Effect of co-morbidities on outcomes of first metatarsophalangeal joint fusion: A systematic review.

Introduction: The pre-existing co-morbidities have a major impact on the outcomes of Orthopaedic procedures as shown by the several studied in various contexts. However, the specific influence of these co-morbidities on first metatarsophalangeal joint fusion remains relatively underexplored. This study aims to address this gap by examining the association between co-morbidities such as obesity, smoking, diabetes, advancing age, and rheumatoid arthritis, and the outcomes of first metatarsophalangeal joint fusion. Methods: A comprehensive search was conducted across multiple databases, including MEDLINE, EMBASE, and CINAHL. Relevant articles were identified and processed using Covidence, with independent assessment conducted to ensure inclusion criteria were met. The focus of the review was on analysing the effects of specific co-morbidities on fusion outcomes. Results: Seven qualifying studies were identified for full-text extraction, revealing significant heterogeneity across the literature, which hindered direct statistical comparisons. The findings presented inconclusive effects of obesity on fusion outcomes, with ambiguous impacts observed for diabetes mellitus and smoking. Additionally, no discernible variance was observed in functional outcomes across different age groups. Furthermore, steroid usage in rheumatoid arthritis cases demonstrated delayed fusion in revision procedures, while primary outcomes remained uncertain. Conclusion: This systematic review highlights the need for further research with standardised methodologies to better understand the correlation between pre-existing co-morbidities and outcomes in first metatarsophalangeal joint fusion. By elucidating these relationships, clinicians can better tailor treatment approaches and optimise patient care in this specific Orthopaedic context. Level of evidence: Level III.

Surgical management of renal cancer metastasis in the humerus: novel use of a trabecular metal spacer.

Humeral metastases from renal cell carcinoma are not uncommon. Current surgical practice centres around adequate tumour resection, but often at the expense of functional outcome. The use of trabecular metal (TM) implants is well described in spine and joint surgery. However, their use as a reconstruction device in osseous tumour surgery has yet to be reported. We present our experience in using a TM vertebral body replacement device (VBR) in treating a patient with painful bilateral diaphyseal humeral metastases. Resection of the tumour resulted in defects which the TM-VBR was able to fill. The defect was then bridged with a locking plate and cables. At 2-year clinical and radiographic review, bony integration and a return to pain free, near-normal function was achieved.

Are Hooded, Crosslinked Polyethylene Liners Associated with a Reduced Risk of Revision After THA?

BACKGROUND: Hooded acetabular liners and head sizes ≥ 32 mm have both shown to have a beneficial effect on the revision rate for dislocation in THA. Experience with noncrosslinked polyethylene (nonXLPE) raised concerns regarding the risk of impingement damage, loosening, and osteolysis with hooded liners; however, the evidence for this in crosslinked polyethylene (XLPE) is inconclusive. The interaction between different femoral head sizes and hooded liners is not well understood, and it is unclear whether hooded XLPE liners have a beneficial effect on overall long-term survivorship. QUESTIONS/PURPOSES: We analyzed a large national joint registry to ask: (1) Is the use of hooded XLPE liners associated with a reduced revision rate for dislocation compared with nonhooded liners? (2) Is there a difference in the revision rate for aseptic loosening/osteolysis? (3) Is head size associated with any difference in the revision rate between hooded and nonhooded liners? METHODS: The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from registry inception in September 1999 until December 31, 2016 in patients with a diagnosis of osteoarthritis who had nonhooded or hooded XLPE bearings in a cementless acetabular shell. The study group included 192,659 THA procedures with XLPE liners, of which 67,904 were nonhooded and 124,755 were hooded. The mean age of patients receiving nonhooded liners was 70 years (range, 11-100 years); 44% were males. This was similar to the patients with hooded liners, who had a mean age of 70 years (range, 16-100 years); 45% were males. The main outcome measure was the cumulative percent revision at 15 years of the THA using Kaplan-Meier estimates of survivorship. We examined reasons for revision and and performed multivariable analysis to control for the confounding factors of three head size groups (< 32mm, 32mm, and > 32mm) and for the method of femoral fixation. RESULTS: There was a higher revision rate for dislocation for patients with nonhooded liners at all times to 15 years (HR, 1.31; 95% CI, 1.17-1.47; p < 0.001). There was a higher revision rate for the diagnosis of aseptic loosening/osteolysis with patients with nonhooded liners compared with hooded liners (HR, 1.19; 95% CI, 1.05-1.34; p = 0.006). Head sizes of 32 mm or larger were independently associated with a lower comparative revision rate between hooded and nonhooded liners, but this was not apparent for head sizes smaller than 32 mm. It appeared that the main driver of the finding in larger heads was a reduced dislocation risk with hooded liners for 32 mm heads (HR, 1.50; 95% CI, 1.23-1.80; p < 0.001) and for heads larger than 32 mm (HR, 1.50; 95% CI, 1.20-1.89; p < 0.001). CONCLUSIONS: Prior research has suggested that hooded acetabular liners may be associated with impingement, loosening, and osteolysis; however, in this large, registry-based report we found that XLPE hooded liners are not associated with an increased revision rate for aseptic loosening/osteolysis. Although there are many potential confounding variables in this registry analysis, if anything, surgeons using larger femoral heads and hooded liners likely did so in patients with a higher perceived dislocation risk. Patients with larger heads and XLPE hooded liners were, however, less likely to experience revision for dislocation. These liners therefore appear reasonable to use in primary THA at the surgeon's discretion. LEVEL OF EVIDENCE: Level III, therapeutic study.