMed and in the Cochrane Library addressing all studies in English and German regarding the prophylaxis of HO with diclofenac after THA. We identified 731 potential studies and included 6 randomised controlled trials with 957 patients.

Results: The studies were heterogeneous with regard to duration of therapy, dose, comparative group and follow-up period. The therapy duration ranged from 9 to 42 days, the applied diclofenac doses ranged from 75 mg to 150 mg daily. Patients treated with diclofenac showed a significant reduction in the total incidence of HO regarding to the Brooker Classification compared to placebo and no clinically relevant ossifications occured (Brooker III and IV).

Conclusions: Diclofenac is efficacious in the prevention of HO and can be used routinely after THA. The existing data indicates that a minimum dose of 75 mg diclofenac per day started on the first postoperative day for a minimum of 9 days is needed to prevent HO with an acceptable incidence of side effects, such as gastrointestinal symptoms.
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http://dx.doi.org/10.1177/1120700020978194DOI Listing
December 2020

Development and Implementation of International Curricula for Joint Replacement and Preservation.

Orthop Clin North Am 2021 Jan 27;52(1):27-39. Epub 2020 Oct 27.

Department of Orthopaedics, Complex Joint Reconstruction Clinic, Gordon & Leslie Diamond Health Care Centre, University of British Columbia, 3rd Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9, Canada. Electronic address:

The number of patients undergoing joint replacement and preservation procedures continues to increase worldwide. Globally, there is no standardized educational pathway, training program, or recognized certification program for surgeons in these procedures. Development and implementation of new competency-based curricula to deliver specific educational events and resources may help trainees and practicing surgeons be able to perform these procedures more effectively and therefore improve patient outcomes in their respective countries. Ideally, a curriculum would be globally standardized and professionally designed to interactively meet the needs of surgeons. A competency-based approach with built-in assessment and evaluation processes is today's educational standard.
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http://dx.doi.org/10.1016/j.ocl.2020.08.003DOI Listing
January 2021

Laminar air flow reduces particle load in TKA-even outside the LAF panel: a prospective, randomized cohort study.

Knee Surg Sports Traumatol Arthrosc 2020 Nov 9. Epub 2020 Nov 9.

Centre for Musculoskeletal Surgery, Charité - University Hospital Berlin, Charitéplatz 1, 10117, Berlin, Germany.

Purpose: Released particles are a major risk of airborne contamination during surgery. The present prospective study investigated the quantitative and qualitative particle load in the operating room (OR) depending on location, time of surgery and use of laminar air flow (LAF) system.

Methods: The particle load/m was measured during the implantation of 12 total knee arthroplasties (6 × LAF, 6 × Non-LAF) by using the Met One HHPC 6 + device (Beckmann Coulter GmbH, Germany). Measurement was based on the absorption and scattering of (laser) light by particles and was performed at three different time-points [empty OR, setting up, ongoing operation) at 3 fixed measurement points [OR table (central LAF area), anaesthesia tower (marginal LAF area), surgical image amplifier (outside LAF area)].

Results: Independent of time and location, all measurements showed a significantly higher particle load in the Non-LAF group (p < 0.01). With ongoing surgical procedure both groups showed increasing particle load. While there was a major increase of fine particles (size < 1 µm) with advancing activity in the LAF group, the Non-LAF group showed higher particle gain with increasing particle size. The lowest particle load in the LAF group was measured at the operating column, increasing with greater distance from the operating table. The Non-LAF group presented a significantly higher particle load than the LAF group at all locations.

Conclusion: The use of a LAF system significantly reduces the particle load and therefore potential bacterial contamination regardless of the time or place of measurement and therefore seems to be a useful tool for infection prevention. As LAF leads to a significant decrease of respirable particles, it appears to be a protective factor for the health of the surgical team regardless of its use in infection prevention.

Level Of Evidence: I.
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http://dx.doi.org/10.1007/s00167-020-06344-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649711PMC
November 2020

Preoperative synovial fluid culture poorly predicts the pathogen causing periprosthetic joint infection.

Infection 2021 Jun 3;49(3):427-436. Epub 2020 Nov 3.

Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Charitéplatz 1, 10117, Berlin, Germany.

Purpose: We investigated the value of preoperative pathogen detection and evaluated its concordance with intraoperative cultures in patients with culture-positive periprosthetic joint infection (PJI).

Methods: Culture-positive PJI episodes with available preoperative (synovial fluid) and intraoperative cultures (periprosthetic tissue, synovial or sonication fluid) were analyzed. The pathogen detection rate in preoperative and intraoperative cultures was compared using Fisher's exact test and their concordance was calculated.

Results: Among 167 included PJI episodes, 150 were monomicrobial with coagulase-negative staphylococci (n = 55, 37%), S. aureus (n = 34, 23%), and streptococci (n = 21, 14%) being the most common pathogens. Seventeen episodes (10%) were polymicrobial infections. The pathogen(s) grew in preoperative culture in 110 and in intraoperative cultures in 153 episodes (66% vs. 92%, p < 0.001). The pathogen detection rate was lower in preoperative compared to intraoperative cultures for low-virulent pathogens (40% vs. 94%, p < 0.001), polymicrobial infections (59% vs. 100%, p = 0.007), and in delayed and late PJI (63% vs. 94%, and 66% vs. 91%, respectively, p < 0.001). Full concordance of preoperative and intraoperative cultures was found in 87 episodes (52%). The pathogen was detected solely preoperatively in 14 episodes (8%) and solely intraoperatively in 57 cases (34%); an additional pathogen was found in 3 episodes (2%) preoperatively and in 6 episodes (4%) intraoperatively.

Conclusion: The concordance of preoperative and intraoperative cultures was poor (52%). The sole or an additional pathogen was found exclusively in intraoperative cultures in 38% of PJI episodes, hence preoperative synovial fluid cultures are considered unreliable for pathogen detection in PJI.
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http://dx.doi.org/10.1007/s15010-020-01540-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159841PMC
June 2021

Metal-Specific Biomaterial Accumulation in Human Peri-Implant Bone and Bone Marrow.

Adv Sci (Weinh) 2020 Oct 3;7(20):2000412. Epub 2020 Aug 3.

Julius Wolff Institute Charité - Universitätsmedizin Berlin Berlin 13353 Germany.

Metallic implants are frequently used in medicine to support and replace degenerated tissues. Implant loosening due to particle exposure remains a major cause for revision arthroplasty. The exact role of metal debris in sterile peri-implant inflammation is controversial, as it remains unclear whether and how metals chemically alter and potentially accumulate behind an insulating peri-implant membrane, in the adjacent bone and bone marrow (BM). An intensively focused and bright synchrotron X-ray beam allows for spatially resolving the multi-elemental composition of peri-implant tissues from patients undergoing revision surgery. In peri-implant BM, particulate cobalt (Co) is exclusively co-localized with chromium (Cr), non-particulate Cr accumulates in the BM matrix. Particles consisting of Co and Cr contain less Co than bulk alloy, which indicates a pronounced dissolution capacity. Particulate titanium (Ti) is abundant in the BM and analyzed Ti nanoparticles predominantly consist of titanium dioxide in the anatase crystal phase. Co and Cr but not Ti integrate into peri-implant bone trabeculae. The characteristic of Cr to accumulate in the intertrabecular matrix and trabecular bone is reproducible in a human 3D in vitro model. This study illustrates the importance of updating the view on long-term consequences of biomaterial usage and reveals toxicokinetics within highly sensitive organs.
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http://dx.doi.org/10.1002/advs.202000412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578891PMC
October 2020

Surgeons' Learning Curve of Renaissance Robotic Surgical System.

Int J Spine Surg 2020 Oct 23;14(5):818-823. Epub 2020 Oct 23.

Department of Orthopaedic Surgery, Columbia University Medical Center-Presbyterian Hospital, The Spine Hospital at New York Presbyterian, New York, New York.

Introduction: A few articles on robot-assisted pedicle screw placement described the learning curve but failed to report on the overall operative time, including cases in which the robotic system malfunctioned. The purpose of this study was to identify a single surgeon's learning curve including estimated blood loss, surgery time, anesthesia time, robot time, and complications.

Methods: A retrospective study was performed between January 2016 and August 2018 for patients who underwent posterior spinal fusion using the Mazor robot. Based on the charts, the robot time, time of anesthesia, and surgery time were recorded, as were the complications, misplacement of screws, and blood loss.

Results: Of 62 robot-assisted surgeries scheduled, only 46 were performed (74.2%) upon patients with a mean age of 63.3 ± 13.0 years. The mean follow-up time was 13.2 ± 8.0 months and most commonly a fusion from L4 to S1 was performed (20/46, 43.5%). A high improvement in estimated intraoperative blood loss was observed of 755.7 ± 344.7 mL (slope = -9.89). A decrease in time in anesthesia, surgery, and robotic usage was identified with a slope factor of -3.64 ( = .22, SE = 85.4, < .005), -3.97 ( = 0.30, SE 75.8, < .005), -0.69 ( = .07, SE = 27.8, < .09), respectively. Furthermore, a decrease in pedicle screw insertion time and operative time was found (slope = -0.05, = .02, SE = 3.4, = .37). In total, 5 major complications (cases 8, 19, 21, 35, 43) and 6 minor complications (cases 4, 14, 15, 20, 29), were identified (21.7%) without any learning curve.

Conclusions: Robot pedicle screw insertion shows no major learning curve; however, the blood loss and the installation process of the system improved with experience.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/7116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671434PMC
October 2020

Metal on Metal Bearing in Total Hip Arthroplasty and Its Impact on Synovial Cell Count.

J Clin Med 2020 Oct 18;9(10). Epub 2020 Oct 18.

Department of Orthopaedic Surgery and Traumatology, Charité Berlin, University Hospital, Charitéplatz 1, 10117 Berlin, Germany.

Introduction: The effect of different bearings on synovial white blood cell (WBC) count and polymorphonuclear percentage (PMN%) in aspirations remains unclear. Therefore, this study investigates the impact of aseptic Metal-on-Metal (MoM) bearing on synovial fluid.

Methods: We searched our arthroplasty registry for aseptic painful THAs with MoM bearings between 2011 and 2018. Then, a case-matched control group was selected with septic and aseptic Total Hip Arthroplasty (THA) with ceramic on a polyethylene (PE) bearing. The matching criteria consisted of gender, age +/-10 years, and time of aspiration (+/-2years). Periprosthetic Joint Infection (PJI) was defined according to the Infectious Diseases Society of America (IDSA), and Musculoskeletal Infection Society (MSIS) using bacterial cultures, sonication and histology.

Results: In total, 19 patients who underwent hip aspiration with MoM bearing were identified. Five patients had to be excluded due to insufficient synovial fluid obtained ( = 2) or bacterial growth after sonication that was initially negative with the standard microbiological cultures ( = 3). As such, 14 were included. These patients were matched with 14 aseptic and 14 septic THAs with ceramic on a PE bearing, which constituted the control group. The mean serum chrome level was 20.0 ± 15.5 nmol/L and cobalt level 18.4 ± 22.1 nmol/L. The synovial WBC and PMN% varied significantly between MoM bearing group and the aseptic THA ceramic PE group (both < 0.001), as well as the septic THA group (WBC = 0.016, PMN% < 0.001). Furthermore, the septic THA group had significantly higher CRP values than the aseptic MoM group ( = 0.016).

Conclusion: MoM bearing shows significantly higher synovial WBC and PMN% when compared to aseptic THA with ceramic on PE bearing above the MSIS cut-off. This is an important consideration when diagnosing periprosthetic joint infection using the MSIS guidelines.
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http://dx.doi.org/10.3390/jcm9103349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603093PMC
October 2020

Implant contamination as a cause of surgical site infection in spinal surgery: are single-use implants a reasonable solution? - a systematic review.

BMC Musculoskelet Disord 2020 Sep 25;21(1):634. Epub 2020 Sep 25.

Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Charitéplatz 1, 10117, Berlin, Germany.

Background: In spine surgery, surgical site infection (SSI) is one of the main perioperative complications and is associated with a higher patient morbidity and longer patient hospitalization. Most factors associated with SSI are connected with asepsis during the surgical procedure and thus with contamination of implants and instruments used which can be caused by pre- and intraoperative factors. In this systematic review we evaluate the current literature on these causes and discuss possible solutions to avoid implant and instrument contamination.

Methods: A systematic literature search of PubMed addressing implant, instrument and tray contamination in orthopaedic and spinal surgery from 2001 to 2019 was conducted following the PRISMA guidelines. All studies regarding implant and instrument contamination in orthopaedic surgery published in English language were included.

Results: Thirty-five studies were eligible for inclusion and were divided into pre- and intraoperative causes for implant and instrument contamination. Multiple studies showed that reprocessing of medical devices for surgery may be insufficient and lead to surgical site contamination. Regarding intraoperative causes, contamination of gloves and gowns as well as contamination via air are the most striking factors contributing to microbial contamination.

Conclusions: Our systematic literature review shows that multiple factors can lead to instrument or implant contamination. Intraoperative causes of contamination can be avoided by implementing behavior such as changing gloves right before handling an implant and reducing the instruments' intraoperative exposure to air. In avoidance of preoperative contamination, there still is a lack of convincing evidence for the use of single-use implants in orthopaedic surgery.
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http://dx.doi.org/10.1186/s12891-020-03653-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519515PMC
September 2020