Publications by authors named "Ioannis Gkiatas"

47 Publications

Irrigation and Debridement With Implant Retention: Does Chronicity of Symptoms Matter?

J Arthroplasty 2021 Aug 4. Epub 2021 Aug 4.

Stavros Niarchos Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY.

Background: Periprosthetic joint infection (PJI) remains a rare, yet devastating complication of total joint arthroplasty (TJA). Chronic infection is generally considered a contraindication to debridement, antibiotics, and implant retention (DAIR); however, outcomes stratified by chronicity have not been well documented.

Methods: A retrospective review of all DAIR cases performed at a single institution from 2008 to 2015 was performed. Chronicity of PJI was categorized as acute postoperative, chronic, or acute hematogenous. Failure after DAIR, defined as re-revision for infection recurrence with the same organism, was evaluated between the 3 chronicity groups at 90 days as well as at a minimum 2-year follow-up.

Results: Overall, 248 patients undergoing DAIR for total hip arthroplasty or total knee arthroplasty PJI were included. Categorization of PJI was acute (acute postoperative) in 59 cases (24%), chronic in 54 (22%), and acute hematogenous in 135 (54%). DAIR survivorship was 47% (range 0.3-10 years). Overall, there were 118 (47.6%) treatment failures after DAIR with a minimum of 2-year follow-up. There was no difference in failure rate between total hip or total knee arthroplasty patients (P = .07). Patients infected with Staphylococcus conferred a higher risk of failure for all DAIR procedures regardless of chronicity category.

Conclusion: Identification of microbial species prior to undertaking DAIR may be more clinically relevant than stratification according to chronicity category when considering treatment options.
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http://dx.doi.org/10.1016/j.arth.2021.07.018DOI Listing
August 2021

Extended Trochanteric Osteotomy Closure Performed Before or After Canal Preparation and Stem Impaction Does Not Affect Axial Stability.

J Arthroplasty 2021 Jul 30. Epub 2021 Jul 30.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY.

Background: An extended trochanteric osteotomy (ETO) safely addresses femoral component removal during challenging revision total hip arthroplasty. However, no prior study has evaluated whether a difference in axial stability exists between ETO closure performed before (reconstitution) or after (scaffolding) canal preparation and stem impaction. We hypothesized that given the absence of clinical reports of outcome differences despite the wide use of both practices, no significant difference in the initial axial stability would exist between the 2 fixation techniques.

Methods: ETOs were performed and repaired using the reconstitution technique for the 6 right-sided femora and the scaffolding technique for the six left-sided femora. The 195-mm long, 3.5°-tapered splined titanium monobloc stems were impacted into 6 matched pairs of human fresh cadaveric femora. Three beaded cables were placed in a standardized fashion on each specimen, 1 for prophylaxis against osteotomy propagation during reaming/impaction and 2 to close the ETO. Stepwise axial loading was performed to 2600 N or until failure, which was defined as subsidence >5 mm or femoral/cable fracture.

Results: All specimens successfully resisted axial testing, with no stem in either ETO repair group subsiding >2 mm. The mean subsidence for the reconstitution group was 0.9 ± 0.4 mm, compared to 1.2 ± 0.5 mm for the scaffolding group (P = .2).

Conclusion: In this cadaveric model with satisfactory proximal bone stock, no difference existed between the reconstitution and scaffolding ETO repair techniques, and both provide sufficient immediate axial stability in a simulated revision total hip arthroplasty setting under physiologic loads.
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http://dx.doi.org/10.1016/j.arth.2021.07.010DOI Listing
July 2021

Relaxation Techniques in Low Back Pain Patients: A Randomized Controlled Trial.

J Long Term Eff Med Implants 2021 ;31(2):39-44

Stress Management and Health Promotion Unit, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.

Low back pain (LBP) is a common problem, affecting 11% of the population in Greece. Pain can last upwards of 6 wk and impact functional ability and quality of life. Treating LBP often includes the use of alternative methods, such as relaxation techniques. We tested whether relaxation techniques could reduce stress and pain and improve quality of life. Patients engaged in methods such as diaphragmatic breathing, progressive muscular relaxation, autogenic training, and guided imagery. The treatment group consisted of 31 randomized patients and the control group had 33. The treatment group followed an 8-wk relaxation program with weekly sessions and practiced techniques every day by listening to a compact disk at home (2×/d). The control group did not follow relaxation techniques. No statistically significant differences were present regarding the Perceived Stress Scale, body-mass index, and satisfaction with functional ability. However, statistically significant differences were found in the Brief Pain Inventory score and multidimensional locus of control. We also found decreases in all three cortisol measurements for the treatment group. Relaxation techniques provide positive results in pain reduction and cortisol decrease and must therefore be incorporated into rehabilitation protocols.
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http://dx.doi.org/10.1615/JLongTermEffMedImplants.2021037026DOI Listing
January 2021

Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes.

JBJS Rev 2021 07 23;9(7). Epub 2021 Jul 23.

Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.

»: Mental health and psychosocial factors play a critical role in clinical outcomes in orthopaedic surgery.

»: The biopsychosocial model of disease defines health as a product of physiology, psychology, and social factors and, traditionally, has not been as emphasized in the care of musculoskeletal disease.

»: Improvement in postoperative outcomes and patient satisfaction is incumbent upon the screening, recognition, assessment, and possible referral of patients with high-risk psychosocial factors both before and after the surgical procedure.
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http://dx.doi.org/10.2106/JBJS.RVW.20.00169DOI Listing
July 2021

Relatively Low Rate of Heterotopic Ossification Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-analysis.

J Am Acad Orthop Surg Glob Res Rev 2021 07 22;5(7). Epub 2021 Jul 22.

From the Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY (Dr. Gkiatas, Mr. Xiang, Mr. Windsor, Dr. Malahias, Dr. Tarity, and Dr. Sculco), and the School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece (Mr. Karasavvidis).

Background: Heterotopic ossification (HO) is abnormal growth of ectopic bone and negatively affects the outcomes after total knee arthroplasty (TKA). This systematic review and meta-analysis were performed to characterize the prevalence and severity of HO after primary TKA.

Methods: A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient demographics, publication year, and HO prevalence after a primary TKA were recorded. A meta-analysis was performed to determine the overall prevalence of HO formation, and a subanalysis compared the studies published in different timeframes to determine whether a temporal effect exists for HO prevalence.

Results: Two thousand nine hundred eighty-eight patients underwent primary TKA across the included studies. Fourteen percent of patients (9% to 20%; I2: 93.68%) developed HO postoperatively during a mean follow-up of 40.1 months (11 to 108 months). HO rates seemed to decrease in studies published in more recent years, with a pooled HO prevalence of 5% (0% to 13%; I2: 92.26%) among studies published in the past 15 years compared with 18% (12% to 25%; I2: 92.49%) among studies published before then.

Conclusion: Although studies reported a relatively low overall rate of HO after a primary TKA, the absence of a single, standardized classification system precludes the comparisons of HO severity between studies. Overall, HO prevalence seems to have decreased over time, likely reflecting the changes in perioperative medication protocols.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301284PMC
July 2021

Cement-in-cement technique of the femoral component in aseptic total hip arthroplasty revision: A systematic review of the contemporary literature.

J Orthop 2021 Jul-Aug;26:14-22. Epub 2021 Jun 30.

Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA.

Background: Clinical outcomes of cemented femoral stems revisions using the cement-in-cement technique in aseptic conditions after total hip arthroplasty have been widely described.

Methods: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried.

Results: Twelve articles were included (620 revision THA). Revision rate for complications related to the femoral side was 1.4% at mid-term follow-up (5.4 years). Periprosthetic femoral fracture rate was 1.1%, aseptic loosening of the femoral component 0.3%.

Conclusions: Cement-in-cement revision technique of the femoral component is associated with a high mid-term success rates (98.6%) and is potentially less challenging than other revision techniques.
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http://dx.doi.org/10.1016/j.jor.2021.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261467PMC
June 2021

Use of elevated liners in primary total hip arthroplasty: a systematic review of the literature.

Eur J Orthop Surg Traumatol 2021 May 29. Epub 2021 May 29.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10021, USA.

Purpose: Instability remains one of the most frequent complications requiring revision surgery after primary total hip arthroplasty (THA). Elevated liners are often utilized to reduce the risk of dislocation; however, the literature is inconclusive, with no systematic reviews summarizing the data. Thus, this systematic review aimed to establish a consensus for the efficacy of elevated liners in primary THA by determining rates of overall revision and revision specifically for recurrent dislocation.

Materials And Methods: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible randomized-controlled trials and observational studies reporting on the use of elevated liners in primary total hip arthroplasty were identified through May 2020. A random effects model meta-analysis was conducted, and the I statistic was used to assess for heterogeneity.

Results: Eight studies met inclusion criteria, and overall, 26,507 patients undergoing primary THA with use of an elevated liner were included. In aggregate, the most common cause of revision was recurrent hip dislocation (1.3%, N = 82/6,267) followed by joint infection (1.2%, N = 45/3,772) and acetabular loosening (0.3%, N = 10/3,772). Notably, elevated liners were associated with a lower risk of revision for recurrent dislocation compared to neutral liners (HR: 0.74; 95% CI: 0.55-1.00; p = 0.048).

Conclusion: This review found that after primary THA with the use of elevated liners, hip dislocation and prosthetic joint infection continued to be the most frequent reasons for revision surgery. However, elevated liners had a lower risk of revision for recurrent dislocation compared to neutral liners.
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http://dx.doi.org/10.1007/s00590-021-03023-yDOI Listing
May 2021

Total knee arthroplasty in dialysis patients: Is it safe? A systematic review of the literature.

J Orthop 2021 May-Jun;25:199-206. Epub 2021 May 14.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA.

Purpose: This systematic review characterizes the safety and efficacy of total knee arthroplasty (TKA) in end stage renal disease (ESRD) patients due to the unique challenges they face.

Results: The cumulative complication rate for 3684 patients on dialysis for ESRD after primary TKA was 25%(N = 925/3702), with incidence rates of 2.5%(N = 92/3702) for periprosthetic joint infection, 3.7%(N = 71/1895) for reoperations, and 2.5%(N = 90/3578) for mortality.

Conclusion: Patients on dialysis for ESRD face significant mortality rates after primary TKA, in addition to other major complications. Careful counseling regarding risks and benefits should be provided prior to TKA in this population.
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http://dx.doi.org/10.1016/j.jor.2021.05.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8144102PMC
May 2021

An Overview of Telehealth in Total Joint Arthroplasty.

HSS J 2021 Feb 21;17(1):51-58. Epub 2021 Feb 21.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA.

With the increase in technological advances over the years, telehealth services in orthopedic surgery have gained in popularity, yet adoption among surgeons has been slow. With the onset of the COVID-19 pandemic, however, orthopedic surgery practices nationwide have accelerated adaptation to telemedicine. Telehealth can be effectively applied to total joint arthroplasty, with the ability to perform preoperative consultations, postoperative follow-up, and telerehabilitation in a virtual, remote manner with similar outcomes to in-person visits. New technologies that have emerged, such as virtual goniometers, wearable sensors, and app-based patient questionnaires, have improved clinicians' ability to conduct telehealth visits. Benefits of using telehealth include high patient satisfaction, cost-savings, increased access to care, and more efficiency. Notably, some challenges still exist, including widespread accessibility and adaptation of new technologies, inability to conduct an in-person orthopedic physical examination, and regulatory barriers, such as insurance reimbursement, increased medicolegal risk, and privacy and confidentiality concerns. Despite these hurdles, telehealth is here to stay and can be successfully incorporated in any total joint arthroplasty practice with the appropriate adjustments.
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http://dx.doi.org/10.1177/1556331620972629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077983PMC
February 2021

How Does Contact Length Impact Titanium Tapered Splined Stem Stability: A Biomechanical Matched Pair Cadaveric Study.

J Arthroplasty 2021 Sep 22;36(9):3333-3339. Epub 2021 Apr 22.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY.

Background: Titanium tapered stems (TTS) achieve fixation in the femoral diaphysis and are commonly used in revision total hip arthroplasty. The initial stability of a TTS is critical, but the minimum contact length needed and impact of implant-specific taper angles on axial stability are unknown. This biomechanical study was performed to better guide operative decision-making by addressing these clinical questions.

Methods: Two TTS with varying conical taper angles (2° spline taper vs 3.5° spline taper) were implanted in 9 right and left matched fresh human femora. The proximal femur was removed, and the remaining femoral diaphysis was prepared to allow for either a 2 cm (n = 6), 3 cm (n = 6), or 4 cm (n = 6) cortical contact length with each implanted stem. Stepwise axial load was then applied to a maximum of 2600N or until the femur fractured. Failure was defined as either subsidence >5 mm or femur fracture.

Results: All 6 femora with 2 cm of stem-cortical contact length failed axial testing, a significantly higher failure rate (P < .02) than the 4 out of 6 femora and all 6 femora that passed testing at 3 cm and 4 cm, respectively, which were not statistically different from each other (P = .12). Taper angle did not influence success rates, as each matched pair either succeeded or failed at the tested contact length.

Conclusion: 4 cm of cortical contact length with a TTS demonstrates reliable initial axial stability, while 2 cm is insufficient regardless of taper angle. For 3 cm of cortical contact, successful initial fixation can be achieved in most cases with both taper angle designs.
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http://dx.doi.org/10.1016/j.arth.2021.04.013DOI Listing
September 2021

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon.

Injury 2021 Apr 20. Epub 2021 Apr 20.

Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina 45110, Greece. Electronic address:

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects. Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle. All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction. Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.
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http://dx.doi.org/10.1016/j.injury.2021.04.009DOI Listing
April 2021

Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases.

Arch Orthop Trauma Surg 2021 Apr 13. Epub 2021 Apr 13.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA.

Background: The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA.

Methods: The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "cross-linked", "polyethylene", "HXLPE", "conventional", "total knee arthroplasty", "TKA", "total knee replacement" and "TKR" combined with Boolean operators AND and OR.

Results: Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39-1.18; I: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20-1.49; I: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31-0.39; I: 0.0%).

Conclusion: The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.
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http://dx.doi.org/10.1007/s00402-021-03887-zDOI Listing
April 2021

Heterotopic Ossification Negatively Influences Range of Motion After Revision Total Knee Arthroplasty.

J Arthroplasty 2021 08 11;36(8):2907-2912. Epub 2021 Mar 11.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York.

Background: The incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) varies and is of unclear clinical significance. This study aimed to identify the incidence of HO in patients undergoing revision TKA for either stiffness or aseptic loosening/instability and determine if the presence of HO is associated with inferior absolute range of motion (ROM) and ROM gains.

Methods: Eighty-seven patients were prospectively enrolled and separated into 2 cohorts to evaluate ROM after revision TKA (2017-2019). Group 1 (N = 40) patients were revised for stiffness, while group 2 (N = 47) patients were revised for either aseptic loosening or instability. Goniometer-measured ROM values were obtained preoperatively and at 6 weeks, 6 months, and 1 year postoperatively. Statistical analysis included a Fisher's exact test to assess for an association between preoperative HO and final ROM at 1 year after revision TKA.

Results: HO was identified on preoperative radiographs in 17 patients (20%). There was a significantly higher rate of preoperative HO in patients revised for stiffness compared to patients revised for instability or loosening (30% vs 11%; P = .03). Five cases of HO qualitatively identified as most clinically severe were associated with lower ROM at each time point compared to the remainder of HO cases in this study cohort (P < .02).

Conclusion: The presence of HO is greater in patients undergoing revision TKA for stiffness. Additionally, HO severity appears to have a major effect on preoperative and postoperative ROM trajectory. This information should help guide patient expectations and highlight the need for a comprehensive, standardized classification system for HO.
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http://dx.doi.org/10.1016/j.arth.2021.03.023DOI Listing
August 2021

Sister, Sister! Siblings With Simultaneous Early Femoral Insufficiency Fractures After Total Knee Arthroplasty.

Arthroplast Today 2021 Feb 1;7:188-193. Epub 2021 Feb 1.

The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Early periprosthetic fractures after total knee arthroplasty are rare but devastating complications which require revision surgery and lead to poor patient satisfaction. We present 2 siblings who underwent primary total knee arthroplasty on the same day and then both presented 2 weeks after surgery with atraumatic periprosthetic femur fractures. The first patient underwent revision for a cemented distal femoral replacement with stemmed tibial fixation. The second patient underwent an isolated femoral component revision with a stemmed femoral component and distal augment. Histological evaluation identified significant peri-implant osteoporosis. The variation in complexity associated with early periprosthetic femoral insufficiency fractures is highlighted by these 2 cases. Surgeons may consider using stemmed femoral components in similar patients if poor distal femoral bone stock is encountered intraoperatively.
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http://dx.doi.org/10.1016/j.artd.2020.12.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856391PMC
February 2021

Nonconcentric and Irregular Dislocations of Total Hip Arthroplasties: Radiographic Analysis and Review of the Literature.

J Emerg Med 2021 Apr 13;60(4):451-459. Epub 2021 Jan 13.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, New York.

Background: Total hip arthroplasty (THA) is one of the most successful operations in all of medicine in improving patient pain and restoring function. However, complications do arise after primary and revision THA. Dislocation of a THA, also known as instability, occurs in 1-2% of primary THAs and up to 30% of revision THAs. Most dislocations in the United States are initially managed with closed reduction under procedural sedation in emergency departments (EDs) by on-call orthopedists or emergency medicine specialists.

Objective: In this review the characteristics of the articulations that may require closed reduction in the ED are described, as well as their radiographic findings prior to reduction. Finally, we present subtle radiographic findings associated with failed closed reductions.

Discussion: Due to the different types of implants that have been introduced, closed reduction can be challenging in certain cases. Iatrogenic intraprosthetic dislocations are becoming more common with the increased use of dual-mobility liners. There are also dislocations after staged revision THA cases with the use of spacers. In spacers with semi-constrained articulation, there is the possibility of partial reduction of the spacer.

Conclusions: Dislocation is one of the most common mechanical complications after primary and revision THA. In the majority of the cases, acute closed reduction can be achieved successfully in the ED setting. However, there are specific dislocation types that present unique challenges to acute reduction.
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http://dx.doi.org/10.1016/j.jemermed.2020.11.023DOI Listing
April 2021

Serum metal ion levels in modular dual mobility acetabular components: A systematic review.

J Orthop 2020 Sep-Oct;21:432-437. Epub 2020 Aug 25.

Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10021, USA.

Background: Dual mobility (DM) constructs effectively reduce the risk of dislocation in revision and high risk primary total hip arthroplasty. However, modular DM designs require the use of a cobalt-chrome liner against a titanium cup which may induce corrosion, metal ions release, and associated biologic response. The purpose of this systematic review study was to collect all reported cases of serum metal ions after DM in the literature and ask the following questions: 1) what is the overall rate of significantly elevated Cobalt and Chromium metal ions and how do these levels change over time? 2) Does femoral head material composition influence serum metal ion levels? and 3) were there any atypical lymphocytic associated lesions after modular DM that required revision surgery?

Methods: A systematic review was performed according to PRISMA guidelines. In addition to patient demographics, information specific to the performance of the DM implant were recorded including: cobalt and chromium serum ion levels and all reported timepoints, the material composition of the femoral head, all revision and reoperations and any failure related to corrosion of the DM bearing. A significant elevation in cobalt or chromium was defined as >1.0 or >1.6 mcg/L.

Results: 248 modular DM THAs were analyzed. The cumulative mean cobalt and chromium levels for all included studies was 0.47mcg/L and 0.53mcg/L, respectively. At final follow-up 13 patients (5.2%) had elevated cobalt ion levels and 4 patients (1.6%) had elevated chromium ion levels. Femoral head material composition trended towards but did not significantly increase serum ion levels. Ceramic heads had elevated cobalt and chromium ions in 4/135 (3%) of patients compared to metal heads which had elevated cobalt ions in 9/113 (8%) and elevated chromium ions in 0/113 (0%), (p = 0.09). There were no reoperations or revisions for metal related reactions at final follow-up (mean 27.4 months).

Conclusion: In this systematic review including 248 modular DM THAs, elevated serum cobalt ions were present in 5.2% of patients at a mean follow-up of 27.4 months. While a trend towards increased Cobalt serum ions with the use of cobalt chrome femoral heads, femoral head composition was not significantly associated with increased serum metal ion levels. At final follow-up, metal ion levels appear to decrease in the majority of patients between 1 and 2 years and no patient was revised for metal ion related complications. Continued serum metal ion surveillance is recommended to ensure the safety of DM constructs in THA with longer term follow-up.
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http://dx.doi.org/10.1016/j.jor.2020.08.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490452PMC
August 2020

Outcomes and Risk Factors of Extended Trochanteric Osteotomy in Aseptic Revision Total Hip Arthroplasty: A Systematic Review.

J Arthroplasty 2020 11 22;35(11):3410-3416. Epub 2020 Jul 22.

The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY.

Background: Although extended trochanteric osteotomy (ETO) is an effective technique for femoral stem removal and for the concomitant management of proximal femoral deformities, complications including persistent pain, trochanteric nonunion, and painful hardware can occur.

Methods: The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "extended" AND "trochanteric" AND "osteotomy."

Results: Nineteen articles were included in the present study with 1478 ETOs. The mean overall union rate of the ETO was 93.1% (1377 of 1478 cases), while the overall rate of radiographic femoral stem subsidence >5 mm was 7.1% (25 of 350 cases). ETO union rates and femoral stem subsidence rates were similar between patients with periprosthetic fractures treated with total hip arthroplasty (THA) revision and ETO and patients treated with THA revision and ETO for reasons other than fractures. There was limited evidence that prior femoral cementation and older age might negatively influence ETO union rates.

Conclusion: There was moderate quality evidence to show that the use of ETO in aseptic patients undergoing single-stage revision THA is safe and effective, with a 7% rate of ETO nonunion and subsidence >5 mm in 7%. ETO can be safely used in cases with periprosthetic fractures in which stem fixation is jeopardized and a reimplantation is required. A well-conducted ETO should be preferred in selective THA revision cases to prevent intraoperative femoral fractures which are associated with deteriorated clinical outcomes. The use of trochanteric plate with cables should be considered as the first choice for ETO fixation.
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http://dx.doi.org/10.1016/j.arth.2020.07.034DOI Listing
November 2020

Microsurgery training: A combined educational program.

Injury 2020 Dec 9;51 Suppl 4:S131-S134. Epub 2020 Mar 9.

Department of Orthopaedic Surgery, University of Ioannina, School of Medicine Greece.

A proposed microsurgical training program is presented that includes all the existing training methods, such as simulation in nonliving models, virtual reality simulation system and exercise in living models. Our experience in microsurgery training over the last decades indicates the need of evolution in training programs. This can be achieved with the introduction of new technologies into education and training. The first primary results of the described training program are promising, however this system needs to be assessed by training greater number of microsurgeons. Furthermore, more complex scenarios (such as whole operations) should be inserted into the virtual reality simulation system to create a more interactive experience.
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http://dx.doi.org/10.1016/j.injury.2020.03.016DOI Listing
December 2020

Composite rib and serratus anterior pedicle transfer for reconstruction of an osteomyelitis of the humerus.

Injury 2020 Dec 25;51 Suppl 4:S59-S62. Epub 2020 Feb 25.

Department of Plastic Surgery, Rehabilitation Hospital, Cluj Napoca University, Romania.

We report the case of a 40 year-old male with Staphylococcus aureus osteomyelitis of the proximal humerus after open reduction and internal fixation of a fracture from motor vehicle accident. Removal of the osteosynthesis, extensive debridement and intravenous antibiotics administration was done followed by external fixation stabilization and reconstruction with a combined pedicled flap using the serratus anterior reversed flap and the 6th rib. At the last follow-up, healing of the bone flap was observed; the patient experienced useful motion of his upper extremity without any evidence of recurrent infection.
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http://dx.doi.org/10.1016/j.injury.2020.02.122DOI Listing
December 2020

Neonatal brachial plexus injuries and their impact on growing bone. An experimental study.

Injury 2020 Dec 24;51(12):2851-2854. Epub 2020 Feb 24.

Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, Greece.

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.
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http://dx.doi.org/10.1016/j.injury.2020.02.118DOI Listing
December 2020

Is TKA with computer-assisted navigation associated with less blood loss? A comparative study between computer-navigated and conventional method.

J Orthop 2020 Jul-Aug;20:50-53. Epub 2020 Jan 13.

Laboratory of Orthopaedics and Biomechanics, University of Ioannina, School of Medicine, University Campus 45110, Ioannina, Greece.

The aim of this study is to evaluate whether computer-assisted navigated TKA reduces perioperative blood loss. Patients were randomly divided into 2 groups and underwent either a conventional TKA (n = 40) or a TKA with computer-assisted navigation (n = 40). Perioperative blood loss was evaluated by laboratory parameters, postoperative drain output and number of required transfusions. Change in hemoglobin concentration and in hematocrit levels was similar. Also, there was no statistically significant difference in drain output and in the number of transfused units. The results of this study showed that TKA with computer-assisted navigation is similar to the conventional TKA regarding perioperative hemorrhage.
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http://dx.doi.org/10.1016/j.jor.2020.01.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000559PMC
January 2020

Vascularized pedicled graft from distal radius for scaphoid nonunion with double stabilization: A long term follow up study.

Injury 2019 Dec 23;50 Suppl 5:S59-S63. Epub 2019 Oct 23.

Department of Orthopaedics, School of Medicine University of Ioannina, Ioannina, Greece.

Purpose: The aim of the present study is to present the long-term efficacy of the graft of the distal radius based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for the treatment of scaphoid nonunion with a proposed treatment of double stabilization with Kirschner wires and external fixator.

Methods: Between 2007 and 2013 we retrospectively reviewed 11 patients who were operated for established scaphoid nonunion with pedicled vascularized distal radius graft based on the 1,2 ICSRA in our department. Stabilization of the graft was achieved with Kirschner wires and the wrist was immobilized with a transarticular external fixator. All patients were evaluated pre- and post-operatively both clinically and radiologically. The DASH score was also completed by the patients before and after the operation. The minimum follow-up of the patients was 5 years.

Results: The mean age of the patients was 28.64 years (range, 18-49 years). Ten patients were males (90.91%) and one female (9.09%). In all patients, union was achieved. The mean time of union was 11.2 weeks (range, 8-18 weeks). The mean follow-up was 61.32 months (range, 60-72 months). Compared to the contralateral hand there was noticed 14° lack in flexion and 18° in extension. The mean DASH score showed also significant improvement from 23.1 (range, 9.4-50.6) preoperatively to 4.72 (range, 0-22.8) during the last follow-up.

Conclusion: The 1,2 ICSRA distal radius graft consists a trustworthy pedicled vascularized graft for the treatment of nonunion presenting very promising long-term outcomes.
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http://dx.doi.org/10.1016/j.injury.2019.10.050DOI Listing
December 2019

Developmental dysplasia of the hip: a systematic literature review of the genes related with its occurrence.

EFORT Open Rev 2019 Oct 1;4(10):595-601. Epub 2019 Oct 1.

Orthopaedic Department, School of Medicine, University of Ioannina, Ioannina, Greece.

Developmental dysplasia of the hip (DDH) is one of the most prevalent congenital malformations. It has a wide spectrum of anatomical abnormalities of the hip joint and is characterized by mild or incomplete formation of the acetabulum leading to laxity of the joint capsule, secondary deformity of the proximal femur and irreducible hip dislocation. It is the leading cause of early hip osteoarthritis in young individuals.Both genetic and environmental factors have been proposed to play an important role in the pathogenesis of DDH. A high prevalence is present in Asian, Caucasian, Mediterranean and American populations, with females being more frequently affected. We evaluated a variety of genetic studies indexed in the PubMed database.Several susceptive genes, including WISP3, PAPPA2, HOXB9, HOXD9, GDF5, TGF Beta 1, CX3CR1, UQCC, COL1A1, TbX4 and ASPN have been identified as being associated with the development of DDH. Moreover, genetic association has also been reported between hip dysplasia and other comorbidities. Even though genetic components are a crucial part in the aetiology of DDH, several DDH susceptibility genes need further investigation.The purpose of this review is to present current literature evidence regarding genes responsible for DDH development. Cite this article: 2019;4:595-601. DOI: 10.1302/2058-5241.4.190006.
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http://dx.doi.org/10.1302/2058-5241.4.190006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836073PMC
October 2019

Intraoperative epidural application of steroid and local anaesthetic agent following lumbar discectomy: A prospective double blinded randomized controlled trial.

J Clin Orthop Trauma 2019 Oct 12;10(Suppl 1):S143-S146. Epub 2019 Mar 12.

Department of Οrthopedics, University Hospital of Ioannina, Stavros Niarchos Avenue, 45500, Ioannina, Greece.

Background: Postoperative pain management following lumbar discectomy is a key part of the procedure and various postoperative pain protocols including a wide range of agents are being used in daily practice worldwide. The aim of this study is to investigate the effect of intraoperative epidural infiltration of local anaesthetic and steroid compared with placebo (normal saline) following microscopic lumbar discectomy.

Methods: Sixty patients undergoing lumbar discectomy were randomized to intraoperative infiltration of 3 mg betamethoasone acetate and 18 mg ropivacaine (Group A) or normal saline (Group B). Infiltration was performed after discectomy and decompression and immediately prior to incision closure. Postoperatively a standard protocol of intravenous acetaminophen administration and physiotherapy was followed. Additional analgesia with tramadol was given only in patients who required further pain management. Postoperative pain was evaluated using VAS score. Opioid consumption was recorded. Primary outcome measures included immediate postoperative back pain VAS score, opioid consumption and infection rate. Patients were reviewed in clinic at 6 weeks, 6 months and 1 year postoperatively.

Results: None of the patients in Group A required further analgesia while 12 Group B patients required further treatment with tramadol (p = 0.01). At 3 h postoperatively the VAS score was significantly lower in Group A compared to Group B (p < 0.05). Fifty-seven patients completed the 1 year follow up (95%) and 2 patients (1 from each group) suffered a complication of postoperative radiculopathy.

Conclusion: Intraoperative application of steroid and local anaesthetic agent is effective on pain reduction for only a short period after surgery, while there is no effect on infection rate or any other long-term outcome compared with placebo. Hence although it is a safe technique, its benefits are limited from the duration of action.
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http://dx.doi.org/10.1016/j.jcot.2019.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823785PMC
October 2019

Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain.

Asian J Neurosurg 2019 Jul-Sep;14(3):657-669

Department of Orthopaedic Surgery, University Hospital of Ioannina, Ioannina, Greece.

Study Design: A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted.

Objective: The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures.

Materials And Methods: English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included.

Results: Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients.

Conclusions: These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.
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http://dx.doi.org/10.4103/ajns.AJNS_119_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703031PMC
September 2019

Dimethylsulfoxide (DMSO) in Peripheral Nerve Regeneration.

J Invest Surg 2021 Apr 12;34(4):466. Epub 2019 Aug 12.

Department of Orthopaedics, School of Medicine, University of Ioannina, Ioannina, Greece.

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http://dx.doi.org/10.1080/08941939.2019.1650314DOI Listing
April 2021

The effect of peripheral nervous system in growing bone biomechanics. An experimental study.

J Orthop 2019 May-Jun;16(3):289-292. Epub 2019 May 6.

Department of Orthoapedic Surgery, School of Medicine, University of Ioannina, Ioannina, Greece.

Objective: There are several factors which affect bone growth. One of them is the peripheralnervous system whose effect on the biomechanics has not been extensively studied. The purpose of this study is to assess the effect of peripheral nervous system in bone biomechanics in an experimental rat model.

Materials & Methods: 27 male Wistar rats were used. In all animals, the roots of the right brachial plexus were dissected and after that the animals were divided into three groups A, B and C. The animals were sacrificed six, nine, and twelve months respectively after the denervation. Both humerus were resected and biomechanical analysis was performed.

Results: According to the findings of the present study the denervated bones sustain less loading before fracture and they become also more elastic. Additionally, in greater time after denervation plastic deformity is noticed.

Conclusion: Apart from structural changes, the peripheral nerves are responsible for biomechanic changes in the bones such the greater elasticity of the bone and the reduced strength.
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http://dx.doi.org/10.1016/j.jor.2019.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522696PMC
May 2019

Is prophylaxis for heterotopic ossification with radiation therapy after THR associated with early loosening or carcinogenesis?

Hip Int 2020 Sep 16;30(5):559-563. Epub 2019 Apr 16.

Laboratory of Orthopedics and Biomechanics, University of Ioannina, School of Medicine, Ioannina, Greece.

Introduction: Heterotopic ossification may develop after major hip surgeries, thus preventive strategies including radiation therapy and non steroid anti-inflammatory drugs are commonly employed. There are certain concerns regarding the effects of radiation therapy on implant loosening and carcinogenesis. Our study aims to evaluate whether radiation therapy results in implant loosening or radiation-induced tumours in the long term.

Patients And Methods: This was a prospective study including 97 high-risk patients for heterotopic ossification who underwent total hip arthroplasty. Patients were divided into 2 groups and received either a combination of radiation therapy and indomethacin (Group A), or indomethacin alone (Group B). Evaluated outcomes included implant loosening or development of radiation-induced tumours during the follow-up period.

Results: The follow-up period of the study was 10 years. Group A consisted of 50 patients, while Group B consisted of 47 patients. 3 patients died during the follow-up. There were 2 cases of implant loosening, 1 from each of the 2 groups at 9 and 10 years after surgery respectively; thus, no statistically significant difference regarding implant loosening was found ( < 0.05). During the follow-up period no cases of radiation-induced tumours were identified.

Conclusion: Our results are consistent with those of other studies supporting the safety of radiation therapy as a preventive strategy for heterotopic ossification following major surgeries in high risk patients. Further studies with even longer follow-up may be required to definitely exclude the possibility of adverse outcomes linked with radiation therapy.
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http://dx.doi.org/10.1177/1120700019842724DOI Listing
September 2020

Trends in pediatric cervical spine injuries in the United States in a 10-year period.

J Orthop Surg (Hong Kong) 2019 Jan-Apr;27(1):2309499019834734

2 Orthopaedic Department, University Hospital of Ioannina, Ioannina, Greece.

Background: Cervical spine fractures (CSFs) are potentially devastating injuries in pediatric population. Fortunately, these injuries are uncommon in pediatric patients. The purpose of this study was to determine the epidemiology, the risk factors, mechanisms of injury and to identify possible strategies for prevention. In addition, the aim of the current study was to compare CSF sustained in 2003 to CSF sustained in 2008 and 2013 so as to recognize the trend of pediatric CSFs in the United States.

Methods: The National Electronic Injury Surveillance System was queried for CSF sustained in pediatric population up to 16 years of age for years 2003, 2008, and 2013. Outcomes of interest were patient characteristics (age and sex), causes of CSF, and mechanism of injury.

Results: Eighty pediatric patients with CSF were identified. The average age was 10.5 years. Boys sustained significantly more CSF than girls. Statistically significant more CSF were occurred in children of 10-16 years than in children up to 9 years. Sports or recreational activities and home-related accidents were the predominant causes of CSF. Mechanisms of injury were age-related, with younger children sustaining CSF as a result of home-related accidents while adolescents commonly injured during sporting or recreational activities. In contrast to current data in literature, motor vehicle accidents were not a major cause of CSF. Comparing the years 2003, 2008, and 2013, statistically significant differences in the incidence of CSF were not found.

Conclusions: Our study confirms previous findings that adolescents who sustain CSF have higher incidence of sport or recreation-related accidents than younger patients who sustain commonly home-related accidents as a consequence of insufficient parental supervision. The perception that motor vehicle accidents comprise major cause of CSF appears not to be true.
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http://dx.doi.org/10.1177/2309499019834734DOI Listing
March 2020

Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy.

Eur J Orthop Surg Traumatol 2019 Feb 8;29(2):329-336. Epub 2019 Jan 8.

Department of Οrthopedics, University Hospital of Ioannina, Stavros Niarchos Avenue, 45500, Ioannina, Greece.

Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.
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http://dx.doi.org/10.1007/s00590-019-02362-1DOI Listing
February 2019
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