Publications by authors named "Hongyi Shao"

40 Publications

Predictors of a forgotten joint after medial fixed-bearing unicompartmental knee arthroplasty.

Knee 2022 Jun 23;37:103-111. Epub 2022 Jun 23.

Department of Orthopedics, General Hospital of Chinese PLA, No. 28 Fuxing Road, Beijing 100853, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, No. 28 Fuxing Road, Beijing 100853, China.

Background: A forgotten joint is considered the ultimate goal of joint replacement. We aim to explore the predictive factors of a forgotten joint after fixed-bearing unicompartmental knee arthroplasty (UKA).

Methods: This retrospective cohort study used prospectively collected data from 302 cases of medial-compartment UKA with a minimum of 2-year follow-up. The primary outcome was the achievement of a forgotten joint after UKA, according to the Forgotten Joint Score (FJS-12) at the last follow-up. Patients with FJS-12 > 84 were considered to have forgotten UKA. Univariate and multivariate logistic regression analyses were conducted with preoperative patient characteristics and surgery-related factors as potential predictors.

Results: Of patients, 94 (31.1%) achieved a forgotten joint post-surgery. Multivariate logistic regression analysis revealed that preoperative hip-knee-ankle angle (HKAA), anatomic lateral distal femoral angle (aLDFA), and postoperative HKAA and HKAA changes were independent predictors of a forgotten joint. The probability of achieving a forgotten joint increased by 29% (OR = 1.29, 95% CI: 1.12-1.51) with a 1° increase in aLDFA. Preoperative HKAA, postoperative HKAA, HKAA changes (ΔHKAA), and outcomes exhibited a non-linear relationship. The probability of achieving a forgotten joint was the highest with preoperative HKAA > 172.0°, postoperative HKAA of 176.0-178.5°, and ΔHKAA < 5.5°.

Conclusion: To achieve the forgotten joint state, the ideal HKAA range after medial fixed-bearing UKA is 176.0-178.5° and ΔHKAA should be <5.5°. Patients with smaller preoperative aLDFA and HKAA have a lower probability of achieving a forgotten joint after UKA.
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http://dx.doi.org/10.1016/j.knee.2022.06.004DOI Listing
June 2022

Total Hip Arthroplasties for Hartofilakidis Type C1 and C2 High Hip Dislocations Demonstrate Similar Survivorship and Clinical Function at Minimum 10-year Follow-up With Cementless Implants.

J Arthroplasty 2022 Jun 14. Epub 2022 Jun 14.

Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.

Background: This study aimed to determine the differences in survivorship, clinical function, and complications among patients who have Hartofilakidis Type C1 or C2 developmental dysplasia of the hips and underwent total hip arthroplasty (THA) with cementless implants.

Methods: This retrospective study identified 84 Hartofilakidis Type C hips that underwent THA between 2002 and 2011 with a minimum 10-year follow-up (mean, 13 years, range, 10 to 19 years). Survivorship, latest Harris Hip Scores and satisfaction levels, radiographic outcomes (eg, implant stability, rate and length of subtrochanteric shortening transverse osteotomy, leg-length discrepancy, cup position, and orientation), as well as complications (eg, dislocation, periprosthetic fracture, periprosthetic joint infection) were compared to analyze the differences between Hartofilakidis C1 and C2 hips.

Results: Between C1 and C2 hips, no difference existed in the 15-year cumulative Kaplan-Meier survivorship, with the endpoint defined as any reoperation (93.1 versus 90.8%), aseptic loosening combined with periprosthetic joint infection (93.1 versus 96.2%), or aseptic loosening (94.8 versus 96.2%), latest Harris Hip Score (87.1 versus 86.1%), vertical (6.1 versus 6.0 mm) and horizontal (11.5 versus 10.3 mm) distance to the anatomic center of rotation, postoperative leg length discrepancy (11.2 versus 15.5 mm), dislocation (5.2 versus 11.5%), stem aseptic loosening (6.9 versus 7.7%), periprosthetic fracture (3.4 versus 7.7%), and intraoperative femoral fracture (32.8 versus 23.1%). However, Type C2 hips demonstrated more severe preoperative leg length discrepancy (66.9 versus 42.5 mm) and required a higher percentage of subtrochanteric shortening transverse osteotomies (84.6 versus 36.2%) that were longer (33.7 versus 26.47 mm) than the Type C1 hips.

Conclusion: With cementless cups positioned near the anatomic acetabular center and cementless stems combined with subtrochanteric shortening transverse osteotomies, THAs for the Hartofilakidis Type C1 and C2 hips demonstrated similar survivorship, clinical function, and complications.
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http://dx.doi.org/10.1016/j.arth.2022.06.005DOI Listing
June 2022

Malposition of components and Femorotibial mechanical Axis changes on pressure distribution in Total knee arthroplasty.

Clin Biomech (Bristol, Avon) 2022 06 6;96:105659. Epub 2022 May 6.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing 100035, China. Electronic address:

Background: To the best of our knowledge, no report has analyzed the postoperative results of poor prosthesis position, particularly when the femoral and tibial components are abnormally positioned relative to neutral lower limb alignment. We aimed to investigate pressure distribution in the knee at different lower limb alignments with diverse positions of femoral and tibial components.

Methods: We established a three-dimensional model of the lower limb using computed tomography and simulated total knee arthroplasty. Tibial and femoral components were changed to 7°, 5°, and 3° of valgus and neutral and 3°, 5°, and 7° of varus positions in the coronal plane. Finite element analysis was performed after applying pressure to simulate weight-bearing, and pressure distribution on the tibial surface was analyzed. We also conducted biomechanical testing using a weight-bearing rig with six cadavers. We measured the pressure at the tibial surface with the position of different components and lower limb alignment.

Findings: Peak pressure on the medial or lateral side of the tibia was determined by the mechanical axis. When tibial components are in 3°,5° and 7° of valgus/varus and femoral components are in 3°,5° and 7° of varus/valgus correspondence, no peak pressure was detected with normal alignment, despite malpositioned components.

Interpretation: Lower limb alignment is more critical than the position of the component. Medial and lateral tibial compartment pressures were evenly distributed if the alignment was neutral. Malpositioned femoral or tibial components changed the femorotibial mechanical axis, and peak pressure of the proximal tibia was positively related to alignment.
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http://dx.doi.org/10.1016/j.clinbiomech.2022.105659DOI Listing
June 2022

Dexpanthenol attenuates inflammatory damage and apoptosis in kidney and liver tissues of septic mice.

Bioengineered 2022 05;13(5):11625-11635

Department of Emergency Intensive Care Medicine, The Central Hospital Affiliated to Shaoxing University, Shaoxing, China.

Sepsis is capable of causing systemic infections resulting in multiple organ damage. Dexpanthenol (DXP) has been reported to protect against kidney and liver injury. Therefore, this paper attempts to explore the role of DXP in sepsis-induced kidney and liver injury. A mice model of sepsis was established using the cecal ligation and puncture (CLP) method. The expressions of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6 and monocyte chemoattractant protein (MCP)-1 in the serum of mice were measured utilizing enzyme linked immunosorbent assay (ELISA). Additionally, the damage of kidney and liver tissues in CLP-induced mice was determined by their respective commercial kits, western blot, and hematoxylin-eosin (HE) staining kits. The apoptosis of kidney and liver tissues in CLP-induced mice was assessed by means of terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and western blot. It was observed that DXP decreased the expressions of TNF-α, IL-1β, IL-6, and MCP-1 in the serum of CLP-induced mice, attenuated the functional impairment, pathological damage, inflammation, and cell apoptosis of kidney tissue. Meanwhile, DXP decreased the functional impairment of liver in CLP-induced mice, reduced the levels of inflammatory factors and antioxidant enzymes, attenuated liver pathological damage, and decreased cell apoptosis in liver tissues. In conclusion, DXP attenuates inflammatory damage and apoptosis in kidney and liver organs in a sepsis model.
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http://dx.doi.org/10.1080/21655979.2022.2070585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9275904PMC
May 2022

Patient-perceived knee enlargement after total knee arthroplasty: prevalence, risk factors, and association with functional outcomes and radiological analysis.

Int Orthop 2022 06 29;46(6):1305-1312. Epub 2022 Mar 29.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.

Purpose: In clinical practice, many patients complained that their knees became larger after total knee arthroplasty (TKA), yet no studies have described this phenomenon. We named this as "patient-perceived enlargement of knee" (PPEK). This study aimed to investigate the prevalence of PPEK after TKA; assess the association between PPEK and demographics, surgical options, or component size; assess the influence of PPEK on patient satisfaction and functional outcomes; and determine whether there was radiological difference between patients with or without PPEK.

Methods: We reviewed patients that underwent unilateral primary TKA between May 2018 and April 2019. We investigated the prevalence of PPEK and acquired functional scores and satisfaction. Patients were divided into two groups according to whether they complained of PPEK. In radiological evaluation, we measured anterior and posterior condyle offset (ACO and PCO) of the femur, tibial coverage lines, tibial overhanging lines, and femoral overhanging lines.

Results: A total of 389 patients were enrolled and 101 patients felt their knee became "larger" after TKA. Patients with PPEK had significantly shorter height and lower weight, yet component size distribution showed no statistical difference. Patients with PPEK had significantly lower functional scores and satisfaction. Patients with PPEK had significantly larger ACO, shorter postoperative PCO, more ACO increase, and less anterior underhang of the tibia.

Conclusion: PPEK is common in TKA patients, especially in individuals with smaller height and weight. PPEK is associated with poor satisfaction and lower functional scores. In radiology, post-operative ACO, PCO, and anterior underhang of the tibial component were correlated with PPEK.
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http://dx.doi.org/10.1007/s00264-022-05388-zDOI Listing
June 2022

Different Deformity Origins and Morphological Features in Subtypes of Valgus Knees: A Radiological Classification System.

Orthop Surg 2022 Jan 6;14(1):96-103. Epub 2021 Dec 6.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, Beijing, China.

Objective: To analyze the deformity origins and distribution among valgus knees to individualize their morphological features.

Methods: Radiographic images of 105 valgus knees were analyzed. Long-film radiographs and computed tomography were collected for every knee. A malalignment test was performed on standing long-film radiographs. The hip-knee-ankle angle (HKA), the anatomical lateral distal femoral angle (aLDFA), and the anatomical medial proximal tibial angle (aMPTA) were measured on long-film radiographs. The distal condylar angle and posterior condylar angle on distal femur were further measured on computed tomography scans. The tibial bone varus angle was measured on long-film radiographs as well. All the valgus knees were sorted into different subtypes according to the origins of bony deformity, and the prevalence of each subtype was reported. Finally, to examine the inter-observer reproducibility of this classification system, two observers measured the deformities and did the classification for all the 105 knees independently and then the intraclass correlation coefficient (ICC) was calculated.

Results: Among the 105 knees, 48 knees (45.7%) had apparent deformity from the tibial plateau, and 62 knees (59.0%) had apparent deformity from the supracondylar region of the femur. Eighteen knees (17.1%) had distal condylar angle >7°, among which 11 knees had posterior condylar angle >3° simultaneously. Valgus knees had five subtypes of bone deformity origins-the supracondylar part of the femur, the distal aspect of the lateral femoral condyle, both distal and posterior aspects of the lateral femoral condyle, the tibial plateau, or the metaphyseal segment of the tibia. A valgus knee could be labeled as only one subtype, or a combination of two or more subtypes. Labeling 105 knees with origin of the most severe deformity, the prevalence of each subtype was 40.0%, 5.7%, 9.5%, 28.6%, and 16.2%, respectively. The intra-observer and inter-observer ICC of this classification system was 0.992 and 0.976, respectively.

Conclusions: Valgus knees can be classified into different subtypes according to deformity origins. This radiological classification system has satisfactory reproducibility. It helps surgeons better individualize morphological features of valgus knees.
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http://dx.doi.org/10.1111/os.13178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8755874PMC
January 2022

Comparison of the success rate after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection among patients with or without a sinus tract.

BMC Musculoskelet Disord 2021 Oct 21;22(1):895. Epub 2021 Oct 21.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No.31 Xinjiekou East Road, Xicheng District, Beijing, 100035, China.

Background: The relevance between the presence of a sinus tract and the failure risk after debridement, antibiotics and implant retention (DAIR) for periprosthetic joint infection (PJI) after hip or knee arthroplasty is still unclear. This study aimed to compare the success rate of DAIR between patients with or without a sinus tract and to explore the possible risk factors for failure after DAIR in patients with a sinus tract.

Methods: Consecutive DAIR cases for PJI after hip or knee arthroplasty between January 2009 and June 2019 with a minimum 1-year follow-up in two tertiary joint arthroplasty centers were included. Patients were classified into the sinus tract group and the non-sinus tract group according to the presence of a sinus tract. The success rate after DAIR were compared using Kaplan-Meier survival analysis. Potential risk factors for failure in the sinus group were also explored.

Results: One hundred seven patients were included. At a median 4.4 years of follow-up, 19 of 52 (36.5%) cases failed in the sinus tract group, while 15 of 55 (27.3%) cases failed in the non-sinus tract group. The 1-year and 5-year cumulative success rates were 71.2% (95% confidence interval (CI): 59.8-84.6%) and 56.8% (95% CI: 42.6-75.7%) in the sinus tract group, respectively, which were similar to the counterparts in the non-sinus tract group (P = 0.214). Among patients with a sinus tract, DAIR with the exchange of modular components showed a higher success rate (75.8% versus 47.4%, P = 0.038).

Conclusions: The presence of a sinus tract does not affect the success rate of DAIR. Modular component exchange in DAIR was proposed for patients with a sinus tract for an improved infection control rate.
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http://dx.doi.org/10.1186/s12891-021-04756-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8532350PMC
October 2021

Reliability and validity of commonly used patient-reported outcome measures (PROMs) after medial unicompartmental knee arthroplasty.

Orthop Traumatol Surg Res 2021 Oct 1:103096. Epub 2021 Oct 1.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China.

Introduction: Many patient-reported outcome measures (PROMs) have been utilized to assess outcomes after unicompartmental knee arthroplasty (UKA). However, most are not specifically designed for UKA and the measurement properties of these PROMs have never been elucidated in the setting of UKA. This study aimed to evaluate the reliability and validity of commonly used PROMs after UKA, which includes the Oxford knee score (OKS), Knee Society Score (KSS)-function score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS).

Hypothesis: The four commonly used PROMs after UKA are of good reliability and validity, but with different floor/ceiling effect.

Material And Methods: Prospectively collected postoperative follow-up PROMs scores of patients after medial UKA cases for osteoarthritis between May 2015 and June 2018 were retrospectively analyzed. All of the PROMs were finished on the same electronic questionnaires. Reliability (internal consistency, test-retest reliability, measurement error), construct validity and floor/ceiling effects were assessed.

Results: The whole cohort was composed of 207 cases, with a median age of 62.0 years and a male ratio of 59/207 (28.50%). Internal consistency was high in the OKS, weak in the KSS-function score and with redundancy in the WOMAC and KOOS scores (Cronbach alpha=0.915, 0.610, 0.953, 0.961, respectively). Each of the four PROMs had a high test-retest reliability (all intraclass correlation coefficient (ICC) >0.97). Convergent validity of the four PROMs with the physical component score of the 12-Item Short Form Health Survey (SF-12 PCS) were proven (all r>0.5; p<0.001). While no ceiling effect occurred in the OKS, one was detected in the KSS-function score with 19.81% of patients achieving the best possible score, as well as in the WOMAC sub-score for pain (54.11%) and stiffness (50.72%), in addition to the KOOS sub-score for symptoms (27.54%) and pain (38.16%).

Discussion: The four commonly used PROMs after UKA showed good test-retest reliability and construct validity. The OKS is more recommended for its better performance in internal consistency and ceiling effect than the KSS-function score, the WOMAC and KOOS scores.

Level Of Evidence: III; Diagnostic study.
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http://dx.doi.org/10.1016/j.otsr.2021.103096DOI Listing
October 2021

A Novel Endosteal Reconstruction of the Femur from Distal Femoral Remnant Using 3D-Printed Titanium Rings: A Two-Case Report.

JBJS Case Connect 2021 08 27;11(3). Epub 2021 Aug 27.

Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Case: Femur reconstruction with only the distal femoral remnant is challenging because of poor bone volume required for stem fixation. Although proximal femoral replacement, total femur replacement, allograft prosthesis composite, and custom porous tantalum implants are options, hybrid fixation enhanced by endosteal reconstruction with three-dimensional (3D)-printed porous titanium rings to reconstruct the femur without supporting isthmus has not been described. We report 2 cases with satisfactory 34- and 22-month follow-up results of hybrid fixation enhanced by endosteal reconstruction with 3D-printed porous titanium rings.

Conclusion: This novel method provides a solution to revise loosened femoral endoprosthesis with only distal femoral remnant.
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http://dx.doi.org/10.2106/JBJS.CC.20.01038DOI Listing
August 2021

Does psychological distress influence postoperative satisfaction and outcomes in patients undergoing total knee arthroplasty? A prospective cohort study.

BMC Musculoskelet Disord 2021 Jul 30;22(1):647. Epub 2021 Jul 30.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.

Background: Preoperative psychological distress may be related to dissatisfaction and poorer outcomes after total knee arthroplasty (TKA). However, the kind of psychological distress that could influence postoperative satisfaction and outcomes remains controversial. Few studies have examined these issues in Chinese cohorts. Thus, this study aimed to examine (1) the prevalence of preoperative psychological distress in patients undergoing TKA and (2) whether preoperative psychological distress influences patient satisfaction, early postoperative outcomes, and improvement of knee function after TKA.

Methods: We prospectively included 210 patients undergoing unilateral primary TKA between March 2017 and September 2017 at our institution. Preoperatively, patients completed the Depression Anxiety and Stress Scales and new Knee Society Scores (KSS) questionnaires. At 3 months and 1 year postoperatively, patients' KSS and overall satisfaction were assessed. Stepwise multivariate linear regression models were used to assess the variables that influenced changes in each KSS item.

Results: Preoperatively, 89 (42.4%) patients experienced psychological distress. The satisfaction rate and postoperative KSS were not significantly different between patients with or without psychological distress; a higher preoperative score was shown to predict less KSS improvement. Patients with depression had fewer symptom score changes.

Conclusions: The prevalence of preoperative psychological distress was relatively high; thus, surgeons should consider the patient's psychological state. Patients' satisfaction was not influenced by psychological factors. Patients with depression and higher preoperative scores had lower symptom scores and KSS improvement, respectively.
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http://dx.doi.org/10.1186/s12891-021-04528-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325222PMC
July 2021

Does robotic assisted technology improve the accuracy of acetabular component positioning in patients with DDH?

J Orthop Surg (Hong Kong) 2021 May-Aug;29(2):23094990211025325

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Background: Accurate positioning of the acetabular component is key in performing total hip arthroplasty (THA). However, reconstruction of the acetabulum in the setting of developmental dysplasia of the hip (DDH) is a challenge. Robotic assisted THA has the potential to improve the accuracy of implantation of the acetabular cup in cases with DDH. The purpose of this study was to assess whether robotic technology improves the accuracy of acetabular component positioning in patients with DDH.

Material And Methods: We included 59 THAs using robotic assisted technology from June 2019 to January 2020 as the study group. These were compared to conventional THAs without robotic technology after control for age, gender, body mass index (BMI), Crowe type and operation date. Radiographic measurements were taken by 2 blinded orthopaedic residents. The percentage of hips within the Lewinnek and Collanan safe zones were calculated, along with acetabular rotation centers for the "target zone." Surgical time and perioperative bleeding were also compared between both groups.

Results: One patient suffered dislocation in conventional group while no dislocation occurred in robotic group. The acetabular components of the robotic assisted group had more cases located within the Lewinnek ( = 0.013) and Collanan ( = 0.008) safe zones than conventional group (94.9% vs 79.7% and 74.6% vs 50.8%). There were 7 cases in conventional group and 4 cases in robotic group that had more lateral or more superior rotational centers of THA, but did not reach statistical significance ( = 0.342). No statistical difference was detected between groups with regards to blood loss ( = 0.098) and surgical time ( = 0.602).

Conclusion: Robot assisted technology can assist surgeons with implanting acetabular cups more in Lewinnek and Callanan safe zone than conventional techniques without additional blood loss and surgical time.

Level Of Evidence: Therapeutic Level Ⅲ.
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http://dx.doi.org/10.1177/23094990211025325DOI Listing
October 2021

Does prior core decompression have detrimental effect on subsequent total hip arthroplasty for osteonecrosis of the femoral head: A systematic review and meta-analysis.

Orthop Traumatol Surg Res 2020 Dec 12;106(8):1553-1560. Epub 2020 Nov 12.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, 100035 Beijing, The People's Republic of China.

Background: Core decompression (CD) is effective in relieving pain and delaying the progression to total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH). However, the influence of CD on subsequent THA has not yet been established. Therefore, we performed this systematic review to answer: does prior CD have detrimental effect on subsequent THA for ONFH, especially with regards to survivorship and functional results, as well as perioperative and postoperative complications.

Patients And Methods: After registration on PROSPERO (CRD42019118861), literature published up to and including November 2018 was searched in the PubMed, Embase and Cochrane library databases with predetermined terms. Comparative studies on the clinical outcomes between conversion to THA with prior CD (the Prior CD group) and primary THA (the Control group) for ONFH were included. The outcomes of interest included survivorship free from revision, the postoperative functional performance, perioperative and postoperative complications. Data was extracted systematically and a meta-analysis was performed.

Results: Overall, 5 retrospective cohort studies with 110 hips were identified for the Prior CD group and 237 hips were identified for inclusion in the Control group. All of the studies were of high quality in terms of the Newcastle-Ottawa Scale. No difference in the rate of revision between the two groups (2/42 (4.8%) vs. 4/160 (2.5%); RR=1.92; 95% CI=0.34 to 10.75; p=0.46) was detected after a minimum two-year follow-up. The mean postoperative Harris Hip Score was similar between the two groups in all 5 studies. The two groups experienced similar blood loss (Mean difference=12.17ml; 95% CI= -15.28 to 39.61ml; p=0.38). Moreover, intraoperative fracture was increased in the Prior CD group, though this did not reach statistical significance (3/31 (9.7%) vs. 0/55 (0.0%); RR=7.05; 95% CI=0.82 to 60.78; p=0.08). Similarly, osteolysis or radiolucent lines were more likely to occur in the Prior CD group without statistical significance (9/81 (11.1%) vs. 6/200 (3.0%); RR=3.14, 95% CI=0.98 to 10.06; p=0.05).

Discussion: The present evidence indicated that prior CD does not detrimentally affect the survivorship nor hip scores of subsequent THA. Attention should be paid, however, to the potential for intraoperative fracture, postoperative osteolysis or radiolucent lines.

Level Of Evidence: III; systematic review and meta-analysis of level III retrospective comparative studies.
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http://dx.doi.org/10.1016/j.otsr.2020.07.004DOI Listing
December 2020

Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations.

Knee Surg Sports Traumatol Arthrosc 2020 Sep 17;28(9):2747-2755. Epub 2020 Aug 17.

CortoClinics, Schijndel, The Netherlands.

Purpose: To plan for the continuance of elective hip and knee arthroplasty during a resurgence or new wave of COVID-19 infections.

Method: A systematic review was conducted using the terms "COVID-19" or "SARS-Cov-2" and "second wave". No relevant citations were found to inform on recommendations the plan. Therefore, an expert panel of the European Hip Society and the European Knee Associates was formed to provide the recommendations.

Results: Overall, the recommendations consider three phases; review of the first wave, preparation for the next wave, and during the next wave. International and national policies will drive most of the management. The recommendations focus on the preparation phase and, in particular, the actions that the individual surgeon needs to undertake to continue with, and practice, elective arthroplasty during the next wave, as well as planning their personal and their family's lives. The recommendations expect rigorous data collection during the next wave, so that a cycle of continuous improvement is created to take account of any future waves.

Conclusions: The recommendations for planning to continue elective hip and knee arthroplasty during a new phase of the SARS-Cov-2 pandemic provide a framework to reduce the risk of a complete shutdown of elective surgery. This involves engaging with hospital managers and other specialities in the planning process. Individuals have responsibilities to themselves, their colleagues, and their families, beyond the actual delivery of elective arthroplasty.
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http://dx.doi.org/10.1007/s00167-020-06213-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429418PMC
September 2020

Forgotten Joint Score Thresholds for Forgotten Joint Status and Patient Satisfaction after Unicompartmental Knee Arthroplasty in Chinese Patients.

J Arthroplasty 2020 10 11;35(10):2825-2829. Epub 2020 May 11.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Background: The Patient Acceptable Symptom State (PASS) and "forgotten joint" represent 2 treatment goals that arthroplasty surgeons often pursue. However, the actual Forgotten Joint Score (FJS-12) that corresponds to the PASS and forgotten joint in unicompartmental knee arthroplasty (UKA) patients remains unknown.

Methods: One hundred ninety-three patients who underwent a medial UKA for knee osteoarthritis with a minimum of 1-year follow-up were included. Patients were asked to complete the FJS-12 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. We used patient-reported satisfaction and the Patient's Joint Perception questions as anchors to determine the achievement of PASS and the forgotten joint, respectively. FJS-12 thresholds for PASS and the forgotten joint were calculated using the anchor-based receiver operating characteristic curve analysis. The ability of the FJS-12 and WOMAC scores to detect the PASS and forgotten joint was compared with DeLong's test.

Results: Based on the answers to the anchor questions, 176 (91.2%) of the 193 total patients achieved the PASS and 34 (17.6%) patients achieved a forgotten joint after UKA. The FJS-12 outperformed the WOMAC with respect to detecting a forgotten joint (P = .008), but they performed equally well in terms of detecting PASS (P = .950). The FJS-12 threshold for PASS was 40.63 (sensitivity: 84.1%, specificity: 76.5%) and for the forgotten joint was 84.38 (sensitivity: 97.1%, specificity: 88.1%).

Conclusion: For UKA patients, the FJS-12 score has a superior ability to detect a forgotten joint when compared to the WOMAC. The FJS-12 threshold for the PASS is 40.63, while a score above 84.38 can be interpreted as having achieved a forgotten joint.
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http://dx.doi.org/10.1016/j.arth.2020.05.010DOI Listing
October 2020

Cementless Total Hip Arthroplasty for Adult Patients With Sequelae From Childhood Hip Infection: A Medium-Term Follow-Up Study.

J Arthroplasty 2020 07 24;35(7):1885-1890. Epub 2020 Feb 24.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, People's Republic of China.

Background: The aim of this study is to evaluate midterm clinical and radiographic results of total hip arthroplasties (THAs) with cementless implants for adult patients with sequelae from childhood hip infection.

Methods: Between 2002 and 2016, 165 patients (165 hips) who had a hip infection during childhood were treated with THAs with cementless implants. The average duration of follow-up was 93.5 months (range 26-206). Clinical results were evaluated via the Harris Hip Score and radiographic results were analyzed with postoperative serial X-rays.

Results: The average Harris Hip Score increased from 27 (range 8-53) before surgery to 91 (range 45-100) at the latest follow-up examination (P < .001). At the latest follow-up evaluation, 9 cementless acetabular components demonstrated partial, nonprogressive radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line was observed around the femoral components. Intraoperative periprosthetic fractures occurred in 11 hips, including 3 acetabular fractures, 2 fractures of greater trochanter, 1 femoral shaft fracture, and 5 fractures of femoral calcar. Postoperative complications included 3 cases of periprosthetic infection, 1 episode of dislocation, 1 case of a femoral periprosthetic fracture, 5 cases of sciatic nerve injury, 1 case of femoral nerve injury, and 1 case of squeaking from a ceramic bearing surface.

Conclusion: Cementless THA for adult patients with sequelae from childhood hip infection presents significant technical challenges and a relatively high complication rate. With meticulous surgical planning and anticipation for the key technical challenges frequently encountered, the medium-term clinical and radiographic results of THA in this setting were good with high implant survivorship and patient satisfaction.
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http://dx.doi.org/10.1016/j.arth.2020.02.034DOI Listing
July 2020

Treatment and outcomes of Vancouver type B periprosthetic femoral fractures.

Bone Joint J 2020 Mar;102-B(3):293-300

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Aims: Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Methods: A total of 97 consecutive PPFs (49 males and 48 females) were included with a mean age of 66 years (standard deviation (SD) 14.9). Of these, 86 patients were treated with surgery and 11 were treated conservatively. All living patients had a minimum two-year follow-up. Patient demographics details, fracture healing, functional scores, and complications were assessed. Clinical outcomes between internal fixation and revisions in patients with or without a stable femoral component were compared. Conservatively treated PPFs were evaluated in terms of mortality and healing status. A logistic regression analysis was performed to identify risk factors for complications.

Results: In surgically treated patients, all fractures united and nine complications were identified. The mean postoperative Visual Analogue Scale (VAS) for pain was 1.5 (SD 1.3), mean Parker Mobility Score (PMS) was 6.5 (SD 2.4), and mean Harris Hip Score (HHS) was 79.4 (SD 16.2). Among type B2 and type B3 fractures, patients treated with internal fixation had significantly lower PMS (p = 0.032) and required a longer time to heal (p = 0.012). In conservatively treated patients, one-year mortality rate was 36.4% (4/11), and two patients ultimately progressed to surgery. Young age (p = 0.039) was found to be the only risk factor for complications.

Conclusion: The overall clinical outcome among Vancouver type B PFF was satisfactory. However, treatment with internal fixation in type B2 and B3 fractures had a significantly longer time to heal and lower mobility than revision cases. Conservative treatment was associated with high rates of early mortality and, in survivors, nonunion. This probably reflects our selection bias in undertaking surgical intervention. In our whole cohort, younger patient age was a risk factor for postoperative complications in Vancouver type B PFF. Cite this article: 2020;102-B(3):293-300.
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http://dx.doi.org/10.1302/0301-620X.102B3.BJJ-2019-0935.R1DOI Listing
March 2020

Hybrid fixation versus full-cemented or full-cementless fixation in total knee arthroplasty: Systematic review and meta-analysis of comparative studies.

J Orthop Sci 2020 Nov 9;25(6):1047-1054. Epub 2020 Jan 9.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing 100035, People's Republic of China.

Objective: Hybrid fixation is one alternative to full-cemented fixation in total knee arthroplasty (TKA) with theoretical advantages. Hybrid fixation may offer the advantages of cementless femoral fixation, while also avoiding the problem of tibial loosening in full-cementless TKA. The purpose of the study is to determine whether hybrid TKA may perform comparably to or better than full-cemented and full-cementless TKA.

Methods: We searched the MEDLINE, EMBASE and Cochrane Library databases through September 2018 for randomized controlled trials and observational studies comparing outcomes of hybrid versus full-cemented or full-cementless fixation techniques. Outcomes of interest included aseptic loosening, overall reoperation rate, infection, radiolucent lines and operating time. Data were pooled with the Mantel-Haenszel random effects model.

Results: We included 14 studies with follow-up ranging from 2.7 to 9.6 years in our quantitative analysis, of which 7 studies compared hybrid fixation with full-cemented TKA and another 7 compared hybrid fixation with full-cementless TKA. Combined data revealed that the hybrid fixation group had a similar rate of aseptic loosening compared with cemented (P = 0.19) and cementless (P = 0.49) groups. There was no difference with respect to other outcomes, including overall reoperation rate, infection, radiolucent lines and operating time between groups.

Conclusion: Hybrid, cementless and cemented TKAs have comparable mid-term results as it pertains to aseptic loosening, overall reoperation, infection, radiolucent lines and operating time. Further comparative studies are needed to investigate these potential effects over the long-term.
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http://dx.doi.org/10.1016/j.jos.2019.12.009DOI Listing
November 2020

Different femoral origins of valgus deformity affect aspect ratios of resected distal femurs in total knee arthroplasty.

Knee 2019 Oct 8;26(5):1073-1079. Epub 2019 Aug 8.

Department of Orthopaedics, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Purpose: This study aimed to evaluate the anthropometry of resected distal femurs in valgus knees at the level of standard cuts during total knee arthroplasty (TKA), and to compare these measurements to neutrally aligned knees.

Methods: Anteroposterior and mediolateral measurements of the distal femur were performed on three-dimensional computed tomography reconstructions of 57 valgus knees (34 intra-articular valgus and 23 juxta-articular valgus) and 40 neutrally aligned knees. The measured dimensions and calculated aspect ratios (ARs) were subsequently compared.

Results: Juxta-articular valgus knees had similar ARs when compared with neutrally aligned knees (1.14 ± 0.06 vs. 1.12 ± 0.05, P = 0.103). However, intra-articular valgus knees had smaller ARs (1.09 ± 0.07) when compared with juxta-articular valgus (P = 0.002) or neutrally aligned knees (P = 0.023).

Conclusion: Different origins of valgus deformity in the femur can significantly affect the AR values on the resected surface of the distal femur. Pre-operative evaluation of a valgus deformity may assist in estimating the morphology of the resected distal femur during TKA.
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http://dx.doi.org/10.1016/j.knee.2019.07.007DOI Listing
October 2019

Is surface modification effective to prevent periprosthetic joint infection? A systematic review of preclinical and clinical studies.

Orthop Traumatol Surg Res 2019 09 19;105(5):967-974. Epub 2019 Jun 19.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing 100035, China. Electronic address:

Background: With increasing recognition of the importance of biofilm formation in the pathogenesis of periprosthetic joint infection (PJI), a push towards finding solutions to prevent PJI via surface modification of prostheses is occurring. Unlike the promising in vitro antimicrobial effects of these surface modifications, the preclinical and clinical prophylactic effects vary and are debated. Therefore, we performed this systematic review to answer: (1) what kinds of methods of surface modification are used in preclinical and clinical studies to prevent PJI, (2) whether these modifications are effective to prevent PJI.

Methods: Electronic searches were performed using PubMed, Embase and the Cochrane library databases up to and including December 2017 with predetermined criteria: (1) in vivo studies with (2) surface modification for prophylactic effects against infection. Both animal studies and clinical trials were included. Data were extracted and presented systematically.

Results: Overall, 21 studies were included. Among these, fourteen were carried out in animal models and seven were clinical studies. In the animal studies, six used antibiotics and six silver modifications, while copper and Cationic Steroidal Antimicrobial-13 were each used for one study. In the seven clinical studies targeting patients with high infection risk, five of them focused on silver-coated prostheses and the remaining two studied iodine-coated implants. In all of the animal studies, when compared with the control group, the surface modified groups had a lower infection risk (RR ranging from 0 to 0.71). Clinical studies using silver-coated prostheses also demonstrated a lower infection risk (RR ranging from 0.24 to 0.70), while iodine-coated implants showed a 0% and 5% incidence of PJI in the two case series included.

Discussion: The results from the publications included in this review indicate that surface modification, especially antibiotic and silver modifications, are helpful preventing PJI in both preclinical animal models and in clinical trials.

Level Of Evidence: III, systematic review of level III retrospective comparative studies and level IV case series and animal experiments.
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http://dx.doi.org/10.1016/j.otsr.2019.05.006DOI Listing
September 2019

Femoral Bone Remodeling in Revision Total Hip Arthroplasty with Use of Modular Compared with Monoblock Tapered Fluted Titanium Stems: The Role of Stem Length and Stiffness.

J Bone Joint Surg Am 2019 Mar;101(6):531-538

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Background: To our knowledge, no previous studies have compared periprosthetic bone remodeling around monoblock versus modular tapered fluted titanium stems with different stem length and thickness.

Methods: A retrospective comparative study was performed on 139 consecutive total hip arthroplasties (THAs) revised with a tapered fluted modular titanium stem and 114 consecutive THAs revised with a tapered fluted monoblock titanium stem. The latest follow-up radiographs were compared with immediate postoperative radiographs to assess bone restoration in residual osteolytic areas, femoral stress-shielding, spot-welds, and radiolucent lines. Diameter and medullary canal filling of the 2 stems were measured.

Results: More patients in the monoblock group demonstrated osseous restoration than in the modular group (p = 0.009), and the modular stem exerted more severe stress-shielding on the femur (p < 0.001). Stem tip spot-welds developed in 88.5% of modular stems compared with 47.4% of the monoblock stems (p < 0.001). Spot-welds developed in 38.8% of modular stems at the modular junction. Partial or circumferential radiolucent lines were observed at the proximal segment of 30.9% of modular stems, compared with 14.0% of monoblock stems (p = 0.002).

Conclusions: Compared with the longer and thinner monoblock stems, modular stems had less proximal osseous restoration in residual osteolytic areas and more severe femoral stress-shielding, stem tip spot-welds, and radiolucent lines around the stems, which were stiffer and had a shorter distal section. The stem diameter and stiffness (which were influenced by stem length, curvature, and modularity) determined bone remodeling patterns.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.18.00442DOI Listing
March 2019

The Utilization of Metal Augments Allows Better Biomechanical Reconstruction of the Hip in Revision Total Hip Arthroplasty With Severe Acetabular Defects: A Comparative Study.

J Arthroplasty 2018 12 29;33(12):3724-3733. Epub 2018 Aug 29.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, People's Republic of China.

Background: Reconstructing the normal hip biomechanics is important for a successful revision total hip arthroplasty (THA). Little is known about whether using metal augments in revision THA is biomechanically superior to traditional techniques.

Methods: A retrospective review was conducted on 74 consecutive THAs revised using metal augments with a cementless hemispherical cup and 77 consecutive THAs revised using the jumbo cup, all with a minimum 2-year follow-up. Biomechanical parameters were measured before and immediately after the revision. Radiological and clinical outcomes at follow-ups were also evaluated.

Results: The metal augment group had a reconstructed center of rotation (COR) that was 6.5 mm closer to the anatomic COR in height (P < .001), had 3.6 m smaller cup size (P < .001), and had 5.7 mm less head-cup difference (P < .001). Moreover, there was a reconstructed COR that was much closer to the anatomic COR (vertical distance: 1.8 vs 14.1 mm, P < .001; horizontal distance: -2.1 vs 7.9 mm, P = .013), had 4.1 mm greater femoral offset (P = .006), and had 8 mm less leg length discrepancy (P = .035) in the subgroup of Paprosky type III bone defects when compared to the jumbo cup group. All cup-augment constructs were radiologically stable with a higher mean postoperative Harris Hip Score (P = .012). One jumbo cup was radiologically unstable.

Conclusion: In revision THA, utilizing metal augments helps to restore the COR position more precisely, avoid using a larger cup, reduce head-cup difference, rebuild femoral offset, and decrease leg length discrepancy, particularly with Paprosky type III bone defects. Moreover, it provides satisfactory radiological and clinical outcomes in the short term.
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http://dx.doi.org/10.1016/j.arth.2018.08.027DOI Listing
December 2018

Tests for predicting reimplantation success of two-stage revision for periprosthetic joint infection: A systematic review and meta-analysis.

Orthop Traumatol Surg Res 2018 11 17;104(7):1115-1123. Epub 2018 Jul 17.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, 100035 Beijing, Xicheng District, China.

Background: Several tests are used before reimplantation to detect persistent infection in patients with periprosthetic joint infection (PJI) undergoing two-stage revision. However, there is no consensus as to the optimal tests for excluding persistent infection or predicting successful reimplantation by stage. We aimed to determine the accuracy of different tests used to detect persistent infection after the first stage, and/or predicting failure following reimplantation in patients with PJI.

Methods: We conducted a systematic review and meta-analysis of PubMed, Embase and the Cochrane Library databases. Two reviewers independently conducted quality assessments and data extractions to estimate pooled sensitivity and specificity, diagnostic odds ratio and area under the receiver operating characteristic curves (AUSROC) for each test.

Results: We included 24 studies published between May 1999 and September 2017. Synovial fluid polymorphonuclear neutrophils (PMN)% had the highest sensitivity of 0.70, followed by serum erythrocyte sedimentation rate (0.57) and spacer sonication fluid culture (0.53). Synovial fluid culture had the highest specificity of 0.97, followed by frozen section (0.93) and the Musculoskeletal Infection Society criteria (0.92). Spacer sonication fluid culture was the most accurate test with an AUSROC of 0.8089, followed by synovial fluid culture (0.7749) and frozen section (0.7819).

Discussion: Spacer sonication fluid culture had a relatively high diagnostic accuracy. We emphasize that no test can be used alone to exclude persistent infection beyond the first stage and/or predict failed reimplantation beyond the second stage.

Level Of Evidence: II, systematic review and meta-analysis of level 2 to level 4 studies with inconsistent results.
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http://dx.doi.org/10.1016/j.otsr.2018.03.017DOI Listing
November 2018

Comparisons of slice-encoding metal artifact correction and view-angle tilting magnetic resonance imaging and traditional digital radiography in evaluating chronic hip pain after total hip arthroplasty.

J Orthop Translat 2018 Jan 20;12:45-54. Epub 2017 Dec 20.

Department of Radiology, Jishuitan Hospital, Beijing, China.

Purpose: The aims of this study were (1) to compare the areas of metal-induced artifacts and definition of periprosthetic structures between patients scanned with the slice-encoding metal artifact correction and view-angle tilting (SEMAC-VAT) turbo-spin-echo (TSE) prototype and those scanned with the standard TSE magnetic resonance (MR) sequences and (2) to further clarify the superiority of the SEMAC-VAT MR imaging technique at detecting lesions in patients after total hip arthroplasty (THA), compared with digital radiography (DR).

Materials And Methods: A total of 38 consecutive patients who underwent THA were referred to MR imaging at our institution. All patients suffered from chronic hip pain postoperatively. Twenty-three patients of the 38 were examined with a 1.5-T MR scanner using a SEMAC-VAT TSE prototype and standard TSE sequence, and the remaining 15 patients were examined with the same 1.5-T MR scanner, but using the SEMAC-VAT TSE prototype only. The traditional DR imaging was also performed for all patients. Two radiologists then independently measured the area of metal-induced artifacts and evaluated the definition of both the acetabular and femoral zones based on a three-point scale. Finally, the positive findings of chronic hip pain after THA based on SEMAC-VAT TSE MR imaging and traditional DR imaging were compared and analysed.

Results: The areas of metal-induced artifacts were significantly smaller in the SEMAC-VAT TSE sequences than those in the standard TSE sequences for both the T1-weighted ( < 0.001) and T2-weighted ( < 0.001) turbo inversion recovery magnitude images. In addition, 28 patients showed a series of positive signs in the SEMAC-VAT images that were not observed in the traditional DR images.

Conclusion: Compared with the standard TSE MR imaging, SEMAC-VAT MR imaging significantly reduces metal-induced artifacts and might successfully detect most positive signs missed in the traditional DR images.

Translational Potential Of This Article: The main objective of this research was to show that MR sequences from the SEMAC-VAT TSE prototype provide a significant advantage at detecting lesions in patients after THA because of the excellent soft-tissue resolution of the MR imaging. SEMAC-VAT MR can evaluate chronic hip pain after THA and determine the cause, which can help the clinician decide on whether a surgical revision is needed.
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http://dx.doi.org/10.1016/j.jot.2017.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866482PMC
January 2018

Accuracy of Digital Tomosynthesis With Metal Artifact Reduction for Detecting Osteointegration in Cementless Hip Arthroplasty.

J Arthroplasty 2018 05 29;33(5):1579-1587. Epub 2017 Dec 29.

Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Background: Cementless hip arthroplasty is increasingly gaining popularity worldwide. Radiologic identification of osteointegration is key to confirming biologic fixation. We conducted the study reported here to determine the sensitivity and specificity of digital tomosynthesis with metal artifact reduction (TMAR), radiography, and conventional computed tomography in detecting osteointegration in cementless hip arthroplasty.

Methods: We prospectively included data for 24 patients who underwent revision hip arthroplasty in our hospital, with 13 femoral and 14 acetabular cementless components retrieved that contained solid evidence of biologic fixation. All patients underwent 3 examinations before surgery, and evidence of osteointegration on retrieved prostheses was used as the reference standard. Seven orthopedic surgeons evaluated these images independently using uniform criteria.

Results: On the femoral side, the sensitivity and specificity of detecting osteointegration were 73.8% ± 4.6% and 94.3% ± 1.5%, respectively, for TMAR; 50.4% ± 5.3% and 87.8% ± 2.1%, respectively, for radiography; and 36.4% ± 5.1% and 90.9% ± 1.9%, respectively, for CT. On the cup side, the corresponding values were 60.2% ± 8.3% and 86.4% ± 5.7%, respectively, for TMAR; 45.9% ± 8.5% and 66.4% ± 7.8%, respectively, for radiography; and 45.1% ± 8.5% and 73.5% ± 7.3%, respectively, by computed tomography.

Conclusion: TMAR significantly improved the accuracy osteointegration detection in cementless hip arthroplasty (P < .017).
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http://dx.doi.org/10.1016/j.arth.2017.12.037DOI Listing
May 2018

Burnout Among Chinese Adult Reconstructive Surgeons: Incidence, Risk Factors, and Relationship With Intraoperative Irritability.

J Arthroplasty 2018 04 3;33(4):1253-1257. Epub 2017 Nov 3.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, People's Republic of China.

Background: Burnout is a major concern in human service occupations, mainly characterizing in emotional exhaustion and depersonalization. There is very limited research dealing with burnout in orthopedic surgeons. Exploring burnout prevalence, risk factors, and intraoperative irritability-related incidences is necessary to improve the quality of life for surgeons.

Methods: The study population consisted of 202 registered adult reconstructive doctors in China. Burnout was measured using a normalized translated version of the Maslach Burnout Inventory-Human Service Survey. Demographics, professional characteristics, and intraoperative irritability-related questions were also collected by electronic questionnaires. Statistical analysis was performed using SPSS 22.0.

Results: The overall rate of burnout was 85.1%. Variables significantly associated with high emotional exhaustion scores included poor sleeping time per day (P = .008), more nights on call per week (P = .048), and absence of research (P = .014). For depersonalization, absence of marriage (P < .001) and more nights on call per week (P < .001) were selected as risk factors. The incidence of losing temper in operation is 58.9%, significantly higher in senior surgeons (P = .001). Three major reasons for irritation during operations included delays by companies providing operative devices, poor coordination of assistants, and slow movements of instrument nurses. Intraoperative irritability was found to be significantly correlated with burnout, especially in emotional exhaustion. Residents were the population having the least opportunities to lose temper in operation.

Conclusion: Burnout is highly prevalent in Chinese adult reconstructive surgeons, and it had some correlations with irritability. Further research is needed to determine more risk factors and reduce intraoperative irritability-related incidences.
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http://dx.doi.org/10.1016/j.arth.2017.10.049DOI Listing
April 2018

Tibial shaft anatomy differs between Caucasians and East Asian individuals.

Knee Surg Sports Traumatol Arthrosc 2018 Sep 22;26(9):2758-2765. Epub 2017 Sep 22.

Rothman Institute, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA.

Purpose: The orientation and distance from the shaft of the femur and tibia to the articular surface centre is important for performing total knee arthroplasty (TKA) with cementless stems. It is important to understand anatomic differences between races to match the tibial and femoral shaft axis to the knee articular surface. Thus, the purpose of this study was to compare knee morphology between Caucasian and East Asian individuals to determine the optimal placement of tibial and femoral stems.

Methods: A retrospective study was conducted on a matched cohort of 50 East Asians (21F, 29M) and 50 Caucasians (21F, 29M) by age and gender. CT scans were obtained in healthy volunteers using < 2-mm slices. The distance from the proximal tibial diaphysis axis to the tibial plateau centre and the distance from the distal femoral diaphysis axis to the centre of distal femoral articular surface were measured separately. Tibial measurements were taken using Akagi's anteroposterior (AP) axis and the widest mediolateral (ML) diameter, and femoral measurements were based on Whiteside's line and the surgical epicondylar axis.

Results: The ML distance between the tibial shaft centre and Akagi's line was significantly higher for Asians (9.9 ± 2.7 mm, Caucasians 7.7 ± 3.1 mm, p < 0.001). The distance between the femoral shaft centre and Whiteside's line was lower, although not significantly different (Asians 1.9 ± 1.0 mm, Caucasians 2.2 ± 1.1 mm, n.s.). However, there were no differences in the AP dimension for the femur or tibia comparing Asians to Caucasians in both tibial side (Asians 10.6 ± 3.3 mm vs. Caucasians 10.9 ± 4.0 mm) and femoral side (Asians 18.1 ± 1.7 mm vs. Caucasians 17.5 ± 1.6 mm).

Conclusion: East Asian individuals have more offset in the ML dimension for the tibia. This finding is clinical relevant, as this dimensional difference should be taken into consideration when designing primary and revision TKA stemmed tibial implants for East Asian individuals.

Level Of Evidence: Case-control study, Level III.
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http://dx.doi.org/10.1007/s00167-017-4724-2DOI Listing
September 2018

Midterm Survivorship and Complications of Total Knee Arthroplasty in Patients With Dwarfism.

J Arthroplasty 2017 11 9;32(11):3364-3367. Epub 2017 Jun 9.

Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.

Background: Dwarfism is associated with skeletal dysplasias and joint deformities that frequently result in osteoarthritis requiring treatment with total knee arthroplasty (TKA). These surgeries can be challenging because of alignment deformities, poor bone stock, and smaller components. This study aims to compare TKA implant survivorship and complications between dwarf and nondwarf patients.

Methods: A retrospective case-control study was performed from 1997-2014 evaluating 115 TKAs in patients under the height threshold of 147.32 cm. This cohort was compared with 164 patients of normal height. Medical records were reviewed for demographics, surgical characteristics, and outcomes. All cases had 2-year minimum follow-up.

Results: The revision rate was 8.7% in dwarfs compared with 3.7% in controls (P = .08). The 2-, 5-, and 10-year implant survivorship in dwarfs was 96.4%, 92.5%, and 90.2%, respectively; and 96.6%, 95.6%, and 94.8% for controls, respectively (P = .24). Dwarfs underwent significantly more manipulations for arthrofibrosis (P = .002). There was greater femoral (17.4% vs 2.1%, P < .01) and tibial (6.5% vs 2.7%, P < .01) component overhang in dwarfs compared with controls.

Conclusion: Despite a 2-fold increase in the revision rate of the dwarf cohort, the midterm survivorship is comparable between the dwarf and nondwarf patients. However, dwarfs were more likely to become stiff and undergo manipulation; the increased propensity for stiffness may be associated with oversized components, as evidenced by greater component overhang. Surgeons should be aware of this increased risk and may consider using smaller or customized implants to account for the morphological differences in this patient population.
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http://dx.doi.org/10.1016/j.arth.2017.06.002DOI Listing
November 2017

Location of the Common Peroneal Nerve in Valgus Knees-Is the Reported Safe Zone for Well-Aligned Knees Applicable?

J Arthroplasty 2017 11 2;32(11):3539-3543. Epub 2017 Jun 2.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Jishuitan Orthopaedic College of Tsinghua University, Beijing, China.

Background: Lateral soft-tissue release can jeopardize the common peroneal nerve (CPN) in total knee arthroplasty for valgus knees. Previous studies reporting safe zones to protect the CPN were based on well-aligned knees. We conducted this study to compare the localization of the CPN in well-aligned knees and in valgus knees.

Methods: We conducted a consecutive 3-dimensional radiographic study on magnetic resonance images of 58 well-aligned knees and 39 valgus knees. We measured the distance between the CPN and the tibia, as well as the mediolateral, anteroposterior, and angular location of the CPN. We compared the results between well-aligned knees and valgus knees.

Results: We found that there is an increased distance between the CPN and the tibia at the level of the tibial cut, but not at the joint line in valgus knees. It is safer to release the posterolateral capsule at the tibial side than at the level above this. The angular location and the mediolateral or anteroposterior location of the CPN in valgus knees are similar to those of well-aligned knees.

Conclusion: The location of the CPN in valgus knees is similar to that in well-aligned knees. The previously reported safe zone in well-aligned knees is applicable in valgus knees to protect the CPN.
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http://dx.doi.org/10.1016/j.arth.2017.05.048DOI Listing
November 2017

What Is the Difference Between Modular and Nonmodular Tapered Fluted Titanium Stems in Revision Total Hip Arthroplasty.

J Arthroplasty 2017 10 18;32(10):3108-3113. Epub 2017 May 18.

Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, Beijing, China.

Background: Both modular and nonmodular tapered fluted titanium stems are used in revision total hip arthroplasty (THA), with follow-up showing good results for both stems. We aimed to determine whether there were any differences in clinical outcomes, survivorship, or frequency of complications.

Methods: A retrospective review of 160 consecutive THAs (153 patients) revised with a tapered fluted modular titanium stem from 2002 to 2014 and 129 consecutive THAs (128 patients) revised with a tapered fluted nonmodular titanium stem between 2008 and 2014 was conducted. The patient's level of satisfaction, clinical assessment, and complications were examined. A Kaplan-Meier survivorship analysis was performed with the endpoint defined as any reoperation due to septic/aseptic complications.

Results: Mean duration of follow-up was longer in the modular group (6.3 years) than the nonmodular group (5.0 years; P = .003). No significant group differences were found in the postoperative Harris Hip Score, the level of overall satisfaction, the 8-year cumulative survival, the rate of infection, dislocation, or postoperative periprosthetic fractures. However, intraoperative fractures occurred significantly more frequently in the modular group (16.9%) than in the nonmodular group (7.0%; P = .011), and stem subsidence was significantly less in the modular group (0.95 mm) than in the nonmodular group (1.93 mm; P = .001). Two mechanical failures associated with the modular design occurred in the modular group.

Conclusion: Both modular and nonmodular tapered fluted titanium stems provide satisfactory midterm results in revision THA. Although tapered fluted modular stems are gaining in popularity in revision THA, tapered fluted nonmodular stems should not be disregarded as a viable alternative, especially for relatively straightforward cases.
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http://dx.doi.org/10.1016/j.arth.2017.05.021DOI Listing
October 2017
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