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The Journal of Bone and Joint Surgery.... Sep 2012The accuracy of intraoperative periprosthetic frozen section histologic evaluation in predicting a diagnosis of periprosthetic joint infection prior to microbiologic... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
The accuracy of intraoperative periprosthetic frozen section histologic evaluation in predicting a diagnosis of periprosthetic joint infection prior to microbiologic culture results is unknown.
METHODS
We performed a systematic review and meta-analysis of all longitudinal studies that compared frozen section histologic results with simultaneously obtained microbiologic culture at the time of revision total hip or total knee arthroplasty. The data sources were Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, ISI Web of Science, and SCOPUS, from the inception of each database to January 2010.
RESULTS
Twenty-six studies involving 3269 patients undergoing revision hip or knee arthroplasty met the inclusion criteria. A culture-positive periprosthetic joint infection was confirmed in 796 (24.3%) of the patients. Frozen section results, using any of the diagnostic criteria chosen by the investigating pathologist, had a pooled diagnostic odds ratio of 54.7 (95% confidence interval [CI], 31.2 to 95.7), a likelihood ratio of a positive test of 12.0 (95% CI, 8.4 to 17.2), and a likelihood ratio of a negative test of 0.23 (95% CI, 0.15 to 0.35) for the diagnosis of periprosthetic joint infection. Fifteen studies utilizing a threshold of five polymorphonuclear leukocytes (PMNs) per high-power field to define a positive frozen section had a diagnostic odds ratio of 52.6 (95% CI, 23.7 to 116.2), and six studies utilizing a diagnostic threshold of ten PMNs per high-power field had a diagnostic odds ratio of 69.8 (95% CI, 33.6 to 145.0). There was no significant difference between the diagnostic odds ratio or likelihood ratios associated with these thresholds. The moderate to high heterogeneity among the included studies was unexplained by variability in the study design, diagnostic criteria for acute inflammation, reference standard for periprosthetic joint infection, or prevalence of infection. This heterogeneity could be due to differences in the inclusion and exclusion criteria, tissue sampling error, experience or technique of the pathologists, number of microscopic fields visualized, and field diameter examined.
CONCLUSIONS
Intraoperative frozen sections of periprosthetic tissues performed well in predicting a diagnosis of culture-positive periprosthetic joint infection but had moderate accuracy in ruling out this diagnosis. Frozen section histopathology should therefore be considered a valuable part of the diagnostic work-up for patients undergoing revision arthroplasty, especially when the potential for infection remains after a thorough preoperative evaluation. The optimum diagnostic threshold (number of PMNs per high-power field) required to distinguish periprosthetic joint infection from aseptic failure could not be discerned from the included studies. There was no significant difference between the diagnostic accuracy of frozen section histopathology utilizing the most common thresholds of five or ten PMNs per high-power field.
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Confidence Intervals; Female; Follow-Up Studies; Frozen Sections; Humans; Intraoperative Care; Likelihood Functions; Longitudinal Studies; Male; Odds Ratio; Postoperative Complications; Prosthesis-Related Infections; Reoperation; Risk Assessment; Treatment Outcome
PubMed: 22992880
DOI: 10.2106/JBJS.J.00756 -
Acta Orthopaedica Belgica Sep 2021The aim of this systematic review was to evaluate the evidence on reservation of Posterior Femoral Condylar Offset (PFCO) and Joint Line (JL) after Revision Total Knee...
The aim of this systematic review was to evaluate the evidence on reservation of Posterior Femoral Condylar Offset (PFCO) and Joint Line (JL) after Revision Total Knee Arthroplasty (RTKA) for im- proved functional outcomes. A comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases was conducted, with papers published from the inception of the database to October 2020 included. All relevant articles were retrieved, and their bibliographies were hand searched for further references on Posterior condylar offset and revision total knee arthroplasty. The search strategy yielded 28 articles. After duplicate titles were excluded, abstracts and full text were reviewed. Nine studies were assessed for eligibility, four studies were excluded because they did not fully comply with the inclusion criteria. Six articles were finally included in this systematic review. Based on this systematic review restoration of the JL and PFCO in RTKR is associated with a significant improvement in the post-operative range of motion, KSS, OKS, patellar function, and SF-36. Reservation of JL should be a major consideration when undertaking RTKA. Of note, increasing PFCO to balance the flexion gap while maintaining joint line should be well assessed intra-operatively. The upper limit of the PFCO that widely accepted is up to 40 % greater than that of the native knee. 4 mm is the upper limit for JL restoration. Level of evidence III.
Topics: Arthroplasty, Replacement, Knee; Humans; Knee Joint; Knee Prosthesis; Patella; Range of Motion, Articular
PubMed: 34808719
DOI: No ID Found -
Acta Orthopaedica Jun 2017Background and purpose - Radiostereometric analysis (RSA) is an accurate method for measurement of early migration of implants. Since a relation has been shown between... (Review)
Review
Background and purpose - Radiostereometric analysis (RSA) is an accurate method for measurement of early migration of implants. Since a relation has been shown between early migration and future loosening of total knee and hip prostheses, RSA plays an important role in the development and evaluation of prostheses. However, there have been few RSA studies of the upper limb, and the value of RSA of the upper limb is not yet clear. We therefore performed a systematic review to investigate the accuracy and precision of RSA of the upper limb. Patients and methods - PRISMA guidelines were followed and the protocol for this review was published online at PROSPERO under registration number CRD42016042014. A systematic search of the literature was performed in the databases Embase, Medline, Cochrane, Web of Science, Scopus, Cinahl, and Google Scholar on April 25, 2015 based on the keywords radiostereometric analysis, shoulder prosthesis, elbow prosthesis, wrist prosthesis, trapeziometacarpal joint prosthesis, humerus, ulna, radius, carpus. Articles concerning RSA for the analysis of early migration of prostheses of the upper limb were included. Quality assessment was performed using the MINORS score, Downs and Black checklist, and the ISO RSA Results - 23 studies were included. Precision values were in the 0.06-0.88 mm and 0.05-10.7° range for the shoulder, the 0.05-0.34 mm and 0.16-0.76° range for the elbow, and the 0.16-1.83 mm and 11-124° range for the TMC joint. Accuracy data from marker- and model-based RSA were not reported in the studies included. Interpretation - RSA is a highly precise method for measurement of early migration of orthopedic implants in the upper limb. However, the precision of rotation measurement is poor in some components. Challenges with RSA in the upper limb include the symmetrical shape of prostheses and the limited size of surrounding bone, leading to over-projection of the markers by the prosthesis. We recommend higher adherence to RSA guidelines and encourage investigators to publish long-term follow-up RSA studies.
Topics: Arthroplasty, Replacement; Elbow Joint; Hand Joints; Humans; Joint Prosthesis; Postoperative Care; Prosthesis Design; Prosthesis Failure; Radiostereometric Analysis; Shoulder Joint; Upper Extremity
PubMed: 28464752
DOI: 10.1080/17453674.2017.1291872 -
Surgical Technology International Nov 2018Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could...
Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could fail due to various well-known causes. Furthermore, metal allergy-related complications have recently gained attention as one of the potential causes of failure when the common reasons have been excluded. Reported symptoms from metal allergy can include chronic eczema, joint effusions, joint pain, and limited range of motion. Few studies have explored the outcomes of patients undergoing revisions due to allergic complications. The aim of our study is to quantitatively evaluate the outcomes of revision joint arthroplasty due to metal allergy and hypersensitivity.
Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Chromium Alloys; Dermatitis, Contact; Female; Hip Prosthesis; Humans; Knee Prosthesis; Male; Middle Aged; Prosthesis Failure; Reoperation; Treatment Outcome
PubMed: 29985516
DOI: No ID Found -
The Journal of Hand Surgery... Apr 2022Unconstrained pyrocarbon and metal-on-polyethylene (MoP) proximal interphalangeal (PIP) joint arthroplasty is an increasingly popular alternative to silicone implants...
Unconstrained pyrocarbon and metal-on-polyethylene (MoP) proximal interphalangeal (PIP) joint arthroplasty is an increasingly popular alternative to silicone implants and arthrodesis. This systematic review appraises their outcomes. Thirty studies comprising 1,324 joints (813 pyrocarbon, 511 MoP) were included. Mean patient age was 59 years (38-78) and mean follow-up period was 54 months (12-118). There were mean improvements of 4.5 points (2-6.9) in pain visual analogue score, 10.5° (-26 to 58) in range of motion (ROM), 3.1 kg (-4 to 7) in grip strength, 0.6 kg (-1.5 to 2) in pinch strength and 18 points (-3 to 29) in the disabilities of the arm, shoulder and hand score, with no significant differences between implant types. ROM gains deteriorated over time. Clinical complications were frequent (23%) and significantly more common with pyrocarbon, as were radiographic complications. However, most were mild-moderate and did not necessarily correlate with negative outcomes or dissatisfaction. Overall re-operation rate was 21%, and revision rate 11%, both more frequent with pyrocarbon. Most revisions were within 24 months, beyond which survival was maintained up to 10 years. Unconstrained PIP joint arthroplasty is effective in improving pain scores, active ROM, grip/pinch strength and patient-reported outcome measures, particularly in patients with osteoarthritis. Results are generally maintained at least to the medium term, although gains diminish in the longer term. Complication and early revision rates are high, particularly with pyrocarbon implants. Most patients express positive attitudes to arthroplasty, with significant improvements in patient-reported outcome measures for both pyrocarbon and MoP implants. Patients with post-traumatic and inflammatory arthropathy are generally less satisfied. There is currently insufficient data to recommend one implant type over another, although the early-to-medium term results of MoP implants are promising. Prospective surveillance via small joint registries is recommended. Level III (Therapeutic).
Topics: Adult; Aged; Arthroplasty; Arthroplasty, Replacement, Finger; Finger Joint; Humans; Joint Prosthesis; Middle Aged; Osteoarthritis; Pain; Prospective Studies; Treatment Outcome
PubMed: 35404211
DOI: 10.1142/S2424835522500266 -
Knee Surgery, Sports Traumatology,... Sep 2018Patient-specific instruments (PSIs) are already in relatively common use, and their post-operative radiographic results are equal to those for total knee arthroplasty... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Patient-specific instruments (PSIs) are already in relatively common use, and their post-operative radiographic results are equal to those for total knee arthroplasty (TKA) with conventional instrumentation. PSI use requires a preoperative MRI scan, CT scan, or a combination of MRI and a long-leg standing radiograph. However, there is no consensus as to which of these modalities, MRI or CT, is the preferred imaging modality when performing TKA with PSIs.
METHODS
This systematic literature review and meta-analysis studied the differences in alignment outliers between CT- and MRI-based PSI for TKA. A search of the Cochrane Database of Systematic Reviews, MEDLINE/PubMed and Embase was conducted, without restriction on date of publication. Only level I evidence studies written in English that included TKA with the use of MRI- and CT-based PSI were selected. A meta-analysis was then performed of the rate of outliers in the biomechanical axis and individual femoral and tibial component alignment. Where considerable heterogeneity among studies was present or the data did not provide sufficient information for performing the meta-analysis, a qualitative synthesis was undertaken.
RESULTS
Twelve randomized controlled trials, studying 841 knees, were eligible for data extraction and meta-analysis. MRI-based PSI resulted in a significantly lower proportion of coronal plane outliers with regard to the lateral femoral component (OR 0.52, 95% CI 0.30-0.89, P = 0.02), without significant heterogeneity (n.s.). There were no significant differences regarding the biomechanical axis or frontal femoral and individual tibial component alignment.
CONCLUSION
This systematic review and meta-analysis demonstrate that alignment with MRI-based PSI is at least as good as, if not better than, that with CT-based PSI. To prevent for malalignment, MRI should be the imaging modality of choice when performing TKA surgery with PSI.
LEVEL OF EVIDENCE
I.
Topics: Arthroplasty, Replacement, Knee; Bone Malalignment; Femur; Humans; Knee Joint; Knee Prosthesis; Magnetic Resonance Imaging; Osteoarthritis, Knee; Surgery, Computer-Assisted; Tibia; Treatment Outcome
PubMed: 28698929
DOI: 10.1007/s00167-017-4637-0 -
The Knee Jan 2023It is unclear whether a difference in functional outcome exists between kinematically aligned (KA) and mechanically aligned (MA) knee replacements. The aim of this study... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
It is unclear whether a difference in functional outcome exists between kinematically aligned (KA) and mechanically aligned (MA) knee replacements. The aim of this study is to perform a comprehensive systematic review and meta-analysis of the available level I-IV evidence.
METHODS
A meta-analysis of randomised controlled trials and observational studies comparing patient reported outcome measures (PROMs), range of motion (ROM), gait analysis and complications in TKA with KA and MA was performed. Quality assessment was performed for each study using the Joanna Briggs Institute (JBI) critical appraisal tools.
RESULTS
Twelve randomised controlled trials and fourteen observational studies published between 2014 and 2022 were included in the final analysis. Meta-analysis revealed KA to have significantly better Oxford Knee Score (OKS) (p = 0.02), Forgotten Joint Score (FJS) (p = 0.006), Knee Society Score (KSS) Objective Knee (p = 0.03) and KSS Functional Activity (p = 0.008) scores. However, these improvements did not exceed the minimum clinically important difference (MCID) values reported in the literature. Subgroup analysis showed robotic assisted KA-TKA to have a clinically superior FJS (p = 0.0002) and trend towards KSS Objective Knee score (p = 0.10), compared to PSI. Gait and plantar pressure distribution of KA cohorts more closely represented healthy cohorts, and KA showed a weak association of a decreased knee adduction moment (KAM) compared to MA. Differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), range of motion and complications were not significant between groups.
CONCLUSION
Although KA results in several improved functional outcomes, these do not reach clinical significance. Further standardised large-scale randomised studies are required to improve the quality of evidence. As it stands, it is difficult to recommend one philosophy over the other.
Topics: Humans; Knee Prosthesis; Osteoarthritis, Knee; Biomechanical Phenomena; Knee Joint; Arthroplasty, Replacement, Knee; Range of Motion, Articular
PubMed: 36403396
DOI: 10.1016/j.knee.2022.11.001 -
Journal of Shoulder and Elbow Surgery May 2022The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral... (Review)
Review
BACKGROUND
The use of reverse total shoulder arthroplasty and stemless anatomic total shoulder replacement has been increasing in the United States every year. Stemless humeral components in reverse total shoulder arthroplasty are only approved for clinical trials in the United States with an investigational device exception with limited data.
METHODS
A systematic review on stemless reverse total shoulder arthroplasty was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search was conducted on November 25, 2020, using the MEDLINE/PubMed, Cochrane, and Embase databases. All articles were reviewed by 2 independent evaluators, with any conflicts or issues resolved by consensus or a final decision by the senior author. The primary outcomes extracted were complications, radiographic results, and outcome scores.
RESULTS
We evaluated 10 studies that used either the Total Evolutive Shoulder System (TESS) or Verso implant. There were 430 total patients and 437 total procedures; 266 patients in the TESS group underwent a total of 272 procedures, and 164 patients in the Verso group underwent a total of 165 procedures. The mean age at the time of surgery was 73.8 years (range, 38-93 years). The mean follow-up period ranged from 6.4 to 101.6 months per study. There was an overall trend of improved clinical outcome scores, a 0.2% humeral component loosening rate, and an 11.2% complication rate.
CONCLUSIONS
This review shows that the clinical and functional outcomes following stemless or metaphyseal reverse total shoulder arthroplasty are quite promising, especially with the low rate of humeral-sided complications. There continues to be a need for additional long-term studies and randomized clinical trials.
Topics: Arthroplasty, Replacement, Shoulder; Humans; Prosthesis Design; Shoulder Joint; Shoulder Prosthesis; Treatment Outcome
PubMed: 35051541
DOI: 10.1016/j.jse.2021.12.017 -
Orthopaedics & Traumatology, Surgery &... Nov 2018Several tests are used before reimplantation to detect persistent infection in patients with periprosthetic joint infection (PJI) undergoing two-stage revision. However,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Several tests are used before reimplantation to detect persistent infection in patients with periprosthetic joint infection (PJI) undergoing two-stage revision. However, there is no consensus as to the optimal tests for excluding persistent infection or predicting successful reimplantation by stage. We aimed to determine the accuracy of different tests used to detect persistent infection after the first stage, and/or predicting failure following reimplantation in patients with PJI.
METHODS
We conducted a systematic review and meta-analysis of PubMed, Embase and the Cochrane Library databases. Two reviewers independently conducted quality assessments and data extractions to estimate pooled sensitivity and specificity, diagnostic odds ratio and area under the receiver operating characteristic curves (AUSROC) for each test.
RESULTS
We included 24 studies published between May 1999 and September 2017. Synovial fluid polymorphonuclear neutrophils (PMN)% had the highest sensitivity of 0.70, followed by serum erythrocyte sedimentation rate (0.57) and spacer sonication fluid culture (0.53). Synovial fluid culture had the highest specificity of 0.97, followed by frozen section (0.93) and the Musculoskeletal Infection Society criteria (0.92). Spacer sonication fluid culture was the most accurate test with an AUSROC of 0.8089, followed by synovial fluid culture (0.7749) and frozen section (0.7819).
DISCUSSION
Spacer sonication fluid culture had a relatively high diagnostic accuracy. We emphasize that no test can be used alone to exclude persistent infection beyond the first stage and/or predict failed reimplantation beyond the second stage.
LEVEL OF EVIDENCE
II, systematic review and meta-analysis of level 2 to level 4 studies with inconsistent results.
Topics: Arthroplasty, Replacement; Blood Sedimentation; Diagnostic Tests, Routine; Frozen Sections; Humans; Joint Prosthesis; Leukocyte Count; Neutrophils; Prosthesis-Related Infections; ROC Curve; Reoperation; Synovial Fluid
PubMed: 30030145
DOI: 10.1016/j.otsr.2018.03.017 -
JBJS Reviews Jul 2017Most total elbow arthroplasty (TEA) designs aim to replicate anatomy and provide stability in the treatment of the degenerative elbow joint. Given the promising results... (Review)
Review
BACKGROUND
Most total elbow arthroplasty (TEA) designs aim to replicate anatomy and provide stability in the treatment of the degenerative elbow joint. Given the promising results that have been reported following the use of TEA for the treatment of complex fractures, the indications for this procedure are growing. The objective of the present study was to review the most recent literature on the results of the most commonly performed TEAs.
METHODS
A comprehensive literature search was conducted. All relevant studies were reviewed according to a set of predefined inclusion and exclusion criteria. After the initial assessment, 2 authors extracted data from the included articles. Groups were created on the basis of the design of TEA implant, the type of implant (linked or unlinked), and the indication for treatment. Outcome parameters were survival rate, pain, range of motion, complications, and specific elbow outcome scores.
RESULTS
Seventy-three articles involving a total of 9,379 TEAs were included. The level of evidence was primarily Level IV. Nineteen specific designs of TEA implants were described, including the Souter-Strathclyde (n = 2,387), Coonrad-Morrey (n = 1,586), Kudo (n = 560), and GSB III (n = 498). The most common indication for TEA was rheumatoid arthritis (70%). The weighted mean survival rate for the linked and unlinked prostheses was 85.5% at 7.8 years and 74% at 12.3 years, respectively. For the Coonrad-Morrey, Souter-Strathclyde, and GSB III, the weighted mean survival rate was 87.2% at 7.2 years, 70.6% at 14.2 years, and 81.7% at 9.5 years, respectively. The range of motion after TEA was good overall, with a mean flexion angle of 129° and a mean extension lag angle of 30°. The complication rates ranged from 11% to 38%, with clinical loosening being the most frequently reported complication (7%).
CONCLUSIONS
The results of TEA are respectable overall. It appears that there are small differences between designs. However, despite the fairly good functional results and elbow scores, the survival and complication rates are still not as favorable as those following arthroplasties in other joints.
LEVEL OF EVIDENCE
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Arthroplasty, Replacement, Elbow; Elbow Prosthesis; Humans; Postoperative Complications
PubMed: 28696952
DOI: 10.2106/JBJS.RVW.16.00089