Prevalence of Deep Vein Thrombosis in Low-Risk Patients After Elective Foot and Ankle Surgery.

BACKGROUND:: The evidence regarding the prevalence of deep vein thrombosis (DVT) after foot and ankle surgery in elective patients that need to be 6 weeks non-weight bearing postoperatively is incomplete and has limitations. METHODS:: The prevalence of DVT in 114 procedures involving the hindfoot and midfoot was determined using ultrasonographic surveillance at 2 and 6 weeks after surgery. RESULTS:: The prevalence of DVT was observed to be 25.4%. The majority (68.9%) of DVTs were diagnosed at the ultrasonographic scan performed 2 weeks postoperatively. The remainder (31.1%) of DVTs were diagnosed at the 6-week postoperative ultrasonographic scan. At least 75% of the patients who had early and late DVT had no clinical symptoms or signs of DVT. The prevalence of DVT in clinically detectable patients was 6%. The average age of patients with early DVT was 62.2 years, significantly higher compared to those who had no DVT. The mean tourniquet time for patients with early DVT was 68.1 minutes, significantly higher compared to those without DVT. All DVTs detected were distal to the popliteal vein. CONCLUSIONS:: The prevalence of clinically silent DVT was significantly higher than was previously thought. We believe this increased rate is directly attributable to the use of ultrasonographic surveillance postsurgery both at 2 and 6 weeks. The risk of DVT continued after the 2-week visit, and 30% of the DVTs were detected at the ultrasonographic scan at 6 weeks. LEVEL OF EVIDENCE:: Level II, prospective cohort.

Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review.

PURPOSE: To determine the suitability of the quadriceps autograft in primary anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was undertaken to identify all clinical studies reporting on the use of the quadriceps tendon autograft in ACL reconstructions. Studies that reported on clinical and functional outcomes, morbidity and complications were selected. RESULTS: Seventeen articles met our inclusion criteria with a total of 1,580 reconstructions studied. This included four comparative studies which compared the quadriceps tendon to either hamstring or patella tendon autografts. The quadriceps tendon autograft had clinical (Lachman, Pivot-shift testing) and functional outcomes (Lysholm and IKDC scores) similar to those reported for the patella tendon and hamstring grafts in the literature. Comparative studies also reported no significant difference between the grafts for any outcome measure. CONCLUSIONS: The quadriceps tendon autograft is a promising alternative for primary ACL reconstructions with good outcomes and minimal donor site morbidity. Further studies are required, however, to determine whether the quadriceps graft is as good as or better than other autografts. LEVEL OF EVIDENCE: IV.

Risk factors associated with loss of position after closed reduction of distal radial fractures in children.

BACKGROUND: Closed reductions of distal radial fractures are among the most common orthopaedic operations but up to 39% of fractures lose position postoperatively. This study was carried out to determine the most significant risk factors for loss of position so that high-risk patients can be identified early and their management tailored accordingly. METHODS: We retrospectively reviewed 48 consecutive children who had redisplacement of their distal radial fractures after closed reduction and compared them with 48 matched controls. Fourteen risk factors were studied and analyzed with univariate and multivariate logistic regression analysis and receiver operating characteristics analysis. These risk factors included pre-reduction and post-reduction fracture characteristics as well as 4 previously described radiological indices of plaster quality. RESULTS: Significant independent clinical risk factors identified were the initial radial fracture displacement [odds ratio (OR) 1.03, P = 0.001] and obliquity (OR 0.93, P = 0.006), a completely displaced radial fracture (OR 5.21, P =0.003), an ipsilateral ulnar fracture (OR 3.56, P = 0.003), residual radial displacement (OR 1.06, P = 0.009), angulation (OR 1.16, P = 0.011), and failure to achieve anatomical reduction (OR 0.18, P = 0.004). Significant radiological indices included the Padding index (OR >100, P = 0.004), Canterbury index (OR 99, P = 0.014), and 3-point index (OR 19.29, P < 0.001). Nonsignificant risk factors included the angulation of the initial radial fracture, a completely displaced ulnar fracture, plaster changes/splitting and the Cast index. The combined preoperative presence of a completely displaced radial fracture, an ipsilateral ulnar fracture and failure to achieve perfect reduction was found to be the best predictor of redisplacement (receiver operating characteristic area under the curve=0.82). This combination was found to be a better predictor of redisplacement than any of the radiological indices (receiver operating characteristic area under the curve ≤ 0.74) and it is also a more practical risk factor for the operating surgeon to use. CONCLUSIONS: The combination of a completely displaced distal radial fracture and an ipsilateral ulnar fracture, which then cannot be perfectly reduced, was the best predictor for redisplacement. We recommend that serious consideration be given to primary wire fixation in these patients. LEVEL OF EVIDENCE: III, prognostic.

Five-year results of the ASR XL Acetabular System and the ASR Hip Resurfacing System: an analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Articular Surface Replacement (ASR) hip prostheses, which have metal-on-metal bearing surfaces, were manufactured by DePuy Orthopaedics (Warsaw, Indiana) for use in both conventional total hip arthroplasty and hip resurfacing. Both the ASR XL Acetabular System and the ASR Hip Resurfacing System were recently recalled worldwide by the manufacturer. This report summarizes an analysis by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) of the outcome of arthroplasties involving the ASR prostheses. METHODS: The first recorded use of the ASR XL Acetabular System in Australia occurred in 2004, and the Registry recorded 4406 procedures involving this system through December 31, 2009. The first recorded use of the ASR Hip Resurfacing System in Australia occurred in 2003, and the Registry recorded 1167 procedures through December 31, 2009. The Kaplan-Meier method and proportional-hazard modeling were used to compare the revision rate of primary total hip arthroplasties involving the ASR XL Acetabular System with that of arthroplasties involving all other conventional prostheses as well as with that of arthroplasties involving all other conventional prostheses with a metal-on-metal-articulation. In addition, the revision rate of primary arthroplasties involving the ASR Hip Resurfacing System was compared with that of arthroplasties involving all other hip resurfacing prostheses. Patient demographics, prosthesis characteristics, and information regarding the type of revision and the reason for revision were also compared. RESULTS: Arthroplasties involving both ASR designs had a significantly greater revision rate compared with those involving all other prostheses. The cumulative revision rate of arthroplasties involving the ASR XL Acetabular System at five years postoperatively was 9.3% (95% confidence interval [CI], 7.3% to 11.9%) compared with 3.4% (95% CI, 3.3% to 3.5%) for total hip arthroplasties involving all other conventional prostheses. The cumulative revision rate of arthroplasties involving the ASR Hip Resurfacing System at five years postoperatively was 10.9% (95% CI, 8.7% to 13.6%) compared with 4.0% (95% CI, 3.7% to 4.5%) for arthroplasties involving all other resurfacing prostheses. Arthroplasties involving the ASR XL Acetabular System had a greater rate of revision due to implant loosening and/or osteolysis and due to metal sensitivity compared with total hip arthroplasties involving all other conventional prostheses. Arthroplasties involving the ASR XL Acetabular System also had a significantly greater revision rate compared with total hip arthroplasties involving all other conventional metal-on-metal prostheses. Arthroplasties involving the ASR Hip Resurfacing System had a greater rate of revision due to metal sensitivity compared with total hip arthroplasties involving all other resurfacing prostheses. CONCLUSIONS: ASR prostheses used in conventional hip arthroplasty and in hip resurfacing exhibited a greater revision rate compared with other prostheses in the AOANJRR. These results are consistent with those derived from other registries and from published studies of individual cohorts.

Review article: paediatric supracondylar humeral fractures: emergency assessment and management.

Supracondylar humeral fractures in children are common presentations to the ED but might be challenging to both diagnose and assess clinically. The ED has a critical role in accurately assessing the child, the limb's neurovascular status and initiating treatment. A specific approach to the clinical assessment of such a child is required as failure to detect neurovascular compromise can delay appropriate treatment and result in serious consequences. Most children can be investigated with X-ray radiograph alone with further treatment directed by severity of the fracture, commonly described using the Gartland classification. Our review article provides an overview of supracondylar humeral fractures and a suggested clinical approach to leave the emergency physician better equipped to assess and manage these fractures.

Outcome of revision of unicompartmental knee replacement.

BACKGROUND AND PURPOSE: Despite concerns regarding a higher risk of revision, unicompartmental knee arthroplasty (UKA) continues to be used as an alternative to total knee arthroplasty (TKA). There are, however, limited data on the subsequent outcome when a UKA is revised. We examined the survivorship for primary UKA procedures that have been revised. METHODS: We used data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to analyze the survivorship of 1,948 revisions of primary UKA reported to the Registry between September 1999 and December 2008. This was compared to the results of revisions of primary TKA reported during the same period where both the femoral and tibial components were revised. The Kaplan-Meier method for modeling survivorship was used. RESULTS: When a primary UKA was revised to another UKA (both major and minor revisions), it had a cumulative per cent revision (CPR) of 28 and 30 at 3 years, respectively. The CPR at 3 years when a UKA was converted to a TKA was 10. This is similar to the 3-year CPR (12) found earlier for primary TKA where both the femoral and tibial components were revised. INTERPRETATION: When a UKA requires revision, the best outcome is achieved when it is converted to a TKA. This procedure does, however, have a major risk of re-revision, which is similar to the risk of re-revision of a primary TKA that has had both the femoral and tibial components revised.