Identifying Critical Evidence Gaps in Wound Closure and Incision Management After Total Knee Arthroplasty: Delphi Panel Insights.

BACKGROUND: Effective surgical wound management in total knee arthroplasty (TKA) is crucial for optimal healing and patient outcomes. Despite surgical advances, managing wounds to prevent complications remains challenging. This study aimed to identify and address evidence gaps in TKA wound management, including preoperative optimization, intraoperative options, and postoperative complication avoidance. Addressing these issues is vital for patient recovery and surgical success. METHODS: This study used the Delphi method with 20 experienced orthopedic surgeons from Europe and North America. Conducted from April to September 2023, the process involved three stages: an initial electronic survey, a virtual meeting, and a concluding electronic survey. The panel reviewed and reached a consensus on 26 statements about TKA wound management based on a comprehensive literature review. Additionally, the panel aimed to identify critical evidence gaps in wound management practices. RESULTS: The panel achieved consensus on various wound management practices but highlighted significant evidence gaps. Consensus was reached on wound closure methods, including mesh-adhesive dressings, skin glue, staples, barbed sutures, and negative pressure wound therapy. However, further evidence is needed to address the cost-effectiveness of these methods and develop best practices for patient outcomes. Identifying these gaps highlights the need for more research to improve TKA wound care. CONCLUSIONS: Identifying major evidence gaps underscores the need for targeted research in TKA wound management. Addressing these gaps is crucial for developing effective, efficient, and patient-friendly wound care strategies. Future research should focus on comparative effectiveness studies and developing guidelines for emerging technologies. Bridging these gaps could improve patient outcomes, reduce complications, and enhance TKA surgery success.

Conventionally instrumented inverse kinematic alignment for total knee arthroplasty: How is it done?

Purpose: For primary total knee arthroplasty (TKA), there is an increasing trend towards patient-specific alignment strategies such as kinematic alignment (KA) and inverse kinematic alignment (iKA), which by restoring native joint mechanics may yield higher patient satisfaction rates. Second, the most recent Australian joint registry report describes favourable revision rates for conventionally instrumented TKA compared to technology-assisted techniques such as those using navigation, robotics or custom-cutting blocks. The aim of this technique article is to describe in detail a surgical technique for TKA that: (1) utilises the principles of iKA and (2) uses conventionally instrumented guided resections thereby avoiding the use of navigation, robotics or custom blocks. Methods: A TKA technique is described, whereby inverse kinematic principles are utilised and patient-specific alignment is achieved. Additionally, the patellofemoral compartment of the knee is restored to the native patellofemoral joint line. The sequenced technical note provided may be utilised for cemented or cementless components; cruciate retaining or sacrificing designs and for fixed or rotating platforms. Results: An uncomplicated, robust and reproducible technique for TKA is described. Discussion: Knee arthroplasty surgeons may wish to harness the emerging benefits of both a conventionally instrumented technique and a patient-specific alignment strategy. Level of Evidence: Level V.

Inverse kinematic total knee arthroplasty using conventional instrumentation restores constitutional coronal alignment.

PURPOSE: Restricted inverse kinematic alignment (iKA) is a contemporary alignment strategy for total knee arthroplasty (TKA), commonly performed with robotic assistance. While superior clinical results are reported for kinematic-type alignment strategies, registry data indicate no survivorship benefit for navigation or robotic assistance. This study aimed to determine the efficacy of an instrumented, restricted iKA technique for achieving patient-specific alignment. METHODS: Seventy-nine patients undergoing 84 TKAs (five bilateral procedures) using an iKA technique were included for preoperative and postoperative lower limb alignment analysis. The mean age was 66.5 (range: 43-82) with 33 male and 51 female patients. Artificial intelligence was employed for radiographic measurements. Alignment profiles were classified using the Coronal Plane Alignment of the Knee (CPAK) system. Preoperative and postoperative alignment profiles were compared with subanalyses for preoperative valgus, neutral and varus profiles. RESULTS: The mean joint-line convergence angle (JLCA) reduced from 2.5° to -0.1° postoperatively. The mean lateral distal femoral angle (LDFA) remained unchanged postoperatively, while the mean medial proximal tibial angle (MPTA) increased by 2.5° (p = 0.001). By preservation of the LDFA and restoration of the MPTA, the mean hip knee ankle angle (HKA) moved through 3.5° varus to 1.2° valgus. The CPAK system was used to visually depict changes in alignment profiles for preoperative valgus, neutral and varus knees; with 63% of patients observing an interval change in classification. CONCLUSION: Encouraged by the latest evidence supporting both conventional instrumentation and kinematic-type TKA strategies, this study describes how a restricted, conventionally instrumented iKA technique may be utilised to restore constitutional lower limb alignment. LEVEL OF EVIDENCE: Level III.

International Delphi Study on Wound Closure and Incision Management in Joint Arthroplasty Part 2: Total Hip Arthroplasty.

BACKGROUND: This modified Delphi study aimed to develop a consensus on optimal wound closure and incision management strategies for total hip arthroplasty (THA). Given the critical nature of wound care and incision management in influencing patient outcomes, this study sought to synthesize evidence-based best practices for wound care in THA procedures. METHODS: An international panel of 20 orthopedic surgeons from Europe, Canada, and the United States evaluated a targeted literature review of 18 statements (14 specific to THA and 4 related to both THA and total knee arthroplasty). There were 3 rounds of anonymous voting per topic using a modified 5-point Likert scale with a predetermined consensus threshold of ≥ 75% agreement necessary for a statement to be accepted. RESULTS: After 3 rounds of voting, consensus was achieved for all 18 statements. Notable recommendations for THA wound management included (1) the use of barbed sutures over non-barbed sutures (shorter closing times and overall cost savings); (2) the use of subcuticular sutures over skin staples (lower risk of superficial infections and higher patient preferences, but longer closing times); (3) the use of mesh-adhesives over silver-impregnated dressings (lower rate of wound complications); (4) for at-risk patients, the use of negative pressure wound therapy over other dressings (lower wound complications and reoperations, as well as fewer dressing changes); and (5) the use of triclosan-coated sutures (lower risk of surgical site infection) over standard sutures. CONCLUSIONS: Through a structured modified Delphi approach, a panel of 20 orthopedic surgeons reached consensus on all 18 statements pertaining to wound closure and incision management in THA. This study provides a foundational framework for establishing evidence-based best practices, aiming to reduce variability in patient outcomes and to enhance the overall quality of care in THA procedures.

International Delphi Study on Wound Closure and Dressing Management in Joint Arthroplasty: Part 1: Total Knee Arthroplasty.

BACKGROUND: The purpose of this modified Delphi study was to obtain consensus on wound closure and dressing management in total knee arthroplasty (TKA). METHODS: The Delphi panel included 20 orthopaedic surgeons from Europe and North America. There were 26 statements identified using a targeted literature review. Consensus was developed for the statements with up to three rounds of anonymous voting per topic. Panelists ranked their agreement with each statement on a five-point Likert scale. An a priori threshold of ≥ 75% was required for consensus. RESULTS: All 26 statements achieved consensus after three rounds of anonymous voting. Wound closure-related interventions that were recommended for use in TKA included: 1) closing in semi-flexion versus extension (superior range of motion); 2) using aspirin for venous thromboembolism prophylaxis over other agents (reduces wound complications); 3) barbed sutures over non-barbed sutures (lower wound complications, better cosmetic appearances, shorter closing times, and overall cost savings); 4) mesh-adhesives over other skin closure methods (lower wound complications, higher patient satisfaction scores, lower rates of readmission); 5) silver-impregnated dressings over standard dressings (lower wound complications, decreased infections, fewer dressing changes); 6) in high-risk patients, negative pressure wound therapy over other dressings (lower wound complications, decreased reoperations, fewer dressing changes); and 7) using triclosan-coated over non-antimicrobial-coated sutures (lower risks of surgical site infection). CONCLUSIONS: Using a modified Delphi approach, the panel achieved consensus on 26 statements pertaining to wound closure and dressing management in TKA. This study forms the basis for identifying critical evidence supported by clinical practice for wound management to help reduce variability, advance standardization, and ultimately improve outcomes during TKA. The results presented here can serve as the foundation for knowledge, education, and improved clinical outcomes for surgeons performing TKAs.

Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures.

INTRODUCTION: Hip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications. METHODS: This retrospective study included 803 IM nails performed between 2008-2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery. RESULTS: The overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years. DISCUSSION: The rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

Does lucency equate to revision? A five-year retrospective review of Attune and Triathlon total knee arthroplasty.

PURPOSE: The Attune® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune® system and the well-established Triathlon® system. METHODS: This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune® (N = 445) and Triathlon® (N = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune® = 338; Triathlon® = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan-Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal-Wallis Test. RESULTS: The Attune® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p = 0.001] and at the implant-cement interface [62.9% (39/62) vs 43.2% (19/44); p = 0.02]. Conversely, the Triathlon® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p = 0.001] and at the cement-bone interface [56.8% (25/44) vs 37.1% (23/62); p = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune® and Triathlon® groups [17.8%, (60/338) vs 17.7%, (41/231); p = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune® 97.8% vs Triathlon® 95.8%; p = 0.129). The Attune® performed better at 5 years in the Oxford Knee Score [Attune® = 42.6 (SD 5.2) vs Triathlon® = 41 (SD 6.4); p = 0.001] and in the EQ-5D [Attune® = 0.773 (SD 0.187) vs Triathlon® = 0.729 (SD 0.218); p = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune® = 80.4 (SD 13.7) vs Triathlon® = 78.5 (SD 15.3); p = 0.25]. CONCLUSION: The Attune® system exhibited a higher incidence of  radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon®. Furthermore, improvements in patient reported outcomes modestly favoured the Attune® system. LEVEL OF EVIDENCE: III.

Distal radial fractures in adults: 4 versus 6 weeks of cast immobilisation after closed reduction, a randomised controlled trial.

PURPOSE: In this study, we aim to evaluate whether the functional outcome of Distal Radius Fractures (DRFs) could be enhanced by shortening the period of immobilisation from six weeks to four weeks. METHODS: This study is a single blinded randomised controlled trial. Four week plaster cast immobilisation was compared with six week plaster cast immobilisation in adult patients (older than 18 years) with adequately reduced DRFs. The primary outcome parameters were functional outcome measured by Quick DASH score after 1-year follow-up. Secondary outcomes were: Quick DASH after three months, 6 months, range of motion, and complications (such as number of re-interventions, secondary displacement, delayed and non-union). RESULTS: 80 patients (16 male and 64 female, mean age, 61.76 years) were included and randomized. 65 patients completed the 1-year follow-up. After 1-year follow up, no significant differences were found between the two groups in the QUICK DASH score (P = 0.55). Moreover, no significant differences in DASH Score after three and six months (P = 0.24, 0.28, respectively). The complication rate among both cohorts was almost similar, (P = 0.51). CONCLUSION: Reduction in the time of cast immobilisation in patients with DRFs in accepted position reported similar outcomes. Of note, the complication rate in the four and six weeks was also the same. Thus, 4 weeks in cast is a safe immobilisation period. Clinical Trials Number Trial registration number and date of registration for prospectively registered trials at http://ClinicalTrials.gov (NCT05012345), on 19/08/2021.

Perspective on the integration of optical sensing into orthopedic surgical devices.

SIGNIFICANCE: Orthopedic surgery currently comprises over 1.5 million cases annually in the United States alone and is growing rapidly with aging populations. Emerging optical sensing techniques promise fewer side effects with new, more effective approaches aimed at improving patient outcomes following orthopedic surgery. AIM: The aim of this perspective paper is to outline potential applications where fiberoptic-based approaches can complement ongoing development of minimally invasive surgical procedures for use in orthopedic applications. APPROACH: Several procedures involving orthopedic and spinal surgery, along with the clinical challenge associated with each, are considered. The current and potential applications of optical sensing within these procedures are discussed and future opportunities, challenges, and competing technologies are presented for each surgical application. RESULTS: Strong research efforts involving sensor miniaturization and integration of optics into existing surgical devices, including K-wires and cranial perforators, provided the impetus for this perspective analysis. These advances have made it possible to envision a next-generation set of devices that can be rigorously evaluated in controlled clinical trials to become routine tools for orthopedic surgery. CONCLUSIONS: Integration of optical devices into surgical drills and burrs to discern bone/tissue interfaces could be used to reduce complication rates across a spectrum of orthopedic surgery procedures or to aid less-experienced surgeons in complex techniques, such as laminoplasty or osteotomy. These developments present both opportunities and challenges for the biomedical optics community.

Midterm results of modern patellofemoral arthroplasty versus total knee arthroplasty for isolated patellofemoral arthritis: systematic review and meta-analysis of comparative studies.

BACKGROUND: Both Patellofemoral Arthroplasty (PFA) and Total Knee Arthroplasty (TKA) are accepted surgical options for end-stage isolated patellofemoral osteoarthritis (PFOA). We performed a systematic review and meta-analysis to compare outcomes of PFA and TKA by evaluation of the patient-reported outcome measures (PROMs). METHODS: We systematically identified publications reporting on patients that underwent either TKA or modern PFA for isolated PFOA. Meta-analysis software was used to screen for potential articles with at least two years' follow-up. Data were extracted and analysed for all PROMs operating time, postoperative inpatient time, complications and cost. We included five studies in our cumulative meta-analysis and reviewed them using Review Manager V.5.0. We computed the risk ratio as a measure of the treatment effect, taking into account heterogeneity. We used random-effect models. RESULTS: No significant difference was found between both TKA and PFA in the context of operating time. No significant difference after five years' follow-up was found between the two treatment options in terms of UCLA score and patient satisfaction. PFA showed significant improvement in WOMAC score at five-year follow-up, less postoperative inpatient time, better cost-effectiveness and significantly less blood loss. CONCLUSION: PFA seems to be a viable alternative to TKA for treatment of isolated PFOA in appropriately selected patients. PFA showed less postoperative inpatient time and blood loss with similar PROMs to the TKA. Moreover, it is an economically beneficial joint-preserving procedure.

Harrington rods for periacetabular pathological lesion: is it an option?

Advancement in cancer treatment has prolonged the survival of cancer patients; as a result, there are an increased number of patients with bone metastases and pathological fractures referred to orthopaedic surgeons for surgical intervention for a better quality of life. Metastasis around the hip joint can be painful and intervene with patients' daily activity, and reconstruction of the hip joint with periacetabular metastasis is complex and challenging especially longer cancer survivals might out-live their fixation. Several acetabular reconstruction techniques and implants have been described to overcome this problem; acetabular reconstruction and total hip arthroplasty still remains the standard surgical treatment, to relief pain and to improve function and quality of life. Harrington reconstruction of periacetabular metastatic disease combined with hip arthroplasty is one of the options that can address this clinical scenario safely; it is reproducible and cost-effective. In this review, we present case series of patients treated in our institution using Harrington rod technique for acetabular pathological lesions with good outcome.

The role of joint line position and restoration of posterior condylar offset in revision total knee arthroplasty : a systematic review of 422 revision knees arthroplasty.

The aim of this systematic review was to evaluate the evidence on reservation of Posterior Femoral Condylar Offset (PFCO) and Joint Line (JL) after Revision Total Knee Arthroplasty (RTKA) for im- proved functional outcomes. A comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases was conducted, with papers published from the inception of the database to October 2020 included. All relevant articles were retrieved, and their bibliographies were hand searched for further references on Posterior condylar offset and revision total knee arthroplasty. The search strategy yielded 28 articles. After duplicate titles were excluded, abstracts and full text were reviewed. Nine studies were assessed for eligibility, four studies were excluded because they did not fully comply with the inclusion criteria. Six articles were finally included in this systematic review. Based on this systematic review restoration of the JL and PFCO in RTKR is associated with a significant improvement in the post-operative range of motion, KSS, OKS, patellar function, and SF-36. Reservation of JL should be a major consideration when undertaking RTKA. Of note, increasing PFCO to balance the flexion gap while maintaining joint line should be well assessed intra-operatively. The upper limit of the PFCO that widely accepted is up to 40 % greater than that of the native knee. 4 mm is the upper limit for JL restoration. Level of evidence III.

Pilot study of micromotion nailing for mechanical stimulation of tibial fracture healing.

AIMS: The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking. METHODS: Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing. RESULTS: A total of 37 micromotion patients and 46 control patients were evaluated. There were no significant differences between groups in terms of age, sex, the proportion of open fractures, or NURD score. There were no nonunions (0%) in the micromotion group versus five (11%) in the control group. The proportion of fractures united was significantly higher in the micromotion group compared to control at 12 weeks (54% vs 30% united; p = 0.043), 18 weeks (81% vs 59%; p = 0.034), and 24 weeks (97% vs 74%; p = 0.005). Structural bone healing scores as assessed by CT scans tended to be higher with micromotion compared to control and this difference reached significance in patients who had biological comorbidities such as smoking. CONCLUSION: In this pilot study, micromotion fixation was associated with improved healing compared to standard tibial nailing. Further prospective clinical studies will be needed to assess the strength and generalizability of any potential benefits of micromotion fixation. Cite this article: Bone Jt Open 2021;2(10):825-833.

Femoral head penetration in Vitamin-E polyethylene liner versus conventional liners in total hip arthroplasty: systematic review and meta-analysis of randomised control trials.

BACKGROUND: Debate encompasses the use of Vitamin E Polyethylene or conventional Polyethylene liner in primary hip arthroplasty. Does the Inclusion of Vitamin E in PE give adequate protection from oxidation and maintains lower rates of wear? PATIENTS AND METHODS: We performed this study following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Studies were included from any region, written in any language. We had only the randomised control trials comparing the femoral head penetration between Vitamin-E diffused highly cross-linked polyethylene (VEPE) liner and conventional liners in primary total hip arthroplasty. RESULTS: We included 10 studies in this meta-analysis. We conducted them using Review Manager V.5.0. We computed the risk ratio to measure the treatment effect, considering the heterogeneity. We used Random-effect models. VEPE had insignificant marginal advantages for FHP within three months post-operative. Additionally, VEPE showed significantly less FHP after two and five years. After one year, it showed significantly less FHP with the VEPE group versus the UHMWPE cohort and a non-significant difference between the VEPE and XLPE group. CONCLUSIONS: In terms of FHP, this metanalysis shows less FHP for the VEPE than conventional PE. A longer follow-up period is required to evaluate whether the oxidation protection gained by Vitamin E results in lower wear rates, less osteolysis, and aseptic loosening compared to the conventional PE in the long term.

Does bicompartmental knee arthroplasty hold an advantage over total knee arthroplasty? Systematic review and meta-analysis.

INTRODUCTION: The role of bicompartmental knee arthroplasty (BKA) in the treatment of medial patellofemoral osteoarthritis (MPFOA) has been debated by orthopaedic surgeons for years. The BKA is a cruciate ligament retaining prosthesis designed to mimic the kinematics of the native knee that requires resurfacing of only two knee compartments. In this study, we aim to assess the patient recorded outcome measures (PROMs), range of motion (ROM), perioperative morbidity, and implant revision rate in patients undergoing BKA and compare them to those undergoing total knee arthroplasty (TKA) for bicompartmental knee osteoarthritis (OA). PATIENTS AND METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Articles from any country and written in any language were considered. We included all randomized control trials and retrospective cohort studies examining BKA versus TKA for bicompartmental knee OA. The primary outcome measure was knee society score (KSS) at one year and the secondary outcome measures were Oxford knee score (OKS) and short-form survey (SF-)12 at six and twelve months. RESULTS: We included five studies in our meta-analysis. In terms of OKS, KSS, and SF-12, our meta-analysis suggests better short-term results for the TKA compared with the BKA. TKA was also associated with a shorter operative time and a lower revision rate. The BKA implant did however result in marginally less intraoperative blood loss and slightly better post-operative ROM. CONCLUSIONS: BKA did not prove to be an equivalent alternative to TKA in bicompartmental knee OA. It was associated with inferior KSS, OKS, and SF-12 at short-term follow-up and a higher revision rate.

Nontraumatic Tibial Polyethylene Insert Cone Fracture in Rotating-Platform Total Knee Arthroplasty.

We report a case of a fracture through the polyethylene (PE) insert cone in a rotating-platform (RP) primary total knee arthroplasty (TKA) implant. This is the first reported case of cone fracture with this particular implant. This case highlights a 65-year-old female presenting with a 4-month history of knee pain and symptoms of instability 10 years after primary RP TKA. At the time of revision surgery, the PE insert cone was found to be fractured 10 mm from the inferior surface of the PE liner. Analysis suggests that the cone fracture occurred by fatigue failure which caused loosening of the tibial tray. Clinicians should be aware that this is a potential cause of failure with an RP TKA in the setting of symptoms including instability and pain.

The partial femoral condyle focal resurfacing (HemiCAP-UniCAP) for treatment of full-thickness cartilage defects, systematic review and meta-analysis.

Knee osteochondral defects are a common problem among people, especially young and active patients. So effective joint preserving surgeries is essential to prevent or even delay the onset of osteoarthritis for these group of patients. This study aims to critically appraise and evaluate the evidence for the results and effectiveness of femoral condyle resurfacing (HemiCAP/ UniCAP) in treatment of patients with focal femoral condyle cartilage defect. Using the search terms : HemiCAP, UniCAP, Episurf, focal, femoral, condyle, inlay and resur-facing, we reviewed the PubMed and EMBASE and the Cochrane Database of Systematic Reviews (CDSR) to find any articles published up to March 2020. The short term follow-up of the HemiCAP shows (6.74 %) revision rate. However, 29.13 % loss of follow up let us consider these results with caution especially if the revision rate progressively increased with time to 19.3 % in 5-7 years with no enough evidence for the long term results except the data from the Australian Joint Registry 2018, where the cumulative revision rate was 40.6 % (33.5, 48.4) at ten years. The UniCAP that used for defect more than 4 cm 2 has a high revision rate (53.66 %) which is considered unacceptable revision rate in com-parison to another similar prosthesis such as Uni-Knee Arthroplasty (UKA). The evidence from published studies and our meta- analysis suggests that partial resurfacing of the femoral condyle (HemiCAP) doesn't support its usage as a tool to treat the focal cartilage defect in middle- aged patients. The UniCAP as femoral condyle resurfacing has very high revision rate at 5-7 years (53.66 %) which make us recommend against its usage.

The decline of hip fracture incidence rates over a 10-year period: A single centre experience.

AIMS: Accurate epidemiological hip fracture data is essential for healthcare planning and targeted prevention strategies. Limited reports of hip fracture incidence rates in the Republic of Ireland (ROI) exist. The aim is to calculate the current age- and gender-specific incidence of hip fractures in a level 1 Trauma Centre in the ROI, and the difference in these rates over a 10 year period. MATERIALS AND METHODS: This was a retrospective, population-based, observational study. The local Hospital In-Patient Enquiry (HIPE) database was used to generate data for analysis; capturing all patients admitted for hip fracture in three time periods over 10 years. Patients < 55 years old, pathological fractures, and periprosthetic fractures were excluded. Age- and gender-specific incidence rate was calculated using HIPE and national census data. RESULTS: Absolute number of hip fractures rose by 8.5% between 2008/09 (n = 800) and 2018/19 (n = 868) time periods. Cervical hip fractures dominated in all 3 time periods. The average age of patients remained at 80 years but length of stay for patients was reduced by 16% 5 years later and by 21% 10 years later from the initial study point. Both the entire and susceptible (> 55 years) population numbers increased by 13% and 30%, respectively, yet overall hip fracture incidence rate declined 10 years on. Hip fracture incidence rate in the entire population fell by 3.23 per 100,000 population, and by 65.11 per 100,000 population in the susceptible population. The majority of both male and female age groups exhibited declining annual incidence rates over the 10 year study period. CONCLUSION: Results are consistent with the global experience of declining overall incidence rate of hip fractures, despite rising susceptible population numbers. This report adds to the sparse hip fracture incidence data available in the ROI which can be applied in future healthcare planning strategies.

Polyethylene liner dissociation in a DePuy pinnacle cup with a manufacturer analysis of the failed component.

A 74-year-old patient presented to the emergency department with acute atraumatic hip pain 9 years after her primary left total hip arthroplasty (THA). Plain radiographic imaging demonstrated lateralisation of the femoral head within the acetabular shell-indicating an issue with the polyethylene liner. The patient required revision of the acetabular component and the femoral head, as well as a new polyethylene liner. A detailed analysis of the components removed was performed by DePuy Synthes Engineering. Between 2009 and 2020, 8 publications have documented 52 cases of liner dissociation with the Pinnacle acetabular component and Marathon polyethylene liner. Various theories have been proposed in the literature as all of these components appear to fail in the same way, with shearing of the locking tabs in the polyethylene liner. In spite of a manufacturer analysis of the components, no root cause was identified as to why the polyethylene liner failed.