European Federation of National Associations of Orthopaedics and Traumatology
European Instructional Lectures Volume 9 2009
European Federation of National Associations of Orthopaedics and Traumatology Committees and Task Forces EFORT Executive Committee
Standing Committees EAR Committee
Executive Board Prof. Dr. Karl-Göran Thorngren, President Prof. Dr. Miklós Szendrıi, Vice President Dr. Manuel Cassiano Neves, Secretary General Prof. Dr. Wolfhart Puhl, Immediate Past President Mr. Stephen R. Cannon, Treasurer Prof. Dr. Enric Caceres Palou, Member at Large Prof. Dr. Pierre Hoffmeyer, Member at Large Prof. Dr. Maurilio Marcacci, Member at Large Co-Opted Members Mr. John Albert Prof. Dr. Thierry Bégué Prof. Dr. George Bentley, Past President Prof. Dr. Nikolaus Böhler, Past President Dr. Karsten Dreinhöfer Dr. Roberto Giacometti Ceroni Prof. Dr. Klaus-Peter Günther Ass. Prof. Dr. Per Kjaersgaard-Andersen Prof. Dr. Karl Knahr
Scientific Coordination 10th EFORT Congress, Vienna 2009 Chairman Prof. Dr. Pierre Hoffmeyer Members Prof. Dr. George Bentley Prof. Dr. Nikolaus Böhler Prof. Dr. Enric Caceres Palou Mr. Stephen R. Cannon Dr. Manuel Cassiano Neves Prof. Dr. Alfred Engel Prof. Dr. Roberto Giacometti Ceroni Prof. Dr. Martti Hämäläinen Prof. Dr. Karl Knahr Prof. Dr. Philippe Neyret Prof. Dr. Miklós Szendrıi
Prof. Dr. Nikolaus Böhler, Dr. Gerold Labek Education Committee Prof. Dr. Enric Caceres Palou EIL Committee Prof. Dr. Wolfhart Puhl, Prof. Dr. Karl-Göran Thorngren Events Committee Dr. Manuel Cassiano Neves Finance Committee Mr. Stephen R. Cannon, Prof. Dr. Pierre-Paul Casteleyn Health Service Research Committee Dr. Karsten Dreinhöfer Portal Steering Committee Prof. Dr. Klaus-Peter Günther Publishing Committee Prof. Dr. George Bentley (Books), Prof. Dr. Klaus-Peter Günther (Portal), Prof. Dr. Wolfhart Puhl (Journal) Scientific Committee Prof. Dr. Pierre Hoffmeyer Venue Committee Prof. Dr. Miklós Szendrıi
Task Forces and Ad Hoc Committees Awards & Prizes Committee Prof. Dr. George Bentley Fora Prof. Dr. Thierry Bégué Liaison & Lobbying Committee Prof. Dr. Wolfhart Puhl Speciality Societies Committee Dr. Roberto Giacometti Ceroni Travelling & Visiting Fellowships Prof. Dr. Maurilio Marcacci
European Federation of National Associations of Orthopaedics and Traumatology
European Instructional Lectures Volume 9, 2009 10th EFORT Congress, Vienna, Austria
Edited by
George Bentley
Editor: Prof. Dr. George Bentley Royal National Orthopaedic Hospital Trust Stanmore, Middlesex HA 7 4LP, UK
[email protected] EFORT Central Office Technoparkstrasse 1 8005 Zürich, Switzerland www.efort.org
ISBN: 978-3-642-00965-5
e-ISBN: 978-3-642-00966-2
DOI: 10.1007/978-3-642-00966-2 Springer Dordrecht Heidelberg London New York Library of Congress Control Number: 2009926014 © EFORT 2009 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Frido Steinen-Broo, eStudio Calamar, Spain Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)
Foreword
The 10th Congress of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) is the most important combined congress of the national societies in Europe. At present a total of 36 societies are members of this organisation. The major goal of EFORT is to bring current knowledge of diseases and trauma of the musculoskeletal system to all European surgeons and additionally to welcome colleagues from all over the world to join us in sharing our daily work experience. In the scientific programme the instructional lectures form a very basic and important part of the Congress. In Vienna a total of 25 sessions are included in the programme. The authors come from all over Europe and they discuss topics from many different fields of trauma and orthopaedics. These lectures not only give the opportunity for us to be informed about various diseases, but they are also influenced by the authors’ experience based on the treatment philosophy in their own country – again an opportunity to widen the European horizon. They are aimed at both the general orthopaedic surgeons and the young residents and trainees who want to widen their knowledge in different topics of orthopaedic and trauma surgery. As the chairman of the Local Organising Committee I thank all the authors for providing their presentation for publication in this volume. I also address my special thanks to Professor George Bentley for organising this edition. I am confident that this book will have the same respected place in the library of the participating orthopaedic surgeons as do all the previous ones. Vienna, Austria
Karl Knahr
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Preface
This is the 9th volume of the European Instructional Lectures, which contains more new material, which will be presented during the 10th EFORT Congress in Vienna by distinguished authors from across Europe. As in former volumes the chapters cover a range of topics, concentrating on both the essentials of the subjects and the latest thinking and technology. Additionally, the authors are from different countries and centres, which reflect the variety of modern European orthopaedic and traumatology practice and their special experience and philosophy. Special thanks are due to these authors who have been called upon to do other tasks, such as paper reviewing and chairing Specialist Symposia and Free Paper sessions, and all of them have responded generously. Without this spirit of collaboration by our colleagues in the National and Specialty Societies, EFORT would not flourish. The preparation and printing of this volume was by the Internationally-recognised Springer team, enthusiastically led by Gabriele Schroeder, to whom we are very grateful. I wish also to thank Larissa Welti, Régine Brühweiler, Sabrina Wolf and the EFORT Central Office for their unfailing support. EFORT has now exceeded 220 essays in the 9 volumes of Instructional Lectures since the series first began at the opening Congress in Paris in 1993. With this in mind we wish to dedicate this volume to the memory of the life and work of our dear colleague Professor Frantz Langlais, tragically and prematurely taken from us in 2007. Stanmore, UK
George Bentley
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Contents
General Orthopaedics Current Status of Arthroplasty Registers in Europe . . . . . . . . . . . . . . . . . . N. Böhler and Gerold Labek
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National Registration of Hip Fractures in Sweden . . . . . . . . . . . . . . . . . . . . Karl-Göran Thorngren
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Current Status of Articular Cartilage Repair. . . . . . . . . . . . . . . . . . . . . . . . Emmanuel Thienpont
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Thromboprophylaxis After Major Orthopaedic Surgery: State of the Art . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alexander G.G. Turpie
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Paediatrics DDH: Diagnosis and Treatment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . R. Graf
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Slipped Capital Femoral Epiphysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. Zilkens, M. Jäger, Y-J. Kim, M.B. Millis, and R. Krauspe
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Major Joint Contractures in Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deborah M. Eastwood
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Trauma Damage-Control Orthopaedic Surgery in Polytrauma: Influence on the Clinical Course and Its Pathogenetic Background . . . . . . . . . . Hans-Christoph Pape
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Fractures and Non-Unions of the Clavicle. . . . . . . . . . . . . . . . . . . . . . . . . . . Patrick Simon
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Proximal Humeral Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. Torrens
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Fixation of Intertrochanteric Femoral Fractures . . . . . . . . . . . . . . . . . . . . . Vilmos Vécsei and Stefan Hajdu
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Surgical Management of Distal Tibial Fractures in Adults . . . . . . . . . . . . . Mathieu Assal and Richard Stern
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Contents
Upper Limb and Hand The Distal Radio-Ulnar Joint: Functional Anatomy, Biomechanics, Instability and Management . . . . . . . . . . . . . . . . . . . . . Panayotis N. Soucacos and Nickolaos A. Darlis
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Distal Radius Fractures: Evolution in the Treatment Standard of Care 2009 . . . . . . . . . . . . . . . Antonio Abramo and Philippe Kopylov
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Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hanno Millesi
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Spine Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R. Eyb and G. Grabmeier
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Hip Total Hip Arthroplasty: A Comparison of Current Approaches . . . . . . . . Martin Krismer
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How to Do a Cemented Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . Eduardo Garcia-Cimbrelo
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How to Do a Cementless Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . Klaus-Peter Günther, Firas Al-Dabouby, and Peter Bernstein
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Knee How to Treat a Meniscal Lesion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Olivier Charrois and The GREC Group
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Soft-Tissue Balance in Total Knee Arthroplasty. . . . . . . . . . . . . . . . . . . . . . David E. Beverland
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Revision Total Knee Arthroplasty with Bone Loss . . . . . . . . . . . . . . . . . . . . Josef Hochreiter and Karl Knahr
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Foot and Ankle Ankle Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X. Crevoisier
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Hallux Rigidus: Arthroplasty or Not? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S. Giannini, F. Vannini, R. Bevoni, and D. Francesconi
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Contributors Preface
Antonio Abramo Hand and Upper Extremity Unit, Department of Orthopaedics, Lund University Hospital, Lund, Sweden Firas Al-Dabouby Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr. 74, D-01307 Dresden, Germany Mathieu Assal Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland,
[email protected] Peter Bernstein Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr. 74, D-01307 Dresden, Germany David E. Beverland Outcomes Unit, Musgrave Park Hospital, Belfast, BT9 7JB, UK,
[email protected] Roberto Bevoni Via Pupilli 1, 40136 Bologna, Italy,
[email protected] Nikolaus Böhler AKH Linz, Orthopaedic Department, Krankenhausstrasse 9, A-4020 Linz, Austria,
[email protected] Olivier Charrois Clinique Arago, 95 Boulevard Arago, 75014 Paris, France,
[email protected] Xavier Crevoisier Centre Hospitalier Universitaire Vaudois (CHUV), Site Hôpital Orthopédique, Pierre-Decker 4, 1011 Lausanne, Switzerland,
[email protected] Nickolaos A. Darlis Department of Orthopaedic Surgery, University of Athens, School of Medicine, Athens, Greece Deborah M. Eastwood Department of Paediatric Orthopaedics, Great Ormond St Hospital for Children and the Royal National Orthopaedic Hospital, London, UK,
[email protected] Richard Eyb Donauspital, Orthopädische Abteilung, Sozialmedizinisches Zentrum Ost, Langobardenstrasse 122, 1220 Wien, Austria,
[email protected] D. Francesconi Via Pupilli 1, 40136 Bologna, Italy,
[email protected] Eduardo Garcia-Cimbrelo Hospital La Paz, Universidad Autónoma de Madrid, Paseo de la Castellana 261, Madrid 28046, Madrid, Spain,
[email protected] xi
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Sandro Giannini Via Pupilli 1, 40136 Bologna, Italy,
[email protected] Georg Grabmeier Donauspital Orthopädische Abteilung Sozialmedizinisches Zentrum Ost Langobardenstrasse 122 1220 Wien, Austria Reinhard Graf Allgemeines u. Orthopädisches Landeskrankenhaus, 8852 Stolzalpe, Austria,
[email protected] Klaus-Peter Günther Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr. 74, D-01307 Dresden, Germany,
[email protected] Stefan Hajdu Department of Trauma Surgery, Vienna Medical University, Währinger Gürtel 18-20, 1090-Wien, Austria,
[email protected] Josef Hochreiter Department of Orthopaedic Surgery, St. Vincent’s Hospital, Linz, Austria,
[email protected] Marcus Jäger Department of Orthopaedic Surgery, University Hospital of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany Young-Jo Kim Children’s Hospital Boston, Harvard Medical School, Department of Orthopaedic Surgery, 300 Longwood Avenue, Boston, MA 02115, USA Karl Knahr Department II of Orthopaedic Surgery, Orthopaedic Hospital Speising, Vienna, Austria,
[email protected] Philippe Kopylov Hand and Upper Extremity Unit, Department of Orthopaedics, Lund University Hospital, Lund Sweden,
[email protected] Rüdiger Krauspe Department of Orthopaedic Surgery, University Hospital of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany,
[email protected] Martin Krismer Department of Orthopaedics, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria,
[email protected] Gerold Labek Medical University Innsbruck, Orthopaedic Department, Anichstrasse 35, A-6020 Innsbruck, Austria Hanno Millesi Wiener Privatklinik, Pelikangasse 15 1090 Wien, Austria,
[email protected] M.B. Millis Children’s Hospital Boston, Harvard Medical School, Department of Orthopaedic Surgery, 300 Longwood Avenue, Boston, MA 02115, USA Hans-Christophe Pape University of Aachen, Chairman, Department of Orthopaedics, Pauwelstreet 30, 52074 Aachen, Germany
[email protected] Patrick Simon Centre Hospitalier Saint Joseph - Saint Luc 20, quai Claude Bernard 69365 Lyon, France,
[email protected] Panayotis N. Soucacos Department of Orthopaedic Surgery, University of Athens, School of Medicine, Athens, Greece,
[email protected] Richard Stern Orthopaedic Surgery Service, University Hospital of Geneva, Switzerland
Contributors
Contributors
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Emmanuel Thienpont University Hospital Saint Luc, U.C.L., Avenue Hippocrate 10, 1200 Brussels, Belgium,
[email protected] Karl-Göran Thorngren Department of Orthopaedics, Lund University Hospital, SE-221 85 Lund, Sweden,
[email protected] Carlos Torrens Orthopaedic Department, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain,
[email protected] Alexander G.G. Turpie McMaster University, 237 Barton Street East, Hamilton, Canada, ON L8L 2X2,
[email protected] F. Vannini Via Pupilli 1, 40136 Bologna, Italy,
[email protected] Vilmos Vécsei Department of Trauma Surgery, Vienna Medical University, Währinger Gürtel 18-20, 1090-Wien, Austria Christoph Zilkens Department of Orthopaedic Surgery, University Hospital of Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
Current Status of Arthroplasty Registers in Europe1 N. Böhler and Gerold Labek
Introduction National Arthroplasty Registers in Scandinavia have proved to be an important and valid instrument to assess the longterm performance of joint arthroplasty procedures and to lead to an improvement in the long-term outcome of arthroplasty [1–8]. Improved quality of joint arthroplasty effects a reduction of costs in public health care by avoiding revision surgery [9]. Starting with the Swedish National Knee Register (Lund, 1975) [10] and the Swedish National Hip Register (Gothenburg, 1979) they have had a high impact on Orthopaedic procedures in Scandinavia and worldwide. In Sweden, for instance, the revision burden as an essential indicator could be substantially reduced. Due to data in the register, products with inferior performance such as Boneloc bone cement were rapidly detected [11]. The product was taken from the market wordwide in 1995. Moreover, the effects of procedures such as the mini-invasive approach, of operating experience [12] or the administration of antibiotics could be evaluated and, as a consequence, standardised improvements could be suggested. Even though the results obtained from arthroplasty registers were accepted by the scientific community worldwide and were often quoted, efforts to establish similar projects in other countries were not really successful. For example,
N. Böhler () AKH Linz, Orthopaedic Department, Krankenhausstrasse 9, A-4020 Linz, Austria e-mail:
[email protected] an ambitious project in Germany, the German Arthroplasty Register e.V. in Göttingen [13], as well as the European Implant Register Committee by EFORT were discontinued after a few years. A multitude of different projects were and still are designated as registers. As there was no commonly-accepted definition of a register, the definition of an Arthroplasty Register was worked out by close dependence on the Scandinavian experience and was finally determined by the European Arthroplasty Register with all European National Arthroplasty Registers participating. These are the aims of a Register: ● Registration of ALL primary and revision operations in a defined area in a central database. ● Follow the implant until it has to be revised, the patient dies or emigrates. ● Definition of Revision (= Failure): at least one part of the implant has to be revised. Other large-scale documentation should be considered as multi-centre studies or surveys. The completeness of data is decisive for the quality of the results drawn from a register. Registers in Scandinavia were the first to prove that area-wide data collection is possible [14–18]. The high quality of statements on activities and results within whole National territories is unique in science. One of the essential criteria is that the bias which is inevitable when working with samples can largely be avoided on a National scale.
Historical Review and Methods 1
International Websites of National Arthroplasty Registers including National Arthroplasty Register Reports and Publications are presented on the EFORT-Website: http://www.efort.org/ getdoc/1b923b01-41d2-4587-bac2-7ca7a11e613e/ArthoplastyRegisters.aspx
Within the scope of an EFORT project in Romania it was decided in 1999 to found a National arthroplasty register. Afterwards, in rapid succession, the Slovak Orthopaedic Society also decided to establish a National arthroplasty
G. Bentley (ed.), European Instructional Lectures. European Instructional Course Lectures 9, DOI: 10.1007/978-3-642-00966-2_1, © 2009 EFORT
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register and the Hungarian Register, founded in 1998, expressed its willingness to co-operate, the opportunity for supra-National co-operation became self-evident. EFORT was given responsibility for these activities, and consequently the EFORT Executive Committee launched the “European Arthroplasty Register” (EAR) project in June 2001. All existing National registers, at that time the Scandinavian Registers, were prepared to join the project and make their experience available to the network. In order to be able to support the increasing number of network activities in the best possible way a non-profit association, EFORT-EAR, was founded in 2005. This association closely co-operates with EFORT. There are multiple organisational links between EFORT and EFORT-EAR. Further information is available from the Internet on www.ear.efort.org. Membership requires either operating a National register according to the EFORT-EAR definition or an exisiting project for the foundation of a National register that is supported by the relevant National orthopaedic society. The EAR network supports initiatives for the foundation of National arthroplasty registers by National orthopaedic societies. These activities are primarily based on the exchange of experience, passing on information for discussions, for instance with health authorities, and the interchange of solutions for common problems in organisation, documentation and evaluation. Particular central standards are being laid down, such as Minimal Datasets, for example, that comprise all parts of information to be collected in a National register. These standardisation efforts aim at improving the supranational comparison of reports. Where necessary central services shall help registers to fulfil their tasks as economically as possible. A central product data base would be one example. Implant tracking is a pre-condition for any kind of evaluation. Setting up a database comprising all products available on the relevant markets is one of the most complex and time-consuming tasks of every register that has to be carried out in co-operation with the producers. A co-operation will thus enable all partners to improve data quality at a lower expenditure. EFORT also supports register activities through its wide range of publication facilities. Within the scope of the EFORT homepage (www.efort.org) all websites of National Arthroplasty Registers have been combined in a user-friendly way. Futhermore publication activities are supported through essential results achieved in the course of EFORT and National conferences. Of course the EAR project also comprises scientific activities. These activities as with all communication within the network of National Registers are run via the
N. Böhler and G. Labek Fig. 1 Number of National Arthroplasty Register projects started
20 18 16
Start of Arthroplasty Registers
14 12 10 8 6 4 2 0 1970s
1980s
1990s
2000-
EAR Office at the Orthopaedic University Hospital of Innsbruck, Austria. The variety of projects in nearly all European countries and the rapidly growing number of register foundations within the last 10 years clearly demonstrate the value and necessity of activities of that kind (Fig. 1). At present 27 registers in 24 countries are members of the EAR. In most of these countries register activities are carried out by one organisation. However, the splitting of activities into several centres, each dealing with a particular joint, is a promising alternative as examples in Sweden and Denmark have shown (Table 1).
Basic Requirements for the Development and Activities of a National Arthroplasty Register Arthroplasty Registers are very complex projects requiring co-operation with a variety of experts and stakeholders. Over the past few years the development of various National registers has shown that several aspects are crucial for successful implementation. 1. The register has to be an integral part of the National health-care system. Registers exclusively based on scientific motivation and the support of academic institutions were not able to cope with the diverse problems and requirements alone, notwithstanding the strong personal
Current Status of Arthroplasty Registers in Europe
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Table 1 Arthroplasty registers according to EAR definitions worldwidea Country
Founded
Status
Data collection
Data validation published
Sweden – Knee Sweden – Hip Finland Norway Denmark – Hip Denmark – Knee New Zealand Hungary Australia Canada Czech Rep. Romania Moldova Turkey Slovakia Austria England and Wales (NJR) Lithuania France Portugal Netherlands Italy
1975 1979 1980 1987 1995 1997 1998 1998 1999 2000 2001 2001 2002 2002 2002 2002 2003 2005 2006 2006 2006 2006 2006 2006 Submitted for agreement 2008 2008 2008 2006
Nationwide Nationwide Nationwide Nationwide Nationwide Nationwide Nationwide Incomprehensive Nationwide Nationwide Incomprehensive Nationwide Incomprehensive In reorgansiation Nationwide Pilot phase Nationwide Pilot phase Pilot phase Pilot phase Pilot phase Inhomogenous according to the development in the regions Project Project Project
Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No
Croatia Bulgaria Germany
Active Active Active Active Active Active Active Active Active Active Active Active Active In reorgansiation Active Active Active Pilot phase Pilot phase Pilot phase Pilot phase Regional registers to be combined Project Project Project Pilot phase Pilot phase Project Pilot project
Pilot phase (30% coverage) Pilot phase Project Pilot project
No No No No
Switzerland Israel Luxembourg Spain
No No No
a
Deadline, 1 Jan 2009
commitment of those involved. Under the prevailing circumstances, particularly the solution of data privacy issues and achieving completeness in data collection can only be handled in co-operation with Institutions pertaining to the public health sector. Furthermore, longterm funding of a high-quality national register through a professional association or academic institution alone has proved difficult. 2. A professional, central structure should be available for data collection and evaluation in order to be able to meet the manifold requirements in an appropriate way. 3. The specific implementation is strongly dependent on the legal framework, particularly with regard to data protection. In some countries there are very stringent restraints
concerning the collection and evaluation of personal data. Usually these countries possess public health institutions holding the necessary authorisations. 4. Task assignment within the central register organsiation should take into account the main areas of expertise of the individual partners. Public health institutions, such as the BQS in Germany or STAKES in Finland, possess high technical and organisational skills regarding data collection and evaluation, and in initiating feedback mechanisms, which have proved essential for the success of the Scandinavian Registers. Science-oriented institutions, such as the Universities of Gothenburg, Lund or Bergen, are also capable of providing highly professional work; however, adequate and long-term funding should
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be guaranteed. Experience has shown that this is generally difficult in the critical start-up phase of register projects, and that projects of this kind often depend on the strong, voluntary and time-consuming commitment of the persons involved. 5. Data interpretation should involve professional specialists. These experts should be authorised by way of nomination by the scientific professional associations concerned. The delegated expert group should consist of experienced and esteemed executive members of the professional associations and of younger colleagues. During the start-up phase of a register it is often underestimated that the need for basic work such as literature research or detailed evaluations increasingly rises in the course of time. Established staff members, who usually have a variety of other responsibilities, will hardly be able to personally do this kind of work. The selection and training of staff as regards the very specific handling of register datasets takes time, and younger members of such committees should be given the opportunity gain the association’s confidence for handling sensitive data. The prospect of high-level publications on the basis of register data usually represents an adequate factor of motivation for qualified colleagues. 6. The close involvement of professional associations is a central point in putting the knowledge gained into practice and thus increasing the potentials for improvement. Intensive feedback mechanisms and scientific discussions within the framework of regular congresses and special meetings are essential in order to approach physicians with the findings and to foster implementation in their everyday decisions in the treatment of patients. The sole publication of reports or one-sided communication through public health Institutions is insufficient.
Registers in Orthopaedics There are perhaps several favourable circumstances that make registers more successful in arthroplasty than in any other field of medicine. (a) Serious problems of an arthroplasty to a high percentage lead to revision, and nearly every revision has to do with a problem of or at the implant. (b) Every operation, no matter if primary or revision, usually involves good documentation comprising all important contents of a register so that the documentation can easily be integrated into the daily working routine.
N. Böhler and G. Labek
(c) The contents to be documented in successful registers barely leave any scope for subjective interpretation. The time or method of documentation is thus less sensitive than it would be with clinical scores, for instance, that involve a high subjective portion of questions. The long-term result is the most important parameter for the success of an operation so that the longitudinal registration of patients – as held in a register – is superior as compared to cross-sectional evaluation. Therefore evaluations from arthroplasty registers are focussed on survival rates. Other contents that are also important in assessing the success of an operation, subjective patient satisfaction, for instance, can also be investigated in close connection with register documentation. However, their registration is organised differently from the registration of key contents. The simultaneous use of different documentation systems may produce essential progress if employed supplementarily [19–23].
Basic Principles in Interpreting Register Data of Other Countries EAR is engaged in methodological research in the medical device sector with the objective of improving the benefit for the users. In evaluating register data the following aspects should be taken into account: 1. In its basic data, a National register reflects the National standards and circumstances characterising the public health system of a country. This allows for consideration of the particular factors of influence even in compact questionnaires as long as one sticks to the respective area. The datasets of a register also reflect a complex sequence of treatments in which the implant only represents one part. For example, in the Norwegian Register the cemented SP stem showed a significantly inferior performance than the average. All revisions could be traced back to one single hospital [24]. Statements of this kind may be lost in evaluations for annual routine reports. As the primary purpose of a National arthroplasty register is quality improvement in the National surgical performance and a broad International discussion of such cases does not promote co-operation on the national level, it is not sensible to consider such findings in the annual report of a National register. The mechanisms that make register data very valid on a National scale may lead to wrong conclusions in the individual case if the National circumstances are ignored.
Current Status of Arthroplasty Registers in Europe
Evaluations from aggregated, multi-National datasets lack direct connection to the general situation and are thus not suited for conclusions on a national level. Therefore, as long as data are available from a National register, these data will always have to be regarded superior for conclusions on a National scale. However, National registers are limited. The use of implants differs significantly in different countries. The validity of statements principally depends on the size of the sample. The Inter-OP cup, which was taken from the market because of a production error resulting in lubricant residues at the surface and lacking osteointegration, served as an example for calculating an estimate: It was carried out by means of the Fischer’s Exact Test with the usual α error margin of 0.05 and a β error margin of 0.2 to find out how many implants a year would be necessary to be able to rapidly record serious problems in an efficient register. When the first US press articles suggested increasing loosening of the implant an extraordinary evaluation of the datasets of the Swedish Hip Register was carried out. With 30 primary implants, already five revisions were documented after 1.5 years. The revision rate of 16.7% was significantly above average. Assuming a revision rate of 17% with a comparative value of 1% on the general average 54 primarily-treated patients would be necessary to achieve statistical significance. Even with an assumed comparative value of 5% – as an assumption for a compromised dataset in an ad hoc evaluation – only 117 patients would be required to make a register an effective early warning system. The estimate that 100 patients per year would be a sufficient sample for the registration of serious problems therefore seems to be plausible. In the Swedish Hip Register [25], however, only 11 cup and 7 stem implants reach this limit. Even if these implants represent the major market share with 88% and 87% a multitude of implants, revision implants, or newly introduced systems that are registered less frequently cannot be sufficiently controlled in the National register of a mediumsized country. In these cases aggregated datasets may offer valuable additional data. Moreover, the effects of National health systems, which differ greatly in Europe, on long-term results can only be compared through supra-National evaluations. At present it is a common practice that implant producers internationally do not clearly assign a product name to a particular implant. Very similar designations are used for different products in different countries. This practice does not only impede the unambiguous assignment of products for register
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publications but is also problematic for the web-based search of literature and for meta-analyses. A fundamental change of these marketing mechanisms cannot be expected. However, the problem can be solved by referring to the product number. This requires a complete and continuously updated list of all products – including product number, product designation, and country – that can be extended by specific product information and categorisation. Thus product registration for registers could be carried out by means of the usual bar code scanners. 2. In order to increase the value of National register reports outside the original country standardisation in certain parameters and definitions would be desirable. As an alternative they could be summarised in supra-National reports according to internationally concerted guidelines. At present, such standardisation does not even exist in Scandinavia [26].
Benefits the Individual Surgeon Can Derive from Registers 1. Arthroplasty registers compile valid information of high accuracy enabling the surgeon to re-consider individual decisions with regard to the outcome and adjust them accordingly. 2. Implants and surgical techniques can be evaluated faster and more accurately, thus allowing for quicker and more target-oriented implementation of improvements in everyday clinical practice. 3. Within the scope of the EUPHORIC (www.euphoricproject.eu) EU project the validity of different scientific data sources was checked against each other. The results were surprising, to some extent alarming. (a) With regard to the revision rate, meta-analyses in clinical sample-based literature show a statistically significant deviation from register data. (b) Authors of implants are clearly over-represented in the scientific literature, most of them show a statistically significant bias. (c) Even studies of high quality according to the current criteria show a significant bias. This observation could be explained by the fact that the high validity of prospective randomised trials is based on ensuring blinding and the un-influenced decision of the examiner. These objectives can well be realised in testing pharmaceuticals; for surgical interventions, however, this is associated with considerable restrictions.
8
N. Böhler and G. Labek
In summary, sample base studies are subject to a clear bias, the value of comprehensive data collections is significantly higher. Four questions are of prime importance to assess the validity of comprehensive datasets: 1. Are the data specifically collected for the purpose the evaluations are going to be made for? If this is not the case, as for instance with discharge records used for outcome-associated purposes, this leads to a decrease in the validity of statements. 2. In which geographic area are the data collected? 3. Are the data complete? Particular importance should be accorded to the question whether patients can undetectedly pass the borders of the areas of collection, e.g. whether the primary operation has been recorded in the dataset while revisions remain undetected. 4. Are the datasets relevant for the purpose of the evaluation? A structured representation of these results can be provided by means of a matrix. The basic aim of the issue can be indicated in the first vertical line, the values referring to the individual dimension can be given in the following lines, with 1 being the highest qualitative value.
Description of Dimension Aim/purpose
Outcome (A)
Process (B)
Structure (C)
Conformity between aim of data collection and aim of evaluation
Data collection performed for the specific purpose of evaluation (1)
Data collection not performed for the specific purpose of evaluation (2)
Coverage
Nationwide (1)
Regional (2)
Local (3)
Data collection
Comprehensive (1)
Incomprehensive (2)
Sample based (3)
Conformity dataset for assessment
Representative (1)
Not representative (2)
For questions referring to the outcome of an implant in a certain country a complete National arthroplasty register of the same country would be described: A.1.1.1.1 If the same dataset was used for the evaluation of another country, the description would read: A.1.1.1.2 If the basic dataset for the same question was taken from incomplete discharge records of a certain region of another country, the description would be: A.2.2.1.2
Discussion The quality of national arthroplasty registers is welldocumented. However, the complex structure of a register makes it very difficult for individuals or small groups to introduce these valuable instruments. Putting them into practice can be positively influenced by forming a network for mutual support enabling the participants to take advantage of the experiences, results, and learning processes in other countries. Even concentrating on adapting successful attempts to one’s National health system is an extremely difficult task. For those responsible for the project it will be essential to receive support from the National experts association. The co-operation with public health authorities will also substantially decide on the success of arthroplasty registers, even if organisational details may differ greatly. Moreover, integrating Orthopaedic expertise is not only essential for data interpretation. Orthopaedists are also the main target group for the results as they are chiefly responsible for implementing the findings in practice. This strong position within the register organisation should be made clear to the other partners and requires an engaged group of physicians supported by the mandate from their National professional association. This group should be stable for a longer period of time in order to gain the necessary detailed expertise, and it should consist of accepted specialists willing to spend a lot of time and energy on the project. It has proven worthwhile to have both in the team, experienced and generally accepted orthopaedists as well as young colleagues. Register staff have access to raw data of high quality and significance. The greatest importance must thus be attached to the fact that any evaluation, communication, and publication must be independent and sufficiently detached from all partners. Manipulative statements have to be avoided at all cost, as they could do great harm to the register as a valid instrument. Critical examination should precede any decision about which contents should be made available to the public and which part of the information should be discussed within a closed circle of experts. Evaluating results without considering the circumstances under which they have been obtained may lead to misinterpretation. The training of physicians or the complexity of the operation based on the diagnosis influences revision rates. Departments with a higher proportion of training tasks and, on average, more difficult initial situations will therefore implicitly have to expect a worse outcome in register data; however, it would be wrong to automatically conclude from this that their performance is generally worse. Being authorised by their professional association places those responsible for a register under an obligation to act
Current Status of Arthroplasty Registers in Europe
independently and thus represents a control mechanism which is exerted by the specialists as a whole. It is an essential advantage of register results that the bias – which in clinical studies carried out on the basis of samples can be reduced but can never be totally avoided – is significantly lower through referencing to the entire population. However, this advantage is only valid in full if you are working within the closed system. Transferring results to other countries may lead to misinterpretation. The development of National registers over the last decade will change the quality of information available to the individual physician as a basis for his decisions. Register publications will increase. From a global view, the precise description of the circumstances under which the results have been obtained will be difficult because of the variety of factors of influence. Efforts to simplify the comparison of National register results are most advisable. In co-operation with all National Registers and by fostering and developing arthroplasty registers, the European Arthroplasty Register project of EFORT will do its best to make a contribution to an improved treatment of patients.
Acknowledgements We thank all surgeons participating in arthroplasty registers. The success of every register depends on the willingness to collaborate in documentation and quality improvement. We thank the members of all National Registers for their cooperation and their support of colleagues in all European countries. We thank EFORT for supporting our work through the large network of orthopaedists, their comprehensive knowledge, and the variety of ideas initiating fruitful discussion. We thank those scientists, such as Prof. Heino Kienapfel and Dr. Ingeborg Lang, who have been trying with great commitment to build up registers and have also reappraised and published problems and set-backs in a most serious scientific way. In doing so they have made a major contribution to the further development of registers in general and have helped to avoid mistakes.
References 1. Robertsson, O. Knee arthroplasty registers. JBJS-B 2007; 89-B:1–4. 2. Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement: A review of the Swedish THR Register comparing 160,000 cases. Acta Orthop Scand 2000;71–2:111–21.
9 3. Herberts P, Malchau H. How outcome studies have changed total hip arthroplasty practices in Sweden. Clin Orthop 1997; 344:44–60. 4. Malchau H, Garrellick G, Eisler T, Karrholm J, Herberts P. Presidential guest address: The Swedish hip registry: Increasing the sensitivity by patient outcome data. Clin Orthop 2005;441:19–29. 5. Havelin LI, Engesaeter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian arthroplasty register: 11 years and 73,000 arthroplasties. Acta Orthop Scand 2000;71(4): 337–53. 6. Robertsson O, Dunbar MJ, Knutson K, Lewold S, Lidgren L. The Swedish knee arthroplasty register. 25 years experience. Bull Hosp Jt Dis 1999;58(3):133–8. 7. Lucht U. The Danish hip arthroplasty register. Acta Orthop Scand 2000;71(5):433–9. 8. Puolakka TJ, Pajamaki KJ, Halonen PJ, Pulkinen PO, Paavolainen P, Nebelainen JK. The Finnish arthroplasty register: Report of the hip register. Acta Orthop Scand 2001; 72(5):433–41. 9. Furnes A, Lie SA, Havelin LI, Engesaeter LB, Vollset SE. The economic impact of failures in total hip replacement surgery. The Norwegian arthroplasty register 1987–1993. Acta Orthop Scand 1996;67:115–21. 10. Robertsson O, Lewold S, Knutson K, Lidgren L. The Swedish knee arthroplasty project. Acta Orthop Scand 2000; 71(1):7–18. 11. Furnes O, Lie SA, Havelin LI, Vollset SE, Engesaeter LB. Exeter and Charnley arthroplasties with boneloc or high viscosity cement. Comparison of 1127 arthroplasties followed for 5 years in the Norwegian arthroplasty register. Acta Orthop Scand 1997;68:515–20. 12. Espehaug B, Halelin LI, Engesaeter L, Vollset S. The effect of hospital-type and operating volume on the survival of hip replacements – A review of 39,505 primary total hip replacements reported to the Norwegian arthroplasty register, 1988–1996. Acta Orthop Scand 1999;70(1):12–18. 13. Pitto RP, Lang I, Kienapfel H, Willert HG. The German arthroplasty register. Acta Orthop Scand Suppl 2002;73(305): 30–3. 14. Pedersen AB, Johnsen SP, Overgaard S, Soballe K, Sorensen HT, Lucht U. Registration in the Danish Hip arthroplasty registry: Completeness of total hip arthroplasties and positive predictive value of registered diagnosis and postoperative complications. Acta Orthop Scand 2004;75(4):434–41. 15. Arthursson AJ, Furnes O, Espehaug B, Havelin LI, Soreide JA. Validation of data in the Norwegian arthroplasty register and the Norwegian patient register: 5,134 primary total hip arthroplasties and revisions operated at a single hospital between 1987 and 2003. Acta Orthop 2005;76(6):823–8. 16. Espehaug B, Furnes O, Havelin LI, Engesaeter LB, Vollset SE, Kindseth O. Registration completeness in the Norwegian arthroplasty register. Acta Orthop 2006;77(1):49–56. 17. Robertsson O, Dunbar M, Knutson K, Lewold S, Lidgren L. Validation of the Swedish knee arthroplasty register: A postal survey regarding 30,376 knees operated on between 1975 and 1995. Acta Orthop Scand 1999;70(5):467–72. 18. Sodermann P, Malchau H, Herberts P, Johnell O. Are the findings in the Swedish National total hip arthroplasty register valid? A comparison between the Swedish National total hip
10 arthroplasty register, the National discharge register, and the National death register. J Arthroplasty 2000;15(7):884–9. 19. Garrelik G, Malchau H, Herberts P. Survival of hip replacements. A comparison of a randomized trial and a registry. Clin Ortho 2000;(375):157–67. 20. Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H. Chronic pain following total hip arthroplasty: A nationwide questionnaire study. Acta Anaesthesiol Scand 2006;50:495–500. 21. Robertsson O, Dunbar MJ, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: A report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acat Orthop Scand 2000;71(3):262–7. 22. Robertsson O, Ranstanm JP. No bias of ignored bilaterality when analysing the revision risk of knee prostheses: Analysis of a population based sample of 44,590 patients with 55,298 knee prostheses from the national Swedish knee arthroplasty register. BMC Musculoskelet Disord 2003;4:1.
N. Böhler and G. Labek 23. Espehaug B, Havelin LI, Engesaeter LB, Langeland N, Vollset SE. Patient satisfaction and function after primary and revision total hip replacement. Clin Orthop 1998; 351: 135. 24. Havelin LI, Espehaug B, Lie SA, Engesaeter LB, Furnes O, Vollset SE. Prospective studies of hip prostheses and cements. A presentation of the Norwegian arthroplasty register 1987–1999. Scientific exhibition presented at the 67th Annual Meeting of the American Academy of Orthopaedic Surgeons, March 15–19, 2000, Orlando, USA. 25. Annual Report 2005. http://www.jru.orthop.gu.se/ (accessed 29/01/2007). 26. Lohmander LS, Engesaeter LB, Herberts P, Ingvarsson T, Lucht U, Puolakka TJ. Standardized incidence rates of total hip replacement for primary hip osteoarthritis in the 5 Nordic countries: Similarities and differences. Acta Orthop 2006; 77(5):733–40.
National Registration of Hip Fractures in Sweden Karl-Göran Thorngren
Development of the National Registration RIKSHÖFT In Sweden there has been developed registers for conditions which have large socio-economic importance both concerning high number of patients as well as a great need for use of resources. The first national registers were created within the area of orthopaedics initiated by Professor Göran Bauer in Lund. He started the Swedish Knee Arthroplasty Register 1975 and then the Swedish Hip Arthroplasty Register was started 1979. In the beginning it registered only reoperations and from 1992 onwards also person linked information about primary hip arthroplasties was collected. The Swedish National Hip Fracture Registry called RIKSHÖFT [1] was started by the author in 1988. The arthroplasty registers deal with information concerning a procedure whereas the hip fracture register in addition to the fracture type and type of operation also deals with information about the patient, function and social conditions, making it a disease register. Based on the experience of the orthopaedic registers successively more registers have been introduced within other medical fields. Swedvasc, the registry for peripheral vascular surgery, was started 1987 as the first non-orthopaedic register. During the 1990s several registers have been started such as RiksStroke, the national quality register for stroke, which was started in 1994. Other examples of registers are the Swedish coronary angiography and angioplasty register as well as the registry on cardiac intensive care, RIKS-HIA. During the last decade the national quality registers have after application received grants yearly from the Swedish National Board of Health and Welfare together with the Swedish Association of Local Authorities and Regions. The latter has taken over the central administration of the quality
Karl-Göran Thorngren Department of Orthopaedics, Lund University Hospital, SE-221 85 Lund, Sweden e-mail:
[email protected] registers since 1 January 2007. All applications are evaluated by a Scientific Advisory Committee to guide the decisions of the Executive Committee composed by representa tives from the Swedish Association of Local Authorities and Regions, the National Board of Health and Welfare, the Swedish Society of Medicine and the Swedish Society of Nursing. In 2008 in total 64 national quality registers received economic support in this way. There are also 18 different national cancer registers usually supported by grants from the Swedish cancer foundation. Areas with more rare diseases and smaller volumes to register are usually covered by research registers supported by specific research grants. These often have higher level of details in the registration with many parameters. To continuously register disease groups on a national level or to register procedures with large patient volumes, demands a small amount of well chosen parameters, so the registration can be complete. One particular factor that facilitates registration in Sweden is the system with national personal identification numbers, which makes it possible to trace patients through the medical system from birth to death. Supported by law the Epidemiological Centre at the National Board of Health and Welfare has registers for statistical use such as the patient register for all in hospital care with diagnoses and operative procedures according to ICD 10, the medical birth register, the cancer register and the pharmaceutical register. They are also responsible for the register concerning dates and causes of death. Since 2006 the Swedish Association of Local Authorities and Regions is publishing a yearly report with open comparisons at regional or hospital level of some key factors from the National Quality Registers. The National Quality Registers have been created by the medical profession which continues to handle the development and analyses of the registers. Within the sector of health care administration there has been a development of systems to follow the activity from economical and personnel administrative aspects. They have not developed registration systems concerning the work with the patients. The traditional patient filing systems have not made it possible
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to compile and analyse data easily. Thus, there is a need for special diagnose related registers.
Hip Fracture Demographics The treatment of elderly patients with orthopaedic problems is dominated by the demand both from the elderly and from the society that they should be able to live an independent, mobile and pain free life [2–5]. In Sweden at the age of 50 years the risk to sustain a hip fracture is 23% for women and 11% for men during the remaining life time. Hip fracture belongs to the most resource consuming groups within health care. All these patients need operation and hospital treatment. They consume 25% of all bed days in hospital for orthopaedic diseases. Due to the increasing amount of elderly in the population the amount of hip fractures is increasing. At present the hip fracture care in Sweden costs 1.5 billions Swedish Crowns yearly. The RIKSHÖFT aims at optimising all aspects of patient treatment. The aim is to create a high and evenly distributed quality of care all over the country. RIKSHÖFT is also a basis for local development projects. Also the reorganisations after administrative decisions with changed patient flow between hospitals and cities find through RIKSHÖFT a form to be evaluated. The awareness of results leads to improved treatment and more effective cost utilisation. During 1995–1998 RIKSHÖFT was spread in Europe with a project supported by grants from the European Commission. This registration was called SAHFE (standardised audit of hip fractures in Europe) [6]. Also other international registration has started [7–9].
Karl-Göran Thorngren
years has now risen to 83 years. Half (48%) of the patients are living alone. There is a slight tendency to diminished living alone since 1999 (Fig. 1). Continuing during the 1980s and the beginning of 1990s the mean hospital treatment time in the operating departments has successively decreased. In 1988 the mean hospitalisation time was 19 days for hip fractures in Sweden. Since 1996 it has been around 11 days with only small changes over the years for the mean hospitalisation time whereas the median hospitalisation time has been constant. In 2007 the mean hospitalisation time was 10.7 days and the median hospitalisation time 9 days. The waiting time from admittance to the hospital until performance of the operation was in 2007 mean 1.2 days and median 1 day (Fig. 2). The lowered mean hospitalisation time during the last years has been possible without lowering the percentage of patients admitted from the acute hospital to their original form of living as they had before the fracture. It has been fairly constant around 50% during the last 10 years. Shortened time in the hospital has previously been related to a greater amount of patients being sent to secondary rehabilitation in some institution instead of primary rehabilitation in the form of living they had before the fracture. Thus, during the last 15 years the hip fracture care in Sweden has been optimised through diminished mean hospitalisation times in the acute hospital combined with a high number of patients possible to return to original place of living (Fig. 3). This evolution is obvious when separate departments in Sweden are compared. In the diagrams below each dot 100 90 80 70
National Data 2007 Hip fractures are predominant in elderly persons due to increasing osteoporosis and falling tendency by age. A hip fracture below 50 years of age is unusual (less than 3% of the total in RIKSHÖFT) and usually caused by severe trauma, like traffic accidents or fall from heights. The elderly person is usually falling on the floor when walking or raising from a chair. In the figures below therefore only patients of age 50 years and above are included. Osteoporosis is very common among the elderly patients. The small number of patients with other pathological change of the skeleton, e.g. metastatic fractures, have been excluded in the analysis. In 2007 in Sweden the patients consisted of 70% women and 30% men. Mean age which in the middle of 1990s was 81
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Fig. 1 Mean age, percentage of women and living alone before the hip fracture
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Fig. 3 Mean time in acute hospital (orthopaedic department) and percentage of patients discharged from there directly to original place of living
represents a hospital. During the years 1988–1990 no hospital had mean hospitalisation time below 10 days and there was a broad range of values up to 27 days (Fig. 4). In 2007 no department has a mean hospitalisation time over 20 days and the majority had a mean hospitalisation time between 6 and 12 days. One department with an
extremely short mean hospitalisation time of 1.2 days combine this by sending 100% of the patients to rehabilitation or other type of institutional care. The policy in Sweden for the departments is to send as many patients as possible to their original place of living with as short hospitalisation time in acute care as possible. Some few hospitals are primarily treating the hip fracture patients directly in a geriatric ward with the orthopaedic surgeon more as a consultant. They have a mean hospitalisation time and percent of patients directly returning home to original living equal to the majority of the orthopaedic departments. In total the comparison of the two periods shows a considerable reduction of the amount of bed days needed to treat the hip fracture patients. The fracture types have shown a stable pattern during the last years. From the medical point of view this is natural as no sudden changes in the falling tendency or grade of osteoporosis is to be expected among the patients. It also shows that the classification system is reproducible on a large scale with
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Fig. 5 Types of hip fracture
well defined groups. In 2007 there were registered in Sweden 15% undisplaced cervical hip fractures, 36% displaced cervical, 3% baso-cervical, 24% trochanteric two-fragment fractures, 14% trochanteric multi-fragment fractures and 8% subtrochanteric hip fractures (Fig. 5). The type undisplaced cervical (femoral neck) fractures comprises Garden types I + II. The type displaced cervical hip fractures comprises Garden types III + IV. Two types of primary operations for cervical (femoral neck) fractures are predominating. One is osteosynthesis with two hook pins or screws. The other is to substitute the proximal end of the femur with an arthroplasty. In Sweden beginning 1999 there has been performed a successively increasing amount of primary hemi/bipolar hip arthroplasties for the displaced cervical fractures. The number of total hip arthroplasties is comparatively constant. For per-trochanteric fractures screw plate is still the most common operation method. A small fraction of intramedullarly nails is increasing since the millennium change (Fig. 6). For all hip fractures comparing 1996–2007 the primary hemi-arthroplasties have increased from 2.1 to 25%. If also the total hip arthroplasties are included the increase of arthroplasties from 1996 to 2007 is from 5.4 to 30%. At the
2002
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Year Total hip arthroplasty Screw, pin or nail with sideplate Intramedullary nail Other operation Not operated
Fig. 6 Operation methods used for all hip fractures
same time the use of two hook pins/screws have diminished from 45.2% in 1996 to 20% in 2007. The use of three screws has ceased. There is a small increase in the number of total hip arthroplasties from 3.3% 1996 to 5% 2007. During the last 4 years the change seems to have levelled off. There is an optimal balance between primary osteosynthesis and primary arthroplasty if consideration is taken to the stress by the operation on the patient and the resource utility at the different types of primary operations as well as the amount of complications and reoperations needed. The future will show when this level has been achieved. For the undisplaced cervical hip fractures (Garden I–II) osteosynthesis is the predominant primary method in accordance with the good healing prognosis for these fractures. They have no or very little displacement which has given little damage to the blood circulation to the femoral head. The use of arthroplasty 1998 was for these fractures 0.4% hemi-prostheses and this had increased to 8% in 2007. The summarized use of arthroplasty including hemi-prostheses and total hip prostheses was 1.5% in 1998 and had increased to 11% in 2007. For the displaced cervical hip fractures (Garden III–IV) the use of hemi-prostheses was 3% in 1998 and in 2007 it had increased to 63%. The use of total hip arthroplasty for
National Registration of Hip Fractures in Sweden
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% 50 40 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
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Total hip arthroplasty
Fig. 7 Operation methods used for displaced, cervical (femoral neck) fractures. The top unmarked area comprises other osteosynthesis types 100 90 80 70 60 % 50 40 30 20 10 0 1996
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Walked alone out of doors Walked out of doors only if accompanied Walked alone indoors but not out of doors Walked indoors only if accompanied Unable to walk Unknown
Fig. 8 Walking ability before the hip fracture
the displaced cervical fractures has been fairly constant around 10%. In 2007 it amounted to 13%. The summarized use of hip arthroplasty including hemi- and total was 12% in 1998 and had increased to 76% in 2007 (Fig. 7). For the trochanteric hip fractures a screw plate is the dominating operation method. In 1998 the trochanteric two-fragment fractures were in 91% operated with a sliding screw and plate and this has slowly diminished to 84% in 2007. The trochanteric multi-fragment fractures were operated with screw plate in 86% of the cases in 1998 and this had diminished to 57% in 2007. Arthroplasty is not the first hand choice for the trochanteric hip fractures unless in some extreme exceptional case. Intramedullarly nails have increased successively since the millennium change. In 2002 for the trochanteric two-fragment fractures they amounted to 3% and for the multi-fragment fractures 15%. In 2007 12% of the two-fragment fractures and 39% of the multi-fragment fractures were operated with a proximal femoral nail. The baso-cervical fractures constitute a transition form between cervical and trochanteric hip fractures. From the stabilisation aspect they are usually operated with a screw plate. Some times the vascular damage to the femoral head leads to pseudarthrosis or femoral head necrosis which makes them more similar to cervical hip fractures. In 2007 11% of the baso-cervical hip fracture patients were operated with two pins/screws, 68% with a screw plate, 3% with other type of osteosynthesis, 12% with hemi-arthroplasty and 4% with total hip arthroplasty. Subtrochanteric hip fractures go by definition as far as 5 cm below the minor trochanter. If they go further they are considered a femoral shaft fracture. The sub-trochanteric fractures are often more multi-fragmented and unstable. In 2007 they were operated with a screw plate in 27%, with a intra medullarly nail in 67%, with other osteosynthesis in 2%, hemi-arthroplasty in 1% and with total hip arthroplasty in 1%. The walking ability for the hip fracture patients shows mainly the same pattern during the last couple of years. More than half of the patients (58%) could before the fracture walk alone outdoors with a slight tendency of increase during recent years. A further 7% could walk outdoors if somebody accompanied them. The rest of the patients could walk indoors except 3% who could not walk at all before the fracture (Fig. 8). The patient’s general walking ability gives a picture of the stability of the hip and the lack of pain as well as the general condition of the patient. The change in choice of
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Fig. 10 Walking aids normally used before the hip fracture occurred
Fig. 9 Walking ability at 4 months after hip fracture 100 90
operations has consequently not in any major way influenced this functional level. There is however a tendency that somewhat more patients can walk alone outdoors at 4 months after the hip fracture with a slight increase from 31% in 1996 to 39% in 2007 (Fig. 9). To evaluate walking ability the walking aids are commonly used as indicator. Before the fracture there is a trend from 1996 until 2000 that an increasing amount of elderly are using rollator whereas the fraction who did not use any walking aids or only one stick have diminished. To use two sticks or walkers before the hip fracture is unusual. The percentage of patients using a wheel chair or not walking at all before the fracture was unchanged around 5% during this period (Fig. 10). At 4 months after the operation the use of walking aids for the hip fracture patients when they walk indoors has shown mainly the same pattern during the last years. There is a tendency to increased use of rollators from 2000 which has then levelled off mirroring the prefracture increased use of rollators. At the same time the group with good walking capacity i.e. walking without aids or with only one stick as well as the group who cannot walk at all have diminished somewhat (Fig. 11).
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Fig. 11 Walking aids normally used at 4 months after the hip fracture occurred
National Registration of Hip Fractures in Sweden
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Motivation
Computing and Feed Back
It is necessary to build up registers that can be prospectively used over many years and that will facilitate the daily work. Motivating the different departments to participate is of vital importance [10–12]. Motives differ in different places and times. The first major motive is the facilitation of everyday routine medical work. The audit form can be used as a standardised party of the patient’s file, thereby simplifying routines. Less unstructured type-written text and thereby less secretarial work is needed. It is also easier to find the information in the file at a later date, e.g. at outpatient follow up visits. It can also be retrieved by computers. The second main motive is its usefulness for administrative purposes, e.g. yearly activity reports, to support resource claims in discussions with administrative authorities and to receive funding. The third motive is scientific. Centrally, the large amount of prospective standardised material provides possibilities for the analysis of the overall panorama of hospitals, diagnoses and modes of treatment. It also provides unique possibilities for studying special rare indications that need the multi-centre approach to collect enough material. Locally, it is possible to use the audit forms as a basis for a study, e.g. comparison between two operation methods, introduction of new types of rehabilitation and so forth. The motivation is especially strong when someone can use the register for his/her thesis work.
The use of PC programs and handling of data on desk top computers, were early used by the Swedish Hip Fracture Register RIKSHÖFT which is now using direct on line web registration accessible through its home-page www.rikshoft.se. The possibility for the participating centres to make their own calculations on their data is important. Permits for the registration from the Swedish Data Inspection have been given. Access to the data is limited on several levels of aggregation to protect individual patients. Feedback to the participants with regular reports containing their own data as well as comparative mean values for the whole country is necessary. The hip fracture register makes a yearly report. To keep the enthusiasm for the project on a high level, regular discussion meetings are required, e.g. in connection with the Swedish Orthopaedic Societies meetings.
Performance In RIKSHÖFT detailed functional parameters are registered, as this is important in the short-term perspective of these elderly patients. Previous studies have shown that over 80% of the complications needing reoperation occur within 2 years after the hip fracture. The registered hip fracture patients also have a considerable mortality with time due to high mean age and concomitant diseases [13–15]. In Sweden all persons have a social security number e.g. 050315-1649. This person was born as child number 164 in Sweden on the 15th of March 1905. The last digit is a control based on the other digits. Due to this social security number, which is unique to the person, it is possible to trace the patient. The number is generally used for all kinds of identification in Sweden. This is a great advantage when checking data with files from different departments and when patients change their address.
Funding Great amounts of energy and idealism are necessary to start a large-scale registration project. Furthermore, economic resources are necessary to print forms, to communicate with the other centres and to register data on computer, as well as to do calculations and print reports. The Swedish Medical Research Council has funded this project during the initial years. From 1990 the Swedish Government has decided to fund the national registers, which are still to be run at the original centres. It has been decided to be advantageous that the profession itself outlines the guidelines for a register and keeps it running. The goodwill and enthusiasm of the orthopaedic community has been the basis for managing the Swedish audit projects.
References 1. Thorngren K-G. Experience from Sweden. In: Medical Audit. Rationale and Practicalities. Cambridge University Press, New York, 1993, pp 365–75. 2. Berglund-Rödén M, Swierstra B, Wingstrand H, Thorngren K-G. Prospective comparison of hip fracture treatment, 856 cases followed for 4 months in the Netherlands and Sweden. Acta Orthop Scand 1994;65:287–94. 3. Thorngren K-G. Epidemiology of fractures of the proximal femur. In: J Kenwright, J Duparc and P Fulford (Ed.), European Instructional Course Lectures 1997;3:144–53.
18 4. Thorngren K-G. Standardisation of hip fracture audit in Europe. J Bone Joint Surg 1998;80-B(Suppl 1):22. 5. Kitamura S, Hasegawa Y, Suzuki S, Ryuichiro S, Iwata H, Wingstrand H, Thorngren K-G. Functional outcome after hip fracture in Japan. Clin Orthop Rel Res 1998;348:29–36. 6. Parker MJ, Currie CT, Mountain JA, Thorngren K-G. Standardized audit of hip fracture in Europe (SAHFE). Hip Int 1998;8:10–15. 7. Tolo ET, Bostrom MPG, Simic PM, Lyden JP, Cornell CM, Thorngren K-G. The short term outcome of elderly patients with hip fractures. Int Orthop (SICOT) 1999;23:279–82. 8. Heikkinen T, Wingstrand H, Partanen J, Thorngren KG, Jalovaara P. Hemiarthroplasty or osteosynthesis in cervical hip fractures: matched-pair analysis in 892 patients. Arch Orthop Trauma Surg 2002;122(3):143–7. 9. Cserhati P, Fekete K, Berglund-Rödén M, Wingstrand H, Thorngren K-G. Hip fractures in Hungary and Sweden – differences in treatment and rehabilitation. Int Orthop (SICOT) 2002; 26(4):222–8.
Karl-Göran Thorngren 10. Thorngren KG, Hommel A, Norrman PO, Thorngren J, Wingstrand H. Epidemiology of femoral neck fractures. Injury 2002;33(Suppl 3):C1–7. 11. Thorngren K-G, Norrman P-O, Hommel A, Cedervall M, Thorngren J, Wingstrand H. Influence of age, sex, fracture type and pre-fracture living on rehabilitation pattern after hip fracture in the elderly. Disabil Rehabil 2005;27(18–19): 1091–7. 12. Thorngren K-G. National registration of hip fractures. Acta Orthop 2008;79(5):580–2. 13. Thorngren M, Nilsson LT, Thorngren K-G. Prognosis-determined rehabilitation of hip fractures. Compr Gerontol 1988;2A(1):12–7. 14. Holmberg S, Kalen R, Thorngren K-G. Treatment and outcome of femoral neck fractures. An analysis of 2418 patients admitted from their own homes. Clin Orthop Rel Res 1987;(218):42–52. 15. Holmberg, S, Thorngren K-G. Rehabilitation after femoral neck fracture. 3053 patients followed for 6 years. Acta Orthop Scand 1985;56(4):305–8.
Current Status of Articular Cartilage Repair Emmanuel Thienpont
Introduction Articular cartilage injury is a common problem that is frequently encountered by practising Orthopaedic Surgeons [1]. Following a retrospective review of 31,516 knee arthroscopies, Curl et al., reported that cartilage lesions were present in 63% of the procedures [2]. More recently, Widuchowski et al., reported similar results, with chondral lesions found in 60% of 25,124 patients who underwent knee arthroscopies [3]. Importantly, both studies reported that patients with lesions had a mean age of approximately 40 years [2, 3]. As it is widely accepted that patients who experience a traumatic cartilage injury when they are young, have a high risk of developing osteoarthritis later in life, effective early treatment of symptomatic cartilage defects is vital to minimise the risk of degeneration of the damaged joint [4–6]. The treatment goals of articular cartilage defects in the knee include replacement, regeneration, or repair methods that result in hyaline tissue that integrates with native host tissue and functions durably under load and over time, and most importantly provides an asymptomatic joint [7–9]. The treatment of chondral defects is challenging, with repair techniques rapidly evolving. Due to its avascular nature and extracellular matrix structure, articular cartilage has a limited intrinsic capacity for healing after injury [1]. A variety of methods have been developed for cartilage repair, with the most recent treatments focussing on tissue regeneration [9]. These regenerative treatments aim to resurface the joint with new tissue that has the structural and mechanical properties of physiological hyaline cartilage [10]. Repair techniques routinely used in clinical practice include reparative or marrow stimulation techniques (MSTs) [9]. Autologous grafting procedures such as osteo-
chondral autologous transplantation system (OATS) and mosaicplasty can be considered as biologic replacements [9]. And more recently, autologous chondrocyte transplantation (ACT)/autologous chondrocyte implantation (ACI) could be seen as a first-generation regeneration technique [9]. In addition to these techniques, arthroscopic lavage, with or without debridement, is also common [9]. A number of factors, including the size and depth of the lesion, as well as patient characteristics such as age and activity level, influence the most appropriate choice of treatment [1, 9]. Several key components have been proposed as essential to optimize the production of new articular cartilage tissue [9]. The first component is a chondroprogenitor cell source for replication, biologic turnover and extracellular matrix production. Sources of chondroprogenitor cell lines include mesenchymal stem cells (MSCs), juvenile chondrocytes or differentiated chondrocytes (as in ACI) [9]. The second component is a porous scaffold to act as a delivery vehicle for the selected chondroprogenitors and to provide a unique 3D structure [9]. Scaffolds may be purely biological in nature (collagen, hyaluronate, alginate,…) whereas others are mineral-based (tricalcium phosphate, hydroxyapatite, calciumsulphate) and still others are carbohydrate-based (polylactide, polyglycolide,…) [9]. A final third component would include the use of bioactive factors that may be used to amplify cell expansion, strengthen phenotype, improve extracellular matrix production (anabolic agents and growth factors), and also reduce cell breakdown and catabolic degradation (catabolic inhibitors) [9, 11].
Arthroscopic Debridement Emmanuel Thienpont University Hospital Saint Luc, U.C.L., Avenue Hippocrate 10, 1200 Brussels, Belgium e-mail:
[email protected] Arthroscopic debridement is employed to remove loose cartilage that can mechanically impede joint function and cause inflammation [12–15].
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Mechanical overloading results in increased matrix metalloproteinase production which has a damaging effect on the surrounding cartilage [16, 17]. While the procedure provides symptomatic relief from pain, the missing cartilage is not replaced and clinical outcome significantly deteriorates by 5 years [18, 19]. Thus, in clinical practice, joint debridement is often combined with reparative techniques, such as drilling or microfracture (MF) [20]. A Cochrane review shows no benefit of arthroscopic debridement for undiscriminated osteoarthritis [21].
Reparative Techniques Reparative techniques, or MST, include subchondral drilling [22], abrasion arthroplasty [23] and MF [24]. The MF technique was developed in the 1980s by Steadman, and is now widely used [25–28]. MF involves perforating the subchondral bone with a number of holes, thereby triggering the release of bone marrow components such as stem cells, growth factors and cytokines into the defect [27, 29]. These components form a “superclot”, providing an enriched environment in which new fibrocartilaginous repair tissue is generated [27]. Published literature supports favourable outcomes for MF [30]; however, few randomised controlled trials (RCTs) comparing MF to other surgical techniques have been reported and limited long-term outcome data are available. Short-term clinical efficacy (i.e. 2–4 years after MF) has been demonstrated in several clinical trials, particularly in younger patients (age < 30–40 years) [24, 25, 29–31], active or athletic patients [24, 30, 32], patients with a low body mass index (BMI; 1 year >2 years >1 year >1 year ? >2 years ? >2 years >2 years >1 year ? ? >2 years 1 year 1 year 1 year 1 year
10/1,037 (1%) 2/91 (2.2%) 18/770 (2.3%) 3/136 (2.2%) 59/1,898 (3.1%) 0/21 (0%) 3/51 (6%) 6/1,515 (0.4%) 12/1,518 (0.8%) 90/3,781 (2.4%) 1/630 (0.2%) 2/306 (0.7%) 0/28 (0%) 1/49 (2%) 6/1,000 (0.6%) 2/2,023 (1%) 4/42 (9.5%) 16/395 (4%) 0/395 (0%) 10/160 (6%) 1/124 (1%)
Trans-trochanteric Lateral
Posterior
The two comparative studies used in the Cochrane assessment are quoted with (Cochrane)
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Infection In the Swedish hip arthroplasty register [51], the 2-year infection rate calculated on re-operations between 2003 and 2006 was 297/53,962 (0.6%). Phillips et al. [52] reported on an infection rate of 537/58,521 (0.9%) in primary THA of varying aetiology, fracture excluded, observation time 6 months. Concerning different infection rates in different approaches, Arthurson et al. [55] found no differences between approaches in their Norwegian register study. The number of revisions due to infection for Charnley prosthesis was 91/30,800 (0.6% in a 7-year observation period) with the lateral approach, 6/3,166 (0.2%) with the posterior approach and 10/4,642 (0.3%) for the trans-trochanteric approach, without statistical significance.
M. Krismer
usually refer to this position. Usually, the up, treated leg will appear slightly shorter than the down leg because it is in an adducted position. Using the posterior approach and lateral decubitus position, pre-operative templating and referencing the well leg intra-operatively, 20/410 hips showed a lengthening of 15 mm or more and 4/410 of 20 mm or more (1%) [65]. Malouny and Keeney [66] recommends several techniques. Before prepping and draping the leg the patient’s feet with symmetric knee flexion can be assessed. During the surgical procedure, one can measure the height of the osteotomy from the top of the lesser trochanter and perform the osteotomy at the level determined by pre-operative templating. After the trial reduction is performed, the surgeon can re-assess the relationship of the feet with the knees bent equally. As an additional crossreference, one can use the relationship of the tip of the greater trochanter with respect to the centre of the femoral head, both before and after femoral neck osteotomy, to assess restoration of leg length.
Outcome Studies related to minimally-invasive approaches are dealt with later in the text. Ritter et al. [45] compared the 81 patients operated with the lateral approach and 132 operated with the posterior approach. The HHS (Harris hip score) after 9–29 months was 93 ± 12 in the lateral group and 92 ± 10 in the posterior.
Leg Length Leg-length discrepancy is one of the most common complaints of patients after THA, and one of the most common reasons for litigation. It is relatively easy to determine leg length in a patient in supine position, palpating both medial malleoli and the superior border of both patellae. A technique leaving a part of the capsule in place helps also to avoid unintentional lengthening. The author is not aware of any comparative studies between different approaches on leg length discrepancies with sufficient statistical power. Horwitz et al. [30] found no differences in leg length between the trans-trochanteric and the lateral approach, based on a total of only 100 patients. The main reason may be that the difference between lateral decubitus and supine position is much more important than the difference between different approaches using the same position. In a lateral decubitus position lengthening is more likely. Descriptions for special techniques to avoid lengthening
Heterotopic Ossification Horwitz et al. [30] found 2/49 Brooker class IV ossifications in the lateral approach and 0/51 in the trans-trochanteric approach at 12 months. Moskal and Mann [44] found 0% Brooker class IV and 6% Brooker class III ossification in a modified lateral approach. Differences between approaches of minor Brooker degrees may occur, differences in class IV can only be detected using high numbers. No study with sufficient statistical power on this topic is known to the author of this article.
Implant Survival The influence of approaches on survival was studied in a study from the Norwegian arthroplasty registry [55]. The survival was the same for the lateral and the posterior approach. For the Charnley prosthesis, the lateral approach with trochanteric osteotomy was associated with a better survival than the lateral approach without trochanteric osteotomy.
Patient Preference Pagnano et al. [67] asked 26 patients who had received a bilateral THA using a 2-incision approach on the one side and a mini-posterior on the other side. 16/26 preferred the mini-posterior approach.
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Such comparative studies are interesting, but encounter considerably difficulties. The technical skills of the surgeons should be the same for both approaches. A comparison between an approach performed by a surgeon being in the learning curve for a new approach vs. the approach the surgeon used almost always during his professional life may reflect rather differences in skills than differences of the approach. Bilateral cases are much less frequent, so the number of observed cases does not allow decisive conclusions.
In a health technology assessment analysis, 9 randomised controlled trials and 17 non-randomised comparative studies were identified, comparing minimally-invasive with normal approaches [11], most of them on posterior approaches. Small peri-operative advantages concerning blood loss and operation time were found, and it may offer a shorter hospital stay and quicker recovery. Evidence on differences in longer-term performance is very limited.
Comparison Between Normal and Minimally-Invasive Technique in the Same Approach Minimally-Invasive Modifications Surgeons have not agreed on what “minimally-invasive” means. Perhaps the intention is meant to cause not more trauma than absolutely necessary to conduct an operation safely and in an acceptable time. Scar length is no criterion, although often advertised. A mobile window technique is typical for some procedures. As long as only the skin incision is reduced in length, and the underlying structures are treated as in a standard approach through a mobile skin window, a better outcome in comparison to a standard approach is not likely.
Outcome of various studies is quoted in Table 11. Several authors [70, 72, 76, 78] have used the posterior approach with a mobile window, dissecting the deep levels as in a standard approach. They could not demonstrate important differences between the MIS and the normal technique, with the exception of reduced blood loss. Laffosse et al. [22] used a modified posterior approach, where only the common tendon of gemelli and obturator internus was cut, and the prirformis tendon was cut and re-sutured, found that a better outcome of MIS could be achieved in the WOMAC total score: at 3 months with 89
Table 11 Comparison of WOMAC or HHS (Harris hip score) between MIS and conventional technique of the same approach
Lateral
Author
Difference of MIS vs. normal
N MIS / normal
Outcome parameter
FU time
MIS
Normal
p
Charles et al. [68] Asayama et al. [69]
Skin incision Skin incision, gluteus max. Skin incision, deep “identical” Incision of skin and fascia lata Skin incision Skin incision Skin incision Skin incision Skin incision, navigation Skin incision Skin incision Skin incision Skin incision, external rotators
16/19 52/50
WOMAC HHS
12 weeks >2 years
92 96
90 96
0.7 ns
30/30
HHS
6 weeks
71 ± 10
67 ± 12
0.2
107/108
WOMAC
6 weeks
74 ± 14
74 ± 13
0.5
27/29 60/60 ? 70/70 60/60 33/33
HHS HHS HHS HHS HHS
2 years ~1 years 2–3 years 6 weeks 1 year
94 95 93 91 96
94 93 91 95 94
ns ns 0.7 ns 0.08
109/56 20/14 37/39 58/58
SF-36 phys HHS HHS WOMAC HHS
>6 months >17 months 5 year 3 months
54 ± 4 99 87 ± 4 89 ± 11
56 ± 4 97 84 ± 6 84 ± 12
Sign 0.4 0.04 0.02
6 months 3 months 6 months
91 ± 12 87 ± 14 79 ± 21
84 ± 14 90 ± 12 83 ± 16
0.01 ns 0.06
De Beer et al. [21] Posterior
Ogonda et al. [70] Chimento et al. [71] Chung et al. [72] Kim [73] Ciminello et al. [74] Di Gioia et al. [75] Dorr et al. [77] Mow et al. [76] Wright et al. [78] Laffosse et al. [22]
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Table 12 Comparisons MIS vs. normal of different approaches MIS
Author
Normal approach
N MIS/normal
Outcome parameter
FU time
MIS
Normal
p
Anterior Antero-lateral
Zhang et al. [79] Wohlrab et al. [29]
Posterior Lateral
60/60? 20/20
HHS HHS
3 months 12 weeks
91 96
79 92
1 year HHS 3 months HHS 12 weeks
Anterior Antero-lateral
Pagnano et al. [67] Tanavalee et al. [81] Zhang et al. [79] Wohlrab et al. [29]
Posterior Posterior Posterior Lateral
26/26 35/35 60/60? 20/20
p
0.003 0.02 0.9 20°) there is a large slightly mobile osteophyte in this area that has to be carefully excised using sharp dissection. I now proceed to the anterior and posterior (AP) femoral cuts. I use the LCS which sets femoral rotation off the tibial axis. In severe varus I often do preliminary A-P cuts by cutting on top of the saw capture rather than through it which makes the cuts conservative by 5 mm. Either a conservative or definitive posterior femoral cut allows easy access to the posterior aspect of the knee when all osteophytes can be removed from the posterior femoral condyles as well as meniscal remains, loose bodies and any residual PCL (posterior cruciate ligament) attachment to the femur. At this stage in the operation all osteophytes have been removed from the tibia and the posterior aspect of the femur and the flexion gap can now be measured using a spacer block. The next step is a “pre-cut” or conservative cut on the distal femur. This cut takes off 5 mm less bone than the amount predicted to restore the distal femoral joint line. My pre-cut is always in 5° of valgus relative to the anatomical axis. Having done this cut any remaining osteophytes are removed from the medial and lateral sides of the femoral condyle and it also provides a good opportunity to remove osteophytes from the patella. An appropriately sized spacer block is then used to firstly assess the dimension of the extension gap and secondly its collateral balance. The latter is assessed by applying a gentle varus and then valgus stress to the extension gap with the spacer block in place and the knee in full extension. The extension gap is correct when, with the spacer block in situ, the weight of the leg completely closes the extension gap so that the flat surfaces of the spacer block, distal femur and proximal tibia are in full contact. This indicates full extension. Then with gentle varus and then valgus stress the gap opens 1–2 mm on both sides. This indicates that the tension in the posterior capsule and the two collaterals are equal – this is a “balanced gap”. There are a number of possible scenarios. 1. The extension gap is balanced and is 5 mm less than the flexion gap – solution – re-cut to remove 5 mm more distal femur thus producing balanced and equal flexion and extension gaps. 2. The extension gap is snug medially but slack laterally – solution – according to my hypothesis this suggests that the initial 5° cut is in too much valgus for this knee and
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between the medial femoral and tibial condyles. Then with a sucker the postero-medial capsule can be palpated to confirm that it is tight before cutting it under direct vision. This has the effect of both correcting the fixed flexion deformity as well as the varus deformity as shown in Fig. 3. Again this achieves the aims of balanced and equal flexion and extension gaps without raising the joint line on the distal femur. Release of the postero-medial capsule in the varus knee is only required in knees with fixed flexion of >20° and even then not always.
Tibial Defect in a Varus Knee Fig. 3 Effect of cutting a tight postero-medial capsule. As well as correcting the fixed flexion deformity it also corrects the varus deformity. NB knee is in extension
At this stage the final cuts can be made and the components inserted. In the situation of a tibial defect as shown in Fig. 4 careful inspection normally reveals that the defect is crescentshaped with an anterior and posterior horn. This crescentshaped area of bone is very sclerotic and strong and therefore the area of unsupported bone on the medial side of the white line, as shown in Fig. 4, is small. As a result I use a standard cementless tibial component without wedges, without a longer stem and without bone graft.
Soft-Tissue Balance in the Valgus Knee with or without Fixed Flexion
Fig. 4 Varus knee with a significant medial tibial defect demonstrating that the true area of unsupported surface is small
therefore depending on the discrepancy I re-cut in 3 or 4°. This does not raise the joint line but takes more bone off the tighter medial side and thus achieves the aims of balanced and equal flexion and extension gaps. 3. The extension gap is snug laterally and slack medially which is less common in a varus knee – solution – same scenario as number 2 except that the re-cut is in 6 or 7°. 4. With the spacer block in place and the knee fully extended when the extension gap is stressed into varus and valgus the gap opens both medially and laterally but more so laterally. This indicates that the posterior capsule is tight on the medial side – solution – the spacer block is removed the knee is kept in extension and the posterior capsule is put under tension by using a laminar spreader placed
I use a medial approach for all valgus knees irrespective of deformity. The tibial preparation tends to be more straightforward than in the varus knee. Any tibial defects tend to be smaller and are usually contained in that the cortical rim is intact. The depth of tibial resection from the normal medial side should normally be less than 10 mm. This is because of the normal inherent varus tibial slope which means less bone is removed from the medial side when the tibia is cut in neutral relative to the mechanical axis. As in the varus knee having done the A-P femoral cuts all osteophytes are cleared from the posterior femoral condyles. Again I use a 5° distal femoral pre-cut after which the extension gap is assessed in exactly the same way as for the varus knee. However unlike the varus knee posterior capsule release is commonly required. In the valgus knee when the extension gap is assessed with the spacer block often the medial laxity is greater than can be corrected by just performing a re-cut in 6 or 7° and this indicates the need to cut the postero-lateral capsule. As before the knee must be extended and then the postero-lateral capsule is put under tension using laminar spreaders positioned laterally between the lateral femoral and
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a neutral mechanical axis. This philosophy does go against perceived wisdom which states firmly that a knee that is not neutrally aligned has an increased risk of early failure [10]. Although there is now some evidence that that knees left in more than 3° of varus or valgus relative to the mechanical axis do not necessarily have a higher failure rate [11]. Doing an initial “pre-cut” of 5° on the distal femur allows the definitive cut to be both measured in terms of the amount of bone that needs to be removed to achieve full extension and also adjusted in angle so as to balance the collateral ligaments. The technique also depends on the careful removal of osteophytes and when required release of either the postero-medial or postero-lateral capsule. The former is rarely required in the varus knee but the latter is frequently required in the valgus knee.
Fig. 5 Valgus knee with tight postero-lateral capsule demonstrating the effect of cutting this structure. Not only does it correct fixed flexion it also corrects the valgus deformity. NB the knee is in extension
tibial condyles. In this position the popliteus tendon is clearly visible, as illustrated by the yellow band in Fig. 5 and is also clearly not tight. When using the sucker it is easy to palpate the tight region of the postero-lateral capsule just lateral to the popliteus. When this is cut using a small blade on a long handle it is normal to see the lateral side of the joint open up. As with the varus knee this corrects both the fixed flexion and the valgus deformity as shown in Fig. 5. In the type II valgus knee where the MCL has become stretched caution is required. In this situation the knee should not be fully balanced in extension but with the spacer block in place the extension gap should stay closed medially. In other words there should be no gapping medially unless a valgus stress is applied. Type II valgus knees tend to occur in low demand elderly female patients and because the knee is stable in flexion they do not complain of instability.
Summary My philosophy of soft-tissue balance is based on the assumption that the medial and LCLs do not contract and therefore should not be released irrespective of deformity. I also feel that we should be trying to restore pre-morbid alignment and not necessarily be always focussed on the restoration of
References 1. Insall JN. Technique of total knee replacement. Instr Course Lect 1981;30:324. 2. Hamelynck K. LCS Mobile Bearing Total Knee Arthroplasty. Springer, Berlin 2002:96–100. 3. Tokuhara Y, Kadoya Y, Nakagawa S, Kobayashi A, Takaoka K. The flexion gap in normal knees. An MRI study. J Bone Joint Surg Br 2004;86(8):1133–1136. 4. Thompson NW, Ruiz AL, Breslin E, Beverland DE. Total knee arthroplasty without patellar resurfacing in isolated patellofemoral osteoarthritis. J Arthroplasty 2001;16(5):607–612. 5. Sperner G, Wantschek P, Benedetto KP, Glotzer W. Spatergebnisse bei Patellafrakturen. Akt Traumatol 1990;20:24. 6. Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br 2002;84(1):50–53. 7. Arabori M, Matsui N, Kuroda R, Mizuno K, Doita M, Kurosaka M, Yoshiya S. Posterior condylar offset and flexion in posterior cruciate-retaining and posterior stabilized TKA. J Orthop Sci 2008;13(1):46–50. 8. Hanratty BM, Thompson NW, Wilson RK, Beverland DE. The influence of posterior condylar offset on knee flexion after total knee replacement using a cruciate-sacrificing mobilebearing implant. J Bone Joint Surg Br 2007;89(7):915–918. 9. Insall J. A midline approach to the knee. J Bone Joint Surg 1971;53-A(8):1584–1589. 10. Ritter MA, Faris PM, Keating EM, Meding JB. Postoperative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res 1994;299:153–156. 11. Mark W Pagnano MW, Trousdale RT, Berry DJ, Parratte S. The mechanical axis may be the wrong target in computerassisted TKA. AAOS Podium No:203, 2008, March 06, Room 3014–3018.
Revision Total Knee Arthroplasty with Bone Loss Josef Hochreiter and Karl Knahr
Introduction It is anticipated that in the near future far more patients will seek help for knee osteoarthritis and that total knee replacements (TKR) will increase as a consequence of age, epidemic proportions of obesity and a reduced willingness to accept physical incapacity. Consequently, also the number of revision TKRs (RTKR) will increase [1, 2].
the individual patient. Several classifications have been proposed, the Anderson Orthopaedic Research Institute (AORI) classification described by Engh being the most frequently used, with type I, II and III defects for the femur and tibia separately [4]. After examination of the soft tissue and ligaments, a classification system permits the surgeon to properly plan the surgery (type of bone graft, implant design), and to analyse the clinical results after RTKR. Because the defects are often underestimated pre-operatively, the final classification is made after debridement (Fig. 1).
Classification Mal-alignment and instability are common indications for RTKR, although aseptic loosening, osteolysis and infection are reported to be the three most frequent reasons for the loosening of a knee prosthesis. Other factors include extensor mechanism dysfunction or loss of function [3]. The surgical options in RTKR will depend on the underlying cause, which must be understood prior to surgery to avoid a poor outcome. In the majority of cases the reason is quite obvious to the clinician but sometimes it proves to be very subtle. Patient history, physical examination, (dynamic) X-rays, synovial fluid analysis, CT for rotatory alignment, or radionucleotide scans are necessary to make the proper diagnosis. A careful functional assessment of the patient’s level of activity and his/her expectations should also be performed and referred pain should be excluded. The use of a classification system for bone defects is helpful in determining the optimal therapeutic option for
Restoration of the Joint Line Re-establishing a correct joint-line position is recognized as one of the most important factors in achieving normal ligament balancing and normal knee kinematics. Failure of Total Knee Replacement is always accompanied by major bone loss and pathologic changes in ligaments. This is the reason why elevation of the joint-line occurs predominantly in revisions. We know from the literature that joint-line elevation can be seen in nearly 80% of the revisions, but only in 1% of the primaries [5]. Diagnosis of joint-line elevation is easy to recognize by comparing the pre- and post-operative height from tibial tubercle to tibial plateau in lateral X-rays and in measuring the position of the patella. Mal-position of the joint-line is connected with different clinical conditions such as anterior knee pain, mid-flexion instability and reduction of flexion mobility.
Anterior Knee Pain Josef Hochreiter () Department of Orthopaedic Surgery, St. Vincent’s Hospital, Linz, Austria e-mail:
[email protected] Join-line elevation in relation to the tibia is followed by patella baja which is the reason for impingement with the polythene and tibial tray in flexion [6].
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Josef Hochreiter and Karl Knahr
Fig. 1 Anderson Orthopaedic Research Institute Classification (AORI)
Mid-Flexion Instability Despite sufficient stability in extension and flexion there is certain instability in mid-flexion when the joint-line is elevated. The patient complains of pain and insecurity when climbing stairs and walking downhill [7].
Fig. 2 Multi-directional/uni-directional movement and wear
Reduction of Flexion Mobility
Treatment Options for Bone Loss
One important reason for joint-line elevation in revision is the down-sizing of the femur as a result of bone loss. A smaller femoral implant and posterior offset lead to a reduction of flexion mobility [8]. Improving the surgical technique of revisions is the most important factor to avoid joint-line elevation. The principles in the reconstruction of the knee joint are the restoration of the tibia as well as the sizing and positioning of the femur in accordance with flexion and extension stability.
Because the joint-line has to be restored in revision TKA to enable a balanced and stable knee, it is crucial to manage the bone loss. AORI Type I defects may be filled with cement, morsellized bone graft or metal augments. AORI Type II defects