Publications by authors named "Michael Drexler"

64 Publications

Who Needs Surgical Stabilization for Pyogenic Spondylodiscitis? Retrospective Analysis of Non-Surgically Treated Patients.

Global Spine J 2021 Sep 16:21925682211039498. Epub 2021 Sep 16.

Swedish Neuroscience Institute, Seattle, WA, USA.

Study Design: Retrospective case series analysis.

Objective: To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process.

Methods: We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as ". Patients who experienced an uneventful course served as controls and were labeled as " (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups.

Results: Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment ("FTG") within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome.

Conclusions: We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.
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http://dx.doi.org/10.1177/21925682211039498DOI Listing
September 2021

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures.

Arch Orthop Trauma Surg 2021 Jan 8. Epub 2021 Jan 8.

Department of Orthopaedic Surgery, Medical Center, Affiliated with the Faculty of Health and Science and Ben Gurion University, Ha-Refu'a St 7, 7747629, Ashdod, Israel.

Background: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN.

Patients And Methods: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life.

Results: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively).

Conclusions: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures.

Level Of Evidence: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.
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http://dx.doi.org/10.1007/s00402-020-03726-7DOI Listing
January 2021

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery.

Arch Orthop Trauma Surg 2021 Jan 8. Epub 2021 Jan 8.

Tel Aviv Medical Center, Department of Orthopaedic Surgery, Affiliated with the Sackler Faculty of Medicine and Tel Aviv University, Weizmann St 6, 6423906, Tel Aviv-Yafo, Israel.

Introduction: Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.

Methods: We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold.

Results: There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively).

Conclusion: We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.
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http://dx.doi.org/10.1007/s00402-020-03721-yDOI Listing
January 2021

[FACTORS INFLUENCING FUNCTIONAL RECOVERY AFTER FEMORAL NECK FRACTURES IN THE ELDERLY].

Harefuah 2020 Nov;159(11):826-828

Orthopedic Department, Assuta Ashdod University Hospital, Ashdod, Israel.

Introduction: Femoral neck fractures (FNF) have been declared to be a worldwide epidemic, as their number is expected to surpass 6 million by the year 2050, with more than 7,000 cases per year in Israel. FNF are more common in patients older than 65 years, and are expected to become even more common as the population ages. Like in many other medical conditions, treatment must be adapted for the unique features of this population. In this report, we sought to review the extent of femoral neck fractures in the elderly and the accompanied clinical outcomes and economic implications. As this population constitutes a major part of the patients suffering from femoral neck fractures, and tend to suffer from a higher rate morbidity and mortality, the orthopedic surgeon must meticulously choose the appropriate treatment, in a relatively short timeframe of up to 24-48 hours. In order to do so, further high-quality research examining the clinical outcomes according to the treatment chosen in this special population is needed.
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November 2020

Uptrend of cervical and sacral fractures underlie increase in spinal fractures in the elderly, 2003-2017: analysis of a state-wide population database.

Eur Spine J 2020 10 23;29(10):2543-2549. Epub 2020 Jun 23.

Swedish Neuroscience Institute, Seattle, WA, USA.

Background: Traumatic spinal injuries can be life-threatening conditions. Despite numerous epidemiological studies, reports on specific spinal regions affected are lacking.

Hypothesis: We hypothesized that fractures at specific regions, such as the cervical spine (including the axis segment), have been affected to a greater degree. We also hypothesized that advanced age may be a significant contributing factor.

Objective: To longitudinally analyze trend of spine fractures and specific fracture subtypes.

Study Design: Longitudinal trend analysis of discharged patient state database.

Patient Sample: Discharged patient's data from 15 years (2003-2017) METHODS: We retrieved pertinent ICD-9 and 10 codes depicting fractures involving the entire spine and specific subtypes. To assess possible association with age, we analyzed the trend of the average age in patients discharged with and without spinal fractures as well as in specific fracture subtypes. Similar analysis was performed for other common fragility fractures. FDA device/drug status: The manuscript submitted does not contain information about medical device(s) or drug(s).

Results: We found that within 15 years, the overall proportion of spinal fractures has increased by 64% (from 0.47 to 0.77% of all discharged patients) with the greatest increase noted in fractures of the cervical spine (123%) and specifically of the second cervical vertebra (84%). Age was found to have increased more in patients with spinal fractures than in the general discharged population. Surprisingly, other non-spinal fractures among patients above 60 remained relatively stable, demonstrating a spine-specific effect.

Conclusions: Our findings confirm a recent increase in all spinal fractures and in the cervical and sacral regions in particular. Advanced age may be an important underlying factor.
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http://dx.doi.org/10.1007/s00586-020-06498-1DOI Listing
October 2020

Apple Watch detecting coronary ischaemia during chest pain episodes or an apple a day may keep myocardial infarction away.

Eur Heart J 2020 06;41(23):2224

Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckstraße 1, 55131 Mainz, Germany.

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http://dx.doi.org/10.1093/eurheartj/ehaa290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299633PMC
June 2020

Use of Intraoperative Tranexamic Acid and Wound Complications in Spine Surgery: A Retrospective Cohort Study.

Asian Spine J 2020 Oct 30;14(5):639-646. Epub 2020 Mar 30.

Department of Orthopedics, Soroka University Medical Center, Beer Sheva, Israel.

Study Design: A retrospective cohort study.

Purpose: This study aims to examine the effect of tranexamic acid (TXA) on postoperative wound healing in spine surgery.

Overview Of Literature: TXA (Cyklokapron, Hexakapron) is a widely used anti-fibrinolytic drug that is shown to be effective in mitigating hemorrhage during and after surgery by competitively blocking plasminogen in fibrinolytic cascade. Plasminogen also plays a role in inflammatory and infectious diseases. The modulation of this role by TXA may influence the development of postoperative infectious complications.

Methods: We collected and reviewed the charts of 110 patients who underwent spine surgery at our academic center. We used multivariate regression analysis to assess the factors affecting surgical site infection (SSI).

Results: Of the 110 patients included in this study, 21 patients (19%) were categorized as having postoperative wound complications, 16 patients (14%) had deep or superficial wound infection, and five patients (4%) had wound dehiscence. Patients with a higher surgical invasiveness index score, longer surgeries, and older patients were found to be at risk for wound complications. TXA was determined not to be a direct risk factor for wound healing complications and SSIs.

Conclusions: We found no risk of wound healing complications and SSI directly attributable to preoperative and intraoperative treatment with TXA in spine surgeries.
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http://dx.doi.org/10.31616/asj.2019.0235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595816PMC
October 2020

Does capsular closure influence patient-reported outcomes in hip arthroscopy for femoroacetabular impingement and labral tear?

J Hip Preserv Surg 2019 Aug 4;6(3):199-206. Epub 2019 Jul 4.

Department of Orthopaedic Surgery, Tel Aviv Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Weizmann St 6, Tel Aviv-Yafo, Israel.

Capsulotomy is necessary to facilitate instrument manoeuvrability within the joint capsule in many arthroscopic hip surgical procedures. In cases where a clear indication for capsular closure does not exist, surgeon's preference and experience often determines capsular management. The purpose of this study was to assess the influence of capsular closure on clinical outcome scores and satisfaction in patients who underwent hip arthroscopy surgery for femoroacetabular impingement (FAI) and labral tear. Data were prospectively collected and retrospectively analysed for hip arthroscopy surgeries with a minimum 2 years follow-up. Patients with developmental dysplasia of the hip, previous back or hip surgeries, and degenerative changes to this hip and secondary gains were excluded. Demographic data, intraoperative findings and patient-reported outcome scores were recorded, including the Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). A total of 29 and 35 patients were included in the non-closure and closure groups, respectively. The mean follow-up time was over 3 years for both groups. The mean pre-operative and post-operative HOS scores and MHHS scores did not significantly differ between groups (pre-operative HOS: 65.6 and 66.3, = 0.898; post-operative HOS: 85.4 and 87.2, = 0.718; pre-operative MHHS: 63.2 and 58.4, = 0.223; post-operative MHHS: 85.7 and 88.7, = 0.510). Overall patient satisfaction did not differ significantly between groups (non-closure 86.3%, closure group 88.6%; = 0.672). Capsular closure did not significantly influence satisfaction or clinical outcome scores in patients who underwent arthroscopic hip surgery for FAI or labral tear.
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http://dx.doi.org/10.1093/jhps/hnz025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874774PMC
August 2019

Does hip morphology correlate with proximal femoral fracture type?

Hip Int 2020 Sep 11;30(5):629-634. Epub 2019 Jul 11.

Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Centre, Israel.

Purpose: To determine if boney morphology influences the anatomic location of hip fractures in elderly patients.

Methods: All patients with hip fractures between 2008 and 2012 who had hip radiographs taken prior to the fracture were reviewed. Fractures were classified as intracapsular or extracapsular and hip morphology was measured on the pre-fracture x-rays. Hip morphology was determined by alpha angle, lateral central edge angle, acetabular index, neck-shaft angle, hip axis length, femoral neck diameter, Tönnis classification for hip osteoarthritis (OA) and the presence of a crossover sign.

Results: 148 subjects (78.4% female, age 83.5 years) with proximal femur fractures were included. 44 patients (29.7%) had intracapsular fractures and 104 (70.3%) had extracapsular fractures. 48% of patients had previous hip fractures on the contralateral side and 74.6% had the same type of fracture bilaterally. The rates of bilateral intracapsular and extracapsular fractures were similar (33.7% vs. 40.9% respectively, 0.39). Extracapsular fractures had a statically significant higher neck-shaft angle, a shorter hip axis length, a narrower femoral neck diameter and a higher grade of Tönnis classification of OA ( 0.04, 0.046, 0.03, 0.02 respectively). Acetabular coverage and the proximal femoral head-neck junction, which were evaluated by lateral centre-edge angle (LCEA), acetabular index and the presence of a crossover sign, did not correlate with fracture type. The alpha angle > 40° had a statistically significant higher likelihood for extracapsular fractures ( 0.013).

Conclusions: Acetabular coverage and proximal femoral head-neck junction morphology, were found to partially correlate with the location of hip fractures and do not fully elucidate fracture type susceptibility.
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http://dx.doi.org/10.1177/1120700019859275DOI Listing
September 2020

Correlation between preoperative imaging parameters and postoperative basic kinematics-based functional outcome in patients with tibial plateau fractures.

Clin Biomech (Bristol, Avon) 2019 05 16;65:87-91. Epub 2019 Apr 16.

Division of Orthopedics, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.

Background: Functional scores and radiographs are often used to assess function and predict development of osteoarthritis in patients with multi-fragmentary tibial plateau fractures (TPFs). Locomotion, which is the primary goal of fracture treatment, is rarely assessed. The objective of this study was to assess functional ability of patients after TPF fixation using spatio-temporal gait analysis (STGA), and to compare STGA variables with self-reported functional scores and preoperative fracture characteristics.

Methods: Preoperative CT scans of 21 patients with complete articular multi-fragmentary TPFs were evaluated for number of fragments, maximum gap between the fragments and maximum articular depression. All patients underwent STGA (velocity, cadence, step length of the affected and the unaffected leg, single-limb support by the affected and the unaffected leg, and double-leg support) and filled the Knee Society Score and the Short Form-12 questionnaires on average 3 years (SD = 1.56, range, 2-5.8) post-injury.

Findings: Step length and single-limb support time of the affected leg were shorter compared to the unaffected leg (p = 0.02 and p = 0.007, respectively). Number of fracture fragments correlated with cadence (R = -0.461, p = 0.04) and velocity (R = -0.447, p = 0.04).

Interpretation: Given that both higher fracture comminution and deformity on the one hand and the above gait parameter alterations on the other hand are associated with knee osteoarthritis, STGA may be used for routine postoperative evaluation of patients after TPF fixation.
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http://dx.doi.org/10.1016/j.clinbiomech.2019.04.009DOI Listing
May 2019

Closed Wound Subfascial Suction Drainage in Posterior Fusion Surgery for Adolescent Idiopathic Scoliosis: A Prospective Randomized Control Study.

Spine (Phila Pa 1976) 2019 03;44(6):377-383

The Department of Pediatric Orthopedics Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.

Study Design: A prospective randomized control study.

Objective: The aim of this study was to compare the complication rate in adolescent idiopathic scoliosis (AIS) posterior spinal fusion (PSF) surgery with and without drainage.

Summary Of Background Data: PSF is the mainstay of surgical treatment for AIS. Drains are commonly used despite contradictory findings in the literature for their having any clear advantage.

Methods: A total of 100 AIS patients undergoing instrumented PSF were blindly randomized into two groups of either a deep drain or no drain. The collected data included wound follow-up findings, hemoglobin, hematocrit, vital signs and fever levels, and mean 20 months follow-up.

Results: Fifty-two patients were randomly allocated to the "no drain" group and 48 to the "drain" group. There were no differences in patient characteristics, surgical data, and hemoglobin and hematocrit levels between the two groups. Only 4 units of packed cells were given in total. Fever during the first postoperative 1 to 3 days was equal, but increased in the no drain group on day 6 (P = 0.017). Length of hospitalization was equal (6 days) for all the patients. The mean follow-up period was 20 months [8.5-30.7 (SD 6.4)]. Complications included one case (1.9%) of pneumonia in the "no-drain" group, wound dehiscence in two cases (3.8%) in the "no-drain" group and in one case (2.1%) in the "drain" group, and two cases (3.8%) of superficial wound infection in the "no-drain" group. There was no case of deep infection in either group.

Conclusion: The current results indicate that there is no advantage to deep drainage in AIS patients undergoing PSF. The number of wound healing complications was low and identical for both the drain and no-drain groups.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000002892DOI Listing
March 2019

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions.

Int Orthop 2019 08 5;43(8):1977-1982. Epub 2018 Sep 5.

Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision.

Methods: ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months.

Results: Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm vs 48 ± 28 cm, P = non-significant).

Conclusion: Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.
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http://dx.doi.org/10.1007/s00264-018-4139-9DOI Listing
August 2019

Relatively High Complication and Revision Rates of the Mayo Metaphysical Conservative Femoral Stem in Young Patients.

Orthopedics 2018 Jul 9;41(4):e516-e522. Epub 2018 May 9.

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18-64 years), and the mean follow-up was 97 months (range, 26.9-166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [Orthopedics. 2018; 41(4):e516-e522.].
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http://dx.doi.org/10.3928/01477447-20180503-01DOI Listing
July 2018

Inhibition of nucleotide pyrophosphatase/phosphodiesterase 1: implications for developing a calcium pyrophosphate deposition disease modifying drug.

Rheumatology (Oxford) 2018 08;57(8):1472-1480

Department of Rheumatology, Tel Aviv University, Tel Aviv, Israel.

Objectives: Calcium pyrophosphate deposition (CPPD) is associated with osteoarthritis and is the cause of a common inflammatory articular disease. Ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (eNPP1) is the major ecto-pyrophosphatase in chondrocytes and cartilage-derived matrix vesicles (MVs). Thus, eNPP1 is a principle contributor to extracellular pyrophosphate levels and a potential target for interventions aimed at preventing CPPD. Recently, we synthesized and described a novel eNPP1-specific inhibitor, SK4A, and we set out to evaluate whether this inhibitor attenuates nucleotide pyrophosphatase activity in human OA cartilage.

Methods: Cartilage tissue, chondrocytes and cartilage-derived MVs were obtained from donors with OA undergoing arthroplasty. The effect of SK4A on cell viability was assayed by the XTT method. eNPP1 expression was evaluated by western blot. Nucleotide pyrophosphatase activity was measured by a colorimetric assay and by HPLC analysis of adenosine triphosphate (ATP) levels. ATP-induced calcium deposition in cultured chondrocytes was visualized and quantified with Alizarin red S staining.

Results: OA chondrocytes expressed eNPP1 in early passages, but this expression was subsequently lost upon further passaging. Similarly, significant nucleotide pyrophosphatase activity was only detected in early-passage chondrocytes. The eNPP1 inhibitor, SK4A, was not toxic to chondrocytes and stable in culture medium and human plasma. SK4A effectively inhibited nucleotide pyrophosphatase activity in whole cartilage tissue, in chondrocytes and in cartilage-derived MVs and reduced ATP-induced CPPD.

Conclusion: Nucleotide analogues such as SK4A may be developed as potent and specific inhibitors of eNPP1 for the purpose of lowering extracellular pyrophosphate levels in human cartilage with the aim of preventing and treating CPPD disease.
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http://dx.doi.org/10.1093/rheumatology/key092DOI Listing
August 2018

Pathological fracture risk assessment in patients with femoral metastases using CT-based finite element methods. A retrospective clinical study.

Bone 2018 05 20;110:215-220. Epub 2018 Feb 20.

School of Mechanical Engineering, Tel-Aviv University, Ramat-Aviv, Israel.

Physician recommendation for prophylactic surgical fixation of a femur with metastatic bone disease (MBD) is usually based on Mirels' criteria and clinical experience, both of which suffer from poor specificity. This may result in a significant number of these health compromised patients undergoing unnecessary surgery. CT-based finite element analyses (CTFEA) have been shown to accurately predict strength in femurs with metastatic tumors in an ex-vivo study. In order to assess the utility of CTFEA as a clinical tool to determine the need for fixation of patients with MBD of the femur, an ad hoc CTFEA was performed on a retrospective cohort of fifty patients. Patients with CT scans appropriate for CTFEA analysis were analyzed. Group 1 was composed of 5 MBD patients who presented with a pathologic femoral fracture and had a scan of their femurs just prior to fracture. Group 2 was composed of 45 MBD patients who were scheduled for a prophylactic surgery because of an impending femoral fracture. CTFEA models were constructed for both femurs for all patients, loaded with a hip contact force representing stance position loading accounting for the patient's weight and femur anatomy. CTFEA analysis of Group 1 patients revealed that they all had higher tumor associated strains compared to typical non-diseased femur bone strains at the same region (>45%). Based on analysis of the 5 patients in Group 1, the ratio between the absolute maximum principal strain in the vicinity of the tumor and the typical median strain in the region of the tumor of healthy bones (typical strain fold ratio) was found to be the 1.48. This was considered to be the predictive threshold for a pathological femoral fracture. Based on this typical strain fold ratio, twenty patients (44.4%) in Group 2 were at low risk of fracture and twenty-five patients (55.5%) high risk of fracture. Eleven patients in Group 2 choose not to have surgery and none fractured in the 5month follow-up period. CTFEA predicted that seven of these patients were below the pathological fracture threshold and four above, for a specificity of 63% Based on CTFEA, 39% of the patients with femoral MBD who were referred and underwent prophylactic stabilization may not have needed surgery. These results indicate that a prospective randomized clinical trial evaluating CTFEA as a criterion for determining the need for surgical stabilization in patients with MBD of the femur may be warranted.
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http://dx.doi.org/10.1016/j.bone.2018.02.011DOI Listing
May 2018

Functional outcomes after removal of hardware in patellar fracture: are we helping our patients?

Arch Orthop Trauma Surg 2018 Mar 28;138(3):325-330. Epub 2017 Nov 28.

Joint Arthroplasty and Sports Medicine Department, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weitzman Street, 6423906, Tel-Aviv, Israel.

Purpose: Functional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee pain, limited range of motion and symptomatic hardware. The purpose of this study was to evaluate if removal of hardware is beneficial to symptomatic patients after patellar fracture fixation.

Methods: Patients who presented to our institution between December 2006 and November 2014 with patella fractures treated with ORIF were eligible for inclusion. Patella ORIF was performed using (1) K-wires (KW) with a tension band construct or (2) Cannulated Screws (CS) with a tension band construct. Radiological analyses included (1) AO classification and (2) measurements of prominent hardware length. Patient medical charts were reviewed for demographic and intraoperative data as well as peri/postoperative complications. All patients completed the SF-12 score, visual analog scale, Kujala score, Lysholm score and questionaries' regarding return to previous activity levels.

Results: Forty-seven patients met the inclusion criteria. The average time from fracture fixation to removal of hardware was 15.8 (SD ± 14.9) months. The mean follow-up was 43.1 (SD ± 27.1) months. Patella fixation was accomplished using tension band constructs with KW in 28 patients (59.5%) or with CS in 19 patients (40.5%). Patient reported quality of life and pain outcomes improved significantly after removal of hardware (p = 0.001, and p = 0.002 respectively). Functional outcome scores (Kujala and Lysholm) did not improve significantly after hardware removal in the KW or CS groups. Significantly more patients in the KW group returned to pre-injury activity (p = 0.005).

Conclusions: Hardware removal after patella ORIF significantly improves patient reported pain and quality of life outcomes but not functional outcomes. Patients should be counseled regarding the expected outcome of hardware removal following patella ORIF and diabetic patients should be given special consideration before undergoing this procedure.
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http://dx.doi.org/10.1007/s00402-017-2852-2DOI Listing
March 2018

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

Knee Surg Sports Traumatol Arthrosc 2018 Aug 17;26(8):2512-2518. Epub 2017 Jul 17.

Department of Orthopedic Surgery, Tel Aviv Medical Center, Affiliated with the Sackler Faculty of Medicine and Tel Aviv University, Tel Aviv, Israel.

Purpose And Hypothesis: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair.

Methods: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS).

Results: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001).

Conclusion: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00167-017-4641-4DOI Listing
August 2018

Subacromial corticosteroid injections transiently decrease suture anchor pullout strength: biomechanical studies in rats.

J Shoulder Elbow Surg 2017 Oct 6;26(10):1789-1793. Epub 2017 Jul 6.

Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Arthroscopic rotator cuff (RC) repair incorporates suture anchors to secure torn RC tendons to the greater tuberosity (GT) bone. RC repair strength depends on the anchor-bone interface and on the quality of the GT. We evaluated the effect of single and multiple corticosteroid injections on the pullout strength of suture anchors.

Methods: Fifty rats were divided into those receiving saline solution injection (control group), a single methylprednisolone acetate (MTA) injection (MTA1 group), or 3 once-weekly MTA injections (MTA3 group). Rats were killed humanely at 1 or 4 weeks after the last injection. A mini-suture anchor was inserted into the humeral head through the GT. Specimens were tested biomechanically.

Results: At 1 week after the last injection, the mean maximal pullout strength was significantly reduced in the MTA1 group (63.5%) and MTA3 group (56%) compared with the control group (P < .05 for both). Mean stiffness decreased significantly in both treatment groups compared with controls (P < .05). At 4 weeks after the last injection, there was a significant increase in the mean maximal pullout strength after single and triple MTA injections compared with values recorded at the 1-week time point (P < .05). At 4 weeks, the mean maximal pullout strength after a single MTA injection was 92.8% of the pullout strength measured in the control group.

Conclusions: We showed a significant detrimental effect of corticosteroid exposure on the pullout strength of a suture anchor at 1 week. However, this effect was transient and resolved within a relatively short period. These findings indicate that a waiting period is required between subacromial corticosteroid injection and RC repair surgery that involves the use of suture anchors.
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http://dx.doi.org/10.1016/j.jse.2017.05.013DOI Listing
October 2017

Hip arthroscopy protocol: expert opinions on post-operative weight bearing and return to sports guidelines.

J Hip Preserv Surg 2017 Jan 23;4(1):60-66. Epub 2017 Feb 23.

Lyon Ortho Clinic, Clinique de la sauvegarde, 25 B avenue des sources, Lyon 69009, France.

The objectives of this study are to survey the weight-bearing limitation practices and delay for returning to running and impact sports of high volume hip arthroscopy orthopedic surgeons. The study was designed in the form of expert survey questionnaire. Evidence-based data are scares regarding hip arthroscopy post-operative weight-bearing protocols. An international cross-sectional anonymous Internet survey of 26 high-volume hip arthroscopy specialized surgeons was conducted to report their weight-bearing limitations and rehabilitation protocols after various arthroscopic hip procedures. The International Society of Hip Arthroscopy invited this study. The results were examined in the context of supporting literature to inform the studies suggestions. Four surgeons always allow immediate weight bearing and five never offer immediate weight bearing. Seventeen surgeons provide weight bearing depending on the procedures performed: 17 surgeons allowed immediate weight bearing after labral resection, 10 after labral repair and 8 after labral reconstruction. Sixteen surgeons allow immediate weight bearing after psoas tenotomy. Twenty-one respondents restrict weight bearing after microfracture procedures for 3-8 weeks post-operatively. Return to running and impact sports were shorter for labral procedures and bony procedures and longer for cartilaginous and capsular procedures. Marked variability exists in the post-operative weight-bearing practices of hip arthroscopy surgeons. This study suggests that most surgeons allow immediate weight bearing as tolerated after labral resection, acetabular osteoplasty, chondroplasty and psoas tenotomy. For cartilage defect procedures, 6 weeks or more non-weight bearing is suggested depending on the area of the defect and lateral central edge angle. Delayed return to sports activities is suggested after microfracture procedures. The level of evidence was Level V expert opinions.
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http://dx.doi.org/10.1093/jhps/hnw045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467404PMC
January 2017

[THE RELATIONSHIP BETWEEN OVERWEIGHT, OBESITY AND KNEE OSTEOARTHRITIS].

Harefuah 2016 Nov;155(11):668-671

Tel Aviv Sourasky Medical Center, Ichilov.

Introduction: The prevalence of overweight and obesity in the western world is growing, and with it there is a growing number of patients with osteoarthritis, a condition that leads to pain and disability. The association between body weight and osteoarthritis is mediated by both mechanical and humeral factors such as growth factors, hormones and mediators of the immune system. This review will present the mechanisms which lead to osteoarthritis, and will discuss available treatments which are suitable for the overweight and obese population, along with promising emerging new treatments.
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November 2016

Rotator interval closure has no additional effect on shoulder stability compared to Bankart repair alone.

Arch Orthop Trauma Surg 2017 May 7;137(5):673-677. Epub 2017 Mar 7.

Shoulder Unit, Division of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizman Street, Tel Aviv, 64239, Israel.

Purpose: Arthroscopic Bankart repair (ABR) provides satisfactory results for recurrent anterior shoulder instability, but the high recurrence rate post-ABR remain a concern. One of the adjunct procedures proposed to improve ABR results is arthroscopic rotator interval closure (ARIC). This study prospectively evaluated the outcomes of ABRs alone compared to combined ABR + ARIC and identified risk factors related to failure of each procedure.

Methods: Thirty-nine consecutive patients (mean age 23.1 (18.3-37.5) years; 37 males) underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. Twenty patients underwent ABR alone and 19 underwent ABR + ARIC. Remplissage was added when glenoid engagement was observed during surgery. All patients were prospectively followed, and their postoperative courses were reviewed and functionally assessed at the last visit.

Results: The re-dislocation rate was higher in the ABR + ARIC group compared to the ABR only group at a mean follow-up of 4.2 (2-5.6) years (3 vs. 0, P = 0.06). More subluxations were found in the ABR only group (2 vs. 1, respectively; P = 0.58). The final limitation of range of motion (ROM) compared with the preoperative ROM was similar in both groups. Remplissage procedures were performed more often in the ABR only group [12 (60%) vs. 4 (21%), P = 0.013].

Conclusions: ARIC performed as an adjunct to ABR showed no superiority in attaining value-added stability compared to ABR alone. Adding a remplissage procedure may achieve better stability.

Level Of Evidence: Level 2.
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http://dx.doi.org/10.1007/s00402-017-2665-3DOI Listing
May 2017

Patient's Height and Hip Medial Offset Are the Main Determinants of the Valgus Cut Angle During Total Knee Arthroplasty.

J Arthroplasty 2017 05 20;32(5):1496-1501. Epub 2017 Jan 20.

Division of Orthopedic Surgery, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.

Background: Valgus cut angle (VCA), defined as the angle between the anatomical and the mechanical axes of femur, is an important parameter upon which a critical step of knee arthroplasty is based. Some variables have been proposed to affect the magnitude of this cut. However, little information is available regarding whether a generic value can be used, or if a patient-specific value from a long leg X-ray, or factors that can be determined preoperatively, is necessary to accurately set the VCA.

Methods: Standard standing 3-joint views were used to measure a number of anatomical measurements in 358 limbs, 202 patients (116 women, 86 men). Neck-shaft angle, medial offset, femoral length (FL), distal femoral articular angle, and VCA were measured. Demographic data including gender and height were extracted from hospital charts. The correlation of VCA with each of the other factors was evaluated using linear regression and t-test and finally multivariate analysis.

Results: The average VCA was 5.76° (range 4-8). Gender and distal femoral articular angle were not related to VCA (P = .343 and .995). FL was found to be a function of height with similar effects on multivariate analysis. Only the height (or FL) and femoral offset were identified as independent factors, with a negative correlation for the former (P < .001) and a positive correlation for the latter (P < .001).

Conclusion: Femoral offset and height are the 2 independent factors determining VCA. Other parameters are indirectly related to these 2 factors. Tall patients with a small femoral offset have smaller VCA and short patients with a large offset have larger VCA. The wide variety of VCA values does not support using a generic value for all patients during knee arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2016.12.021DOI Listing
May 2017

The Use of a Supra-Acetabular Antibiotic-Loaded Cement Shelf to Improve Hip Stability in First-Stage Infected Total Hip Arthroplasty.

J Arthroplasty 2016 11 30;31(11):2574-2578. Epub 2016 Apr 30.

Orthopedic Department, Mount Sinai Hospital, Toronto, Ontario, Canada.

Background: Antibiotic-loaded cement spacers in first-stage revision total hip arthroplasty (THA) for managing infection are associated with high dislocation and fracture rates. The aim of this study was to report the use of an antibiotic-loaded cemented supra-acetabular roof augmentation to reinforce hip stability after cement spacer insertion for first-stage total hip revision in the treatment of infected THA.

Methods: We retrospectively reviewed a consecutive series of 50 THAs involving 47 patients with an infected hip requiring staged revisions of THA. We documented dislocation, reinfection, and time for revision and outcome.

Results: There were no cases of hip dislocation, cement fractures, or any other technical complications associated with the use of the roof augmentation lip. Thirteen cases (26%) had a cemented spacer for longer than 120 days. Seven (14%) cases had recurrent infection after staged revision THA.

Conclusion: The antibiotic-loaded cemented supra-acetabular roof augment improved femoral head spacer coverage for patients requiring a staged revision THA for infection.
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http://dx.doi.org/10.1016/j.arth.2016.04.029DOI Listing
November 2016

Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine.

Arthroscopy 2017 Jan 8;33(1):118-124. Epub 2016 Oct 8.

Division of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Israel; Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel.

Purpose: To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy.

Methods: Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery.

Results: Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P < .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption.

Conclusions: Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.

Level Of Evidence: Level I, randomized controlled trial.
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http://dx.doi.org/10.1016/j.arthro.2016.07.026DOI Listing
January 2017

Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.

Arch Orthop Trauma Surg 2017 Jan 26;137(1):73-79. Epub 2016 Sep 26.

Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction: Chronic exertional compartment syndrome (CECS) is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise. The gold standard treatment is fasciotomy, but most of the reports on its effectiveness include relatively small cohorts and relatively short follow-up periods. This study reports the long-term results of a large cohort of young athletes who underwent single-incision fasciotomy for CECS.

Materials And Methods: This a retrospective case-series study. All patients treated by fasciotomies performed for CECS between 2007 and 2011, in a tertiary medical institution. CECS was diagnosed following history taking and clinical evaluation, and confirmed by compartment pressure measurements. Ninety-five legs that underwent single-incision subcutaneous fasciotomy were included. Data on the numerical analog scale (NAS), Tegner activity score, and quality-of-life (QOL) as measured via the short form-12 (SF-12) were retrieved from all patients preoperatively and at the end of follow-up.

Results: The average time to diagnosis was 22 months and the mean follow-up was 50.1 months. Sixty-three legs underwent anterior compartment fasciotomy (an additional 30 legs also underwent lateral compartment release), and two legs underwent lateral and peroneal compartment releases. The average change in Tegner score was an improvement of 14.6 points. Similarly, the patients reported a significant improvement in the SF-12 and NAS scores. Satisfaction rates were high (average 75.5 %). The main complications were wound infection (2 patients) and nerve injuries (4 patients). Eight patients had recurrence.

Conclusion: Single-incision fasciotomy leads to long-term improvement in the activity level and QOL of patients with CECS.
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http://dx.doi.org/10.1007/s00402-016-2569-7DOI Listing
January 2017

Preoperative Planning of Orthopedic Procedures using Digitalized Software Systems.

Isr Med Assoc J 2016 Jun;18(6):354-8

The progression from standard celluloid films to digitalized technology led to the development of new software programs to fulfill the needs of preoperative planning. We describe here preoperative digitalized programs and the variety of conditions for which those programs can be used to facilitate preparation for surgery. A PubMed search using the keywords "digitalized software programs," "preoperative planning" and "total joint arthroplasty" was performed for all studies regarding preoperative planning of orthopedic procedures that were published from 1989 to 2014 in English. Digitalized software programs are enabled to import and export all picture archiving communication system (PACS) files (i.e., X-rays, computerized tomograms, magnetic resonance images) from either the local working station or from any remote PACS. Two-dimension (2D) and 3D CT scans were found to be reliable tools with a high preoperative predicting accuracy for implants. The short learning curve, user-friendly features, accurate prediction of implant size, decreased implant stocks and low-cost maintenance makes digitalized software programs an attractive tool in preoperative planning of total joint replacement, fracture fixation, limb deformity repair and pediatric skeletal disorders.
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June 2016

Hip arthroscopy for intra-capsular benign tumors: a case series.

J Hip Preserv Surg 2016 Oct 15;3(4):312-317. Epub 2016 Jul 15.

Tel Aviv University Sackler Faculty of Medicine.

The purpose of this study is to demonstrate the assessment of intra-capsular femoral head and neck tumors, and to describe the arthroscopic surgical technique used to resect and fill the bone defects. Three cases of benign femoral head and neck lesions are presented. Two benign enchondromas and one benign osteochondroma were resected arthroscopically. Traction was used in one case. Modified Harris Hip Score improved in all three cases to scores of 95 or greater with an average improvement of 16 points with a minimum follow up of 15 months. Arthroscopic surgical resection of intra-capsular femoral hip lesions offers an effective alternative to open resection. This technique offered good outcomes in the limited cohort. We suggest that arthroscopic resection of intra-capsular femoral hip lesions be considered in relevant cases as an alternative to open resection.
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http://dx.doi.org/10.1093/jhps/hnw025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883178PMC
October 2016

The Use of a Closed-Suction Drain in Revision Knee Arthroplasty May Not Be Necessary: A Prospective Randomized Study.

J Arthroplasty 2016 07 29;31(7):1544-8. Epub 2015 Aug 29.

Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: The benefit of suction drains (SD) for the first 24-48 hours following joint replacement surgery is controversial. We aimed to determine if there is any difference in the early outcome of revision TKA when performed with, or without SD.

Methods: 83 cases indicated for revision knee arthroplasty were randomized to receive (42) or not receive (41) a deep intra-articlular drain. First-stage revisions for treating periprosthetic infection were excluded. Patients were statistically compared for demographic parameters, early complications and early knee functional outcome. The assessed outcomes included total blood loss, number of transfusions, fever and wound complication rate at 24 months follow-up. In addition, the change in knee society score at 12 weeks postoperatively was compared between the groups.

Results: There were no significant difference in demographic factors, wound complications, knee scores at 12 weeks and infection rate 24 months after surgery in either group. Average blood loss was 1856ml and 1533ml for the drain and no drain groups, respectively (P value=0.0470). The need for transfusion was significantly less in the no-drain group with an average of 0.15 unit/patient as compared to an average 0.37 unit/patient for the drain group (P value=0.0432).

Conclusion: We were unable to find a point of superiority for using a drain for revision knee arthroplasty. Future studies with longer follow-up and larger population of patients are needed to make a valid conclusion.
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http://dx.doi.org/10.1016/j.arth.2015.08.041DOI Listing
July 2016

The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA).

Knee Surg Sports Traumatol Arthrosc 2017 Jun 26;25(6):1736-1742. Epub 2016 Mar 26.

Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.

Purpose: The objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA).

Methods: The angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10 mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection.

Results: This angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°-24°) vs. 20.7° (range 16°-25°), respectively]. In 89.3 % of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median -20.7° (range 16°-25°) vs. 19.9° (range 15°-24°)] and post-TKA tibiae [median 21.4° (range 19°-24°) vs. 20° (range 16°-25°)].

Conclusion: This study found that in 90 % of the patients, the medial border of the tibial tuberosity is internally rotated 17°-24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used "medial 1/3", it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position.

Level Of Evidence: Cohort and case control studies, Level III.
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http://dx.doi.org/10.1007/s00167-016-4072-7DOI Listing
June 2017

Is There a Benefit for Liposomal Bupivacaine Compared to a Traditional Periarticular Injection in Total Knee Arthroplasty Patients With a History of Chronic Opioid Use?

J Arthroplasty 2016 08 30;31(8):1702-5. Epub 2016 Jan 30.

Department of Anesthesiology and Perioperative Care, University of California Irvine Medical Center, Orange, California.

Background: Postoperative pain after total knee arthroplasty (TKA) poses a major challenge. It delays mobilization, increases opioid consumption and side effects, and lengthens hospitalization. This challenge multiplies when treating an opioid-dependent population. We examined whether a novel suspended release local anesthetic, liposomal bupivacaine (LB) would improve pain control and decrease opioid consumption after TKA compared to a standard periarticular injection in opioid-dependent patients.

Methods: Thirty-eight patients undergoing TKA were randomly assigned to receive either a periarticular injection (PAI) with LB (n = 20) or with a standard PAI (including a combination of ropivacaine, clonidine, Toradol, Epinepherine, and saline; n = 18) as part of a multimodal pain management approach. All periarticular injections were done by a single surgeon. Perioperative treatment was similar between groups. Postoperative information regarding pain level was evaluated by a pain visual analog scale score. Postoperative opioid consumption was recorded.

Results: After controlling baseline narcotic usage before surgery, no differences were found between groups in daily postoperative narcotic usage (P = .113), average daily pain score (P = .332), or maximum daily pain score (P = .881). However, when examining pain levels separately for each day, pain visual analog scale scores were reported higher in post operative day 1 in the LB group (P = .033).

Conclusions: LB was not found to be superior to standard PAI in opioid-dependent patients undergoing TKA. This patient population continues to present a challenge even with modern multimodal pain protocols.
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http://dx.doi.org/10.1016/j.arth.2016.01.037DOI Listing
August 2016
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