We performed a systematic review of the literature involving a number of databases to identify studies that included outcomes of surgical treatment of acetabular fractures in patients aged > 55 years. An initial search identified 1564 studies. After exclusion by two independent reviewers, 15 studies met the inclusion criteria. All studies were case series and the mean Coleman Methodology score for methodological quality assessment was 43.7 (standard deviation 12.3). There were 354 patients with acetabular fractures. Pooled analysis revealed a mean age of 71.6 years (55 to 96) and a mean follow-up of 43 months (20 to 188). Complex fractures were reported in 70.1% of patients.Seven studies presented the results of open reduction and internal fixation (ORIF); in eight other studies a total hip arthroplasty (THA), alone or combined with different internal fixation techniques, was the chosen treatment. In the ORIF sub-group, conversion to THA was performed at a mean of 25.5 months with anatomical reduction in 11.6% and imperfect and poor reduction in 22.3%. In the THA sub-group, an acetabular ring or cage with a cemented acetabular component was used in four studies (52 patients) and a cementless acetabular component was implanted in five studies (78 patients). Six patients (4.9%) underwent revision at a mean of 39 months after the index procedure.The analysis of intra-operative and post-operative parameters showed a statistical difference between the two sub-groups with regards to the mean operating time (236 mins ORIF vs 178 mins THA), the mean blood loss (707 mL ORIF vs 974 mL THA) and the mean mortality rate at one year (22.6% ORIF vs 8.8% THA).Based on the current data available, acute THA (alone or in combination with internal fixation) may have a role in the treatment of older patients with complex acetabular fractures. Despite the wide heterogenecity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures.Cite this article: EFORT Open Rev 2017;2:97-103. DOI: 10.1302/2058-5241.2.160036

The management of severe acetabular bone deficiency and a stable femoral stem can be a challenging problem in revision hip surgery. Replacement of both the acetabular and femoral component in elderly patients can increase perioperative risks without the certainty of a better functional outcome. We report the long-term outcome of reinforcement rings in isolated acetabular revision to determine whether this procedure allows hip function restoration and implant longevity. Methods: A retrospective study was conducted to evaluate the long-term results of isolated acetabular revision in thirty patients with a mean age of 70.6 years. 16 patients (16 hips) received an acetabular reinforcement ring, and 14 patients received a reconstruction cage. Acetabular defects were classified as Paprosky Type II in 16 cases and Type III in 14 cases. The mean follow-up was 11.3 years (range 10-15 years). Results: Radiographic signs of loosening were found in 9 cases (30%). 4 cases (13.3%) with severe osteolysis and implant migration underwent further revision surgery. All 30 unrevised femoral stems were considered stable. 1 (3%) early dislocation, was conservatively treated. Clinical assessment showed a significantly improved mean Harris Hip Score from 45.1 points preoperatively to 85.4 at the latest follow-up (p < 0.05). The 15-year survival rate was 86.7%. Conclusions: Our long-term results showed that in selected patients, isolated acetabular revision with rings or antiprotrusio cages represents a reasonable surgical technique for the management of severe acetabular bone loss. However, concerns about the high radiographic loosening rates are possibly related to low bone ingrowth compared to new porous implants.

Treatment of osteoporotic fractures leads to significant challenges for the surgeon, including poor implant fixation related to low bone quality and compromised capacity of fracture healing. This article reviews the osteosynthesis and arthroplasty results in the surgical treatment of proximal femur, proximal humerus and wrist fractures to define the current options to decrease failure in fragility fracture management.

Objectives:The purpose of this study was to determine if patellar tendon (PT) thickness measured on pre-operative magnetic resonance imaging (MRI) is a risk factor for failure after anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BTB) autograft.Methods:18 patients [age (mean 96 Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:”Table Normal”; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow: yes; mso-style-priority:99; mso-style-parent:”“; mso-padding-alt:0in 5.4 pt 0in 5.4 pt; mso-para-margin:0in; mso-para-margin-bottom:.0001 pt; mso-pagination: widow-orphan; font-size:11.0 pt; mso-bidi-font-size:12.0 pt; font-family: Helvetica;} ± standard deviation) 21.5 ± 4.99years] that underwent an ACLR with BTB autograft and returned for revision ACLR between July 2005-January 2017 at our institution were included in the study. Failures were age-, sex-, height-, and weight-matched to 36 control (age 21.5 ± 4.99years) BTB-ACLR patients that have not required revision at a minimum of 2-years follow-up. Demographic data and mechanism of injury were recorded from patients’ medical records. PT thickness was measured at 3 points (5 mm lateral to the center, center, and 5 mm medial to the center) each at the level of the inferior pole of the patella (IPP), midpoint (MP), and insertion to tibial tubercle (ITT) on pre-operative axial-cut MRI.Results:All ACLR failures occurred after a non-contact pivot-shift type injury. Mean time between primary ACLR and revision was 2.4 ± 2.4 years and mean follow-up time was 3.1 ± 0.9 years in the control group. Patients with a failed ACLR had significantly thicker PTs at the IPP (lateral: 4.66 ± 1.47 vs 3.96 ± 0.66 mm; central: 5.39 ± 1.49 vs 4.51 ± 1.04 mm; medial: 5.51 ± 1.52 vs 4.59 ± 1.05 mm) and MP (lateral: 4.50 ± 0.83 vs 4.12 ± 0.54 mm; central: 4.83 ± 0.80 vs 4.43 ± 0.59 mm; medial: 4.57 ± 0.88 vs 4.13 ± 0.59 mm). There were no significant differences in PT thickness at the ITT. PT width tended to be larger in the failure cohort but this was not statistically significant (IPP: 32.2 ± 4.6 vs 29.8 ± 4.3 mm; MP: 31.3 ± 4.9 vs 29.5 ± 3.8 mm; ITT: 27.7 ± 3.7 vs 26.2 ± 2.9 mm).Conclusion:Contrary to conventional wisdom, we found that BTB autograft ACLR failures had significantly thicker patellar tendons at the inferior pole of the patella and midpoint. Further studies are need to investigate possible causes for this inverse correlation, such as poor histological tendon quality or mechanical impingement due to increased tendon size.

Objectives:Bone marrow edema lesions (BMELs) frequently occur following acute anterior cruciate ligament (ACL) rupture secondary to the pivot-shift mechanism of injury. The aim of the current study is to evaluate whether synovial fluid biomarker concentrations are associated with bone edema lesion volume as measured by magnetic resonance imaging (MRI) in patients undergoing ACL reconstruction.Methods:A total of 53 patients (26 females, 27 males, mean age 35.0 years [range 18-59]) undergoing ACL reconstruction with MRI knee scans available for analysis participated in the study. Synovial fluid was collected intra-operatively and analyzed for 10 biomarkers hypothesized to be involved in inflammation and post-traumatic osteoarthritis. BMELs were identified on MRI and their volumes (cm3) were quantified on two independent occasions using FireVoxel imaging software for image segmentation and region-of-interest drawing. The correlation between synovial fluid biomarker levels and BMEL volume was evaluated using Spearman’s correlation coefficient. Measurement reliability was assessed using intraclass correlation coefficient (ICC) analysis. Significance was set at p<0.05.Results:Mean time from initial injury to synovial fluid aspiration was 319 days (std. dev. 892; range 15-4320) and mean lesion volumes were: tibial=6.4 cm3 (range 0-38.6); femoral=5.8 cm3 (range 0-34.0); total=12.2 cm3 (range 0-50.5). Measurement reliability of BMEL volume was excellent [ICC(2,1)=0.968 (CI 0.945-0.981)]. Analysis of patients with MRI within 30 days of injury (n=35) showed increased tibial BMEL volume was significantly (p<0.05) correlated to decreased concentrations of interleukin (IL)-6 (ρ=-0.481), IL-1 receptor antagonist (ρ=-0.361), and vascular endothelial growth factor (VEGF) (ρ=-0.397) and increased time from injury to aspiration was correlated to decreased concentration of IL-6 (ρ=-0.463), monocyte chemotactic protein-1 (ρ=-0.453), VEGF (ρ=-0.457), IL-1Ra (ρ=-0.448), and matrix metalloproteinase (MMP)-3 (ρ=-0.426). However, among all patients, synovial fluid biomarker levels had no significant correlations to BMEL volume or time from injury to aspiration.Conclusion:Analysis of synovial fluid at the time of ACL reconstruction demonstrated that increased volume of injury-associated BMEL on MRI performed within 30 days of initial injury was significantly correlated to decreased concentrations of pro-inflammatory and growth factor cytokines. These findings suggest that the impact of the pivot-shift mechanism of injury and presence of BMEL may have an affect the local joint microenvironment.Table 1.Biomarker Values and Correlation with Bone Edema Lesion Size in Patients with MRI Within 30 Days of Initial Injury*p<0.05