Search Results (71)

Background: Robotic-assisted systems have transformed total knee arthroplasty (TKA), promising improved accuracy and intraoperative consistency, yet real-world data from non-academic centers remain limited. Objective: This study evaluates five-year clinical integration of a semi-autonomous, CT-based, robotic-arm-assisted TKA at a tertiary non-teaching hospital in Germany, focusing on planning accuracy, gap balancing, and intraoperative outcomes. Methods: We retrospectively analyzed all patients (n = 457) who underwent MAKO-assisted TKA from 2020 to 2025, performed by three orthopedic surgeons using a standardized subvastus approach. We assessed preoperative deformities, intraoperative alignment, implant sizing, and gap balancing. Surgical plans were adapted intraoperatively when indicated. Pre- vs. post-implantation values were compared using slopes to evaluate execution consistency. Results: Median patient age was 67.0 years (IQR: 60.0–75.0), with varus in 84.1% (7.0°, IQR: 4.0°–10.0°), valgus in 13.2% (3.0°, IQR: 1.5°–5.8°), and neutral alignment in 2.7%. Flexion contracture occurred in 80.4% (6.0°, IQR: 3.0–10.0%), hyperextension in 12.7% (2.0°, IQR: 1.5°–5.0°). Planning-to-execution consistency was high, even with plan adaptations. Slope values for alignment parameters were: tibial rotation in degrees (slope value: 1.0), femoral sagittal angle in degrees (0.8), tibial sagittal angle in degrees (0.9), coronal posterior condylar angle in degrees (0.9), femoral component size (1.0), tibial component size (1.0). Over 95% of cases showed ≤3.0° deviation between planned and final values. Bone resection concordance showed moderate agreement, with slopes from 0.8 (posterior medial femoral cut in mm) to 0.5 (lateral tibial cut in mm). Gap balancing improved at all stages, with reduced variability in medial/lateral extension and flexion gaps (all p < 0.05). Functional reconstruction showed significant improvements in extension, flexion, and deformities (all p < 0.001). Conclusions: Semi-autonomous, CT-based, robotic-arm-assisted TKA was successfully implemented in this non-academic setting, demonstrating acceptable intraoperative and functional reconstruction outcomes, supporting the feasibility of robotic-assisted surgery outside academic centers. Full article

A 75-year-old patient was transferred to the oncology department due to the discovery of a large pelvic tumor compressing the femoral neurovascular bundle suspected to be of malignant origin. Further investigation revealed a rare complication related to a 27-year-old total hip arthroplasty (THA). The final diagnosis was a severe adverse local tissue reaction (ALTR) resulting from excessive implant wear—first from a metal-on-metal (MoM) bearing and later exacerbated by a revision to a metal-on-polyethylene (MoP) articulation. The clinical course was further complicated by periprosthetic joint infection (PJI). The patient underwent extensive tumor-like mass resection followed by two-stage revision arthroplasty. Despite these interventions, infection persisted, ultimately necessitating joint resection. This case highlights the rare but serious convergence of dreaded orthopedic complications (ALTR and PJI). It underscores the diagnostic challenge posed by wear-induced pseudotumors, which are rare even among arthroplasty specialists and are often unfamiliar to oncologists. This case illustrates the importance of early orthopedic evaluation, maintaining a high index of suspicion in atypical presentations, and invites further discussion about the interplay between ALTRs and infection risk in arthroplasty patients. Full article

Background/Objectives: Periprosthetic joint infection (PJI) is a challenging problem in orthopedic surgery and is often associated with high morbidity. The treatment becomes even more challenging whenever the microorganism is virulent and/or not widely known as a causative organism on these occasions. This study aims to report on the clinical outcomes of hip hemiarthroplasty prosthetic hip joint infection by an atypical, rare microorganism, Morganella morganii (M. morganii), focusing on morbidity, revisions, and mortality. Methods: This is a retrospective series of four cases of prosthetic joint infections with Morganella morganii, a rare Gram-negative opportunistic facultative anaerobic pathogen, in four patients who received hip hemiarthroplasty for displaced femoral neck fractures at a level 1 trauma center. Clinical notes, laboratory findings, and radiographs were reviewed to extract relevant information regarding the history and outcomes. Results: The patients were four females, with a mean age of 84.27 years at the time of surgery. Two cases (50%) underwent surgical debridement and implant retention, followed by lifelong antibiotic suppression for symptomatic control of persistent wound drainage, and the other two underwent implant removal and resection arthroplasty (one patient) or received an antibiotic spacer (one patient), followed by chronic antibiotic therapy until wound closure. Conclusions: Periprosthetic hemiarthroplasty infection secondary to M. morganii was associated with overall poor outcomes. Antibiotic suppression could be a reasonable option after the surgical debridement or implant removal in M. morganii PJI to control the symptoms. Full article

Background/Objectives: Bone reconstruction using megaprostheses is increasingly performed following bone tumour resections, including sarcomas, to enhance patient outcomes and quality of life. However, this is a complex patient group, and there is little consensus as to postoperative rehabilitation and associated outcomes. Methods: A systematic search was conducted in MEDLINE and EMBASE databases according to the Implementing Prisma in Exercise, Rehabilitation, Sport medicine and SporTs science (PERSiST) guidelines. Studies describing rehabilitation protocols and functional outcomes following bone tumour resection and modular oncologic megaprosthesis reconstruction were included. All papers were individually assessed for methodological quality using the Joanna Briggs Institute (JBI) critical appraisal tool. Results: The search generated 105 records, 28 underwent full-text review, and 13 studies were included. Available data reflect 371 patients with a mean age of 49.17 (S.D. 21.40) years and a mean postoperative follow-up of 41.88 (S.D. 32.88) months. Surgical indications were documented as sarcomas in 9 studies, and tumour metastasis to the bone in 10 studies. Rehabilitation protocols were reported in 5 studies following proximal humerus resection with a mean dislocation rate of 14.5% (S.D. 5.26). All protocols advised brace immobilisation for a period ranging between 10 days and 6 months. Superior Constant-Murley shoulder score was reported in patients with early active isometric exercises at 6 weeks. Six studies reported proximal femur prosthesis rehabilitation and functional outcomes, with a mean dislocation rate of 10% (S.D. 9.82). Enhanced outcomes were reported in studies employing early mobilisation. Two studies assessed distal femur prosthesis; both studies reported similar protocols with full weight bearing 3 weeks following surgery. The methodological quality of the studies varied, but was overall modest, with 10/13 studies meeting at least 50% of JBI reporting criteria. Conclusions: The existing literature on rehabilitation and outcomes in orthopaedic oncology patients following arthroplasty with megaprosthesis is limited, with rehabilitative protocols variably described. However, it seems that early active mobilisation does not increase the risk of joint dislocations or infections. Full article

Background/Objectives: Resection arthroplasty is well established in treating bone defects following tumor resection, with the distal femur and proximal tibia being its most common localizations. The aim of this study was to analyze the functional outcomes and quality of life following endoprosthetic reconstruction for malignant bone tumors of the knee joint. Methods: We retrospectively included all patients treated with an endoprosthetic reconstruction following resection of a malignant bone tumor of the knee at our institution. Functional outcomes (KOOS, OKS, MSTS, and KSS) and health-related quality of life scores [QoL] (SF-36, Karnofsky Index) were evaluated. Chi-square and Fisher’s exact test was used for categorical variables, T-test and Whitney U-Mann tests for continuous variables. Survival was calculated using the Kaplan–Meier curves. Results: 32 patients were included. A total of 12 patients had died at the time of follow-up. Among the remaining 20 patients (m:w 17:3), mean follow-up was 8.1 years (range, 8.12 ± 6.8). Mean age at the time of tumor diagnosis was 50 ± 23.3 (10–83) years. According to age, patients were divided into two groups (group C1: <29 years, group C2: >29 years). Group C1 showed significantly better results regarding functional outcome (p < 0.05). The anatomic location of the replacement and a revision surgery did not influence the functional outcome (p > 0.05). QoL showed no significant differences in subgroup analysis (p > 0.05). Primary bone tumors had a significantly better survival (primary tumor: 216.90 months [168.42–265.83]; secondary tumor: 37.03 months [11.71–62.35] p = 0.01). Furthermore, pathologic fractures were associated with significantly worse survival (pathologic fracture: 50.24 months [0.00–102.43]; pathologic fracture 190.63 moths [139.28–241.45]; p = 0.007). Conclusions: Knee resection arthroplasty can offer meaningful long-term functional outcomes and acceptable quality of life in selected patients with musculoskeletal tumors. While the rarity and heterogeneity of such cases remain a challenge, our findings contribute to the growing evidence supporting this complex but limb-sparing surgical option. Full article

Periprosthetic joint infection (PJI) caused by Streptococcus bovis (S. bovis) is rare but clinically significant due to its established association with colorectal neoplasia. Early recognition and interdisciplinary management are essential to ensure favorable outcomes. We report the case of a 68-year-old woman who presented with a chronic fistula and signs of active infection 20 years after uncemented total hip arthroplasty. Cultures from the wound identified S. bovis, prompting further evaluation. Imaging and laboratory tests supported a diagnosis of chronic PJI. A two-stage revision was performed, beginning with implant removal, debridement, and placement of a vancomycin/gentamicin-loaded spacer. Given the pathogen’s known link to gastrointestinal malignancy, the patient underwent colonoscopy, which revealed a tubulovillous adenoma with carcinoma in situ. Surgical resection was performed with curative intent. Six months later, the patient underwent successful reimplantation. At three-month follow-up, clinical and radiographic assessments showed favorable recovery. This case reinforces the importance of gastrointestinal screening in patients with S. bovis PJI, as early detection of associated colorectal lesions may impact treatment strategies and prognosis. Full article

Background and objectives: Patient-specific components (PSC) represent an innovative option for total knee arthroplasty (TKA) in advanced osteoarthritis. Their effectiveness, however, closely relies on accurate positioning. Our study investigates the accuracy achieved by means of an inertial-based extramedullary cutting guide and the postoperative clinical and radiographic outcomes. Methods and materials: This was a prospective, single-arm, pilot study involving patients undergoing primary TKA with YourKnee^TM PSC. Femoral and tibial bone resections were performed using the Perseus inertial-based extramedullary cutting guide. Postoperative mechanical alignment and component positioning were assessed by computed tomography. Clinical outcomes were evaluated preoperatively and at 1, 3, 6, and 12 months postoperatively by main knee function and clinical outcome measures. Results: The study population included a small cohort (n= 12, four females/eight males, mean age 69 ± 5.65 years, mean BMI 25.7 ± 3.8 kg/m², KL grade > 3) with no control group. The mean absolute error between the planned and obtained Hip–Knee–Ankle angle was 1.36° ± 1.06 and within ±3° of all cases. Mean coronal alignment error was 1.87° ± 0.87 and 1.67° ± 0.75 for the femoral and tibial components, respectively. The mean sagittal alignment error was 1.89° ± 1.24 and 2.45° ± 0.87 for the femoral and the tibial components, respectively. Patients showed significant improvement in clinical and functional scores within the first 6 months: OKS increased from 20.64 ± 2.77 at the preoperative screening to 42.27 ± 4.34 (p < 0.0001), total KSS rose from 90.64 ± 17.25 to 169.36 ± 23.57 (p < 0.0001), and FJS reached 85.09 ± 17.14 at 6 months (p = 0.0031), indicating excellent functional recovery and forgotten joint effect. Knee ROM improved from 90.91° ± 11.14 to 110.36° ± 8.44 (p < 0.0001). After 6 months, outcome scores plateaued, suggesting an early stabilization of clinical benefits. No signs of radiolucency were detected on X-rays at 3- and 12-month follow-ups. Conclusions: The Perseus inertial-based extramedullary cutting guide used in combination with the YourKnee^TM PSCs resulted in accurate intraoperative prosthesis positioning and significant improvements in clinical and functional outcomes at 6 months after surgery. Despite the small sample size and absence of a control group, the results suggest that such combination represents a viable option to conventional surgical instrumentation and current off-the-shelf prosthetic designs. Full article

Background: Subacromial impingement or pain syndrome (SAPS) is the most common diagnosis for chronic shoulder pain. Current surgeries do not reduce long-term pain, suggesting they miss the root etiology. Previously, we described the Human Disharmony Loop (HDL), where the unique lower trunk innervation to the pectoralis minor (PM) causes scapular dyskinesis and deforms its connections, including tugging the acromion down and impinging the subacromial structures. We hypothesize that SAPS patients who meet HDL criteria would benefit significantly from PM tenotomy with infraclavicular brachial plexus neurolysis (PM + ICN) alone. Methods: SAPS patients who met HDL diagnostic criteria were treated with PM + ICN, with secondary distal neurolysis if needed. Outcomes included pain and shoulder abduction ROM. Six-month follow-up minimum was required. Results: N = 140 patients were included. Median age was 49. Prior surgeries included 27% subacromial decompression/acromioplasty, 21% rotator cuff repair, 16% biceps tenodesis, 4% SLAP repair, 2% labral repair, 7% distal clavicle resection, 10% reverse total shoulder arthroplasty (rTSA), 1% rib resection with scalenectomy, 16% cervical spine fusion, 28% distal neurolysis. Median pain decreased from 8 to 2 and median shoulder ROM increased from 90 to 180 degrees. Positive impingement signs on exam decreased from 100% to 11%. (p < 0.01) Conclusions: In a large series of SAPS patients, evaluation and treatment for the HDL significantly reduced pain and restored motion. These findings suggest that in many patients SAPS may be a subset of the HDL: the ventral PM disturbing the scapula constitutes the anatomic basis and optimal surgical target behind SAPS. Full article

Background and Objectives: Adequate bone quality is essential for promoting initial bone ingrowth and preventing early migration during cementless total knee arthroplasty (TKA). However, gold-standard criteria for identifying suitable bone strength have yet to be established. Dual-energy computed tomography (DECT)-based volumetric bone mineral density (vBMD) is an emerging tool for assessing bone quality. This study aimed to determine whether DECT-derived vBMD can accurately predict suitable bone strength for cementless TKA. Materials and Methods: A total of 190 patients undergoing primary TKA with a standardized posterior-stabilized implant were prospectively enrolled. Prior to TKA, DECT-derived vBMD was measured in the femoral box region. Actual bone strength was evaluated using an indentation test on resected femoral box specimens. Correlation and linear regression analyses were performed to assess the relationship between DECT vBMD and actual bone strength. Receiver operating characteristic (ROC) curve analysis and area under the curve (AUC) calculations were used to determine the optimal cut-off value and diagnostic accuracy of DECT vBMD in identifying candidates suitable for cementless TKA. Results: DECT-derived vBMD exhibited a strong correlation with actual bone strength (correlation coefficient = 0.719, p < 0.01), while linear regression analysis revealed a moderate association (R² = 0.51, p < 0.01). In addition, it demonstrated excellent diagnostic performance in predicting adequate bone quality for cementless TKA, yielding an AUC of 0.984, with a sensitivity of 91.9% and a specificity of 92.0%. Conclusions: DECT-derived vBMD is a reliable and accurate tool for assessing bone strength around the knee and predicting the suitable bone quality for cementless TKA. Full article

Background: Surgical neck nonunions of the proximal humerus present a complex clinical challenge, especially in elderly patients with pre-existing glenohumeral arthritis. Reverse total shoulder arthroplasty (RTSA) offers a reliable treatment option in these cases; however, resection of the tuberosities may compromise joint stability, increase the risk of postoperative dislocation and compromise postoperative function. This article describes a reproducible RTSA technique that preserves and repairs the greater and lesser tuberosities, aiming to enhance construct stability and optimize outcomes. Methods: We present a 74-year-old female with underlying glenohumeral arthritis who underwent RTSA for a symptomatic surgical neck nonunion via an extended deltopectoral approach. The nonunion is first mobilized, and tuberosity osteotomies are performed. After implant placement, the tuberosities are secured to the implant, to each other, and to the humeral shaft. A cerclage suture is also passed circumferentially to reinforce the repair and prevent posterior gapping. Results: The patient regained her pre-injury level of function by her last follow-up. She had pain-free, active forward elevation to 110 degrees and radiographic evidence of maintained tuberosity reduction and healing. There was no evidence of instability. Conclusions: In conclusion, incorporating tuberosity preservation and repair into RTSA for proximal humerus nonunion may reduce dislocation risk and improve functional recovery in elderly, low-demand patients. Full article

The development of an instrumented patellar prosthesis, able to measure the contact forces at the patellofemoral joint, can significantly aid in investigating the causes of total knee arthroplasty failures due to patellar complications. This study focuses on developing and validating an instrumented patellar prosthesis to measure contact forces in the patellofemoral joint. A piezoresistive force sensor was characterized and integrated into a conditioning circuit, with the aim of its implementation in the prosthesis. To measure medial and lateral forces independently, the sensors were trimmed in half. Compression tests (up to 2000 N) assessed sensor performance in terms of linearity (R² = 0.998 intact vs. 0.989 trimmed), repeatability (0.9% intact vs. 0.8% trimmed), and accuracy (1.7% intact vs. 2.3% trimmed) for forces up to 250 N. Higher force levels resulted in increased errors, but at a rate still comparable to that of existing sensors in the literature. Key considerations for the design of the instrumented prosthesis, such as minimizing point and shear loads, were identified. A prototype prosthesis capable of housing the sensor was proposed. The integrated system shows potential for improving the understanding of Total knee arthroplasty (TKA) failures through in vitro studies and could serve as an intraoperative tool for the evaluation of bone resections. Full article

Background/Objectives: According to the modified Mason classification, radial head fractures can be treated with open reduction and internal fixation (ORIF), radial head arthroplasty, or resection. This study by the Department of Traumatology and Orthopedics of the Military Institute of Medicine aimed to compare the clinical and radiological outcomes of fractures treated with ORIF. Methods: This retrospective study analyzed 55 patients with radial head fractures treated between April 2020 and February 2023. Fractures were classified using Mason system as 15 type II, 26 type III, and 14 type IV. Clinical outcomes were evaluated using the VAS for pain, Broberg–Morrey scale, and the DASH questionnaire, alongside assessments of range of motion, grip strength, and elbow stability. Follow-up radiographs examined bone union, bone fragments displacement, degenerative changes and periarticular ossification. Results: The mean follow-up period was 21.0 ± 10.2 months. There were no statistically significant differences in VAS scale results for Mason types II, III, and IV fractures (4.0 vs. 6.0 vs. 5.0, respectively; p = 0.825), the Broberg–Morrey scale (82.0 ± 15.2 vs. 80.9 ± 15.5 vs. 84.2 ± 15.1, respectively; p = 0.845), or the DASH questionnaire (10.0 vs. 11.7 vs. 17.5, respectively; p = 0.937). Mean extension deficit and supination angles were at the limit of statistical significance (p = 0.076 and p = 0.051). No cases of lateral instability were observed, whereas medial instability was seen in only one case. Bone union was observed in 97.5% of cases, with elbow joint osteoarthritis and periarticular ossification in 15.0% and 45.0% of cases, respectively. Conclusions: Mason type II, III and IV radial head fractures treated with open reduction and internal fixation showed good functional and radiological outcomes with rare complications, including degenerative changes, periarticular ossifications and nonunion. Full article

The stability of the tibial component in Total Knee Arthroplasty (TKA) is critical to preventing aseptic loosening, a major cause of implant failure. However, existing tibial stem designs often lead to stress shielding and bone resorption, highlighting the need for further optimization. This study addresses these challenges by employing the Design of Experiments (DOE) methodology, specifically utilizing a full factorial design approach combined with finite element analysis (FEA), to optimize the geometry of the tibial stem. The material properties of the cortical and cancellous bone, as well as the tibial tray, were assigned based on values from the literature, representing their elastic moduli and Poisson’s ratios. For boundary conditions, the distal end of the tibia was fully constrained to simulate realistic load transfer, while compressive loads representative of walking and daily activities were applied to the tibial base. Key design parameters, including stem diameter, length, mediolateral ratio (M/L ratio), and wing angle, were systematically analyzed. The results identified stem diameter and length as the most influential factors in improving biomechanical performance, while the wing angle showed minimal impact. The optimized design, featuring a stem diameter of 12 mm, length of 40 mm, M/L ratio of 0.61, and a wing angle of 60°, demonstrated significant reductions in stress shielding and aseptic loosening compared to conventional models. These findings provide valuable insights into enhancing the long-term success of TKA implants by balancing implant stability and minimizing bone resection. Full article

Background/Objectives: Iatrogenic hallux varus is a rare complication often arising after hallux valgus surgery, characterized by medial deviation of the hallux. This report presents the case of a 58-year-old female with iatrogenic hallux varus complicated by rheumatoid arthritis (RA). The objective is to highlight the challenges and outcomes of surgical treatment in RA patients with complex foot deformities. Methods: The patient presented with severe medial deviation of the hallux and claw positioning of the lesser toes, resulting in pain and functional limitations. Radiological analysis indicated overcorrection of the first intermetatarsal angle and deformity of the lesser toes. Surgical management included arthrodesis of the first metatarsophalangeal (MTP) joint using K-wires and resection arthroplasty of the lesser metatarsals. Results: Postoperative outcomes revealed correct alignment, pain reduction, and restoration of functional capabilities. However, a non-union was observed in the first MTP arthrodesis after 24 months, which remained asymptomatic. Conclusions: This case underscores the importance of careful surgical planning in RA patients to balance joint preservation and deformity correction. Arthrodesis proved effective for stability and pain relief in RA-associated deformities, although long-term follow-up remains critical to address complications. Tailored interventions are necessary to improve the quality of life in RA patients with complex foot deformities. Full article

Background: Diabetic ischemic ulcers with toe deformities are challenging to manage due to combined ischemia, infection, and mechanical stress. This case report highlights the successful treatment of a complex diabetic ischemic ulcer using a multidisciplinary approach that included revascularization and surgical offloading. Case Presentation: A 70-year-old male with type 2 diabetes mellitus presented with non-healing ulcers on the right third toe. The ulcers, located at the dorsal PIP joint and plantar MTP joint, were attributed to ischemia, infection, and progressive toe deformity. Angiography revealed significant arterial stenosis, which was treated with percutaneous transluminal angioplasty (PTA) to restore in-line flow and improve skin perfusion pressure. Surgical offloading included PIP resection arthroplasty and metatarsal shortening osteotomy. Postoperative management ensured complete ulcer healing, and no recurrence was observed during the three-year follow-up. Discussion: This case underscores the importance of combining revascularization to improve perfusion and surgical offloading to alleviate mechanical stress. Key factors for success included the restoration of in-line flow, achieving sufficient skin perfusion pressure, and reducing plantar pressure. Multidisciplinary collaboration among vascular surgeons, orthopedists, and wound care specialists played a critical role in achieving excellent long-term outcomes. Conclusions: Revascularization followed by surgical offloading provided effective treatment for a diabetic ischemic ulcer with toe deformity. This multidisciplinary approach demonstrates the necessity of individualized strategies to manage complex diabetic foot cases and prevent recurrence. Full article