Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association.

A survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association conducted in 2022 found considerable variation in care across the region. A Call to Action is proposed to improve acute care, rehabilitation and secondary fracture prevention across Asia Pacific. PURPOSE: Fragility fractures impose a substantial burden on older people and their families, healthcare systems and national economies. The current incidence of hip and other fragility fractures across the Asia Pacific region is enormous and set to escalate rapidly in the coming decades. This publication describes findings of a survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association (APOA) conducted in 2022. METHODS: The survey was developed as a collaboration between the Asia Pacific Osteoporosis and Fragility Fracture Society and the Asia Pacific Fragility Fracture Alliance, and included questions relating to aspects of care upon presentation, during surgery and mobilisation, secondary fracture prevention, and access to specific services. RESULTS: In total, 521 APOA members completed the survey and marked variation in delivery of care was evident. Notable findings included: Fifty-nine percent of respondents indicated that analgesia was routinely initiated in transit (by paramedics) or within 30 minutes of arrival in the Emergency Department. One-quarter of respondents stated that more than 80% of their patients underwent surgery within 48 hours of admission. One-third of respondents considered non-hip, non-vertebral fractures to merit assessment of future fracture risk. One-third of respondents reported the presence of an Orthogeriatric Service in their hospital, and less than a quarter reported the presence of a Fracture Liaison Service. CONCLUSION: A Call to Action for all National Orthopaedic Associations affiliated with APOA is proposed to improve the care of fragility fracture patients across the region.

Long-Term Outcomes of Articular Surface Replacement (ASR) Implant in Hip Arthroplasty: A Single Institution Review.

Various metal-on-metal (MoM) total hip replacements (THRs) have been found to have high short-term failure rates due to adverse responses to metal debris (ARMD). As a consequence, several low-performing THRs have been removed off the market. The purpose of this research was to look at the at least five-year outcomes of patients who had MoM hip arthroplasty at our institution. In one specialised centre between 2007 and 2008, 24 Articular Surface Replacement (ASRTM, DePuy, Warsaw, IN, USA) MoM THRs (in 24 patients, mean age: 56.4 years) were implanted. DePuy ASR hip prosthesis for osteoarthritis or hip fractures were employed in the THR system. All patients were summoned back for a clinical assessment, and imaging was done as needed. The average period of follow-up was 8.0 years (6.0-10 years). In all, eight instances (33.3%) were discovered to have pseudotumors, four hips (16.7%) were revised, and one (4.1%) was operated for ARMD. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Oxford ratings improved statistically significantly five years after surgery in all three areas of pain, disability, and stiffness; however, there was no statistically significant change in the 36-Item Short Form Survey (SF-36) (mental) score. MoM hip arthroplasty had a greater revision incidence at five years in our group, presumably owing to the adoption of a smaller femoral head size.

Patterns of orthopaedic injury among hospitalised personal mobility device users and bicycle riders: a comparative study.

Introduction: Personal mobility devices (PMDs), such as electronic scooters or motorised bicycles, are efficient modes of transportation. Their recent popularity has also resulted in an increase in PMD-related injuries. We aimed to characterise and compare the nature of injuries sustained by PMD users and bicycle riders. Methods: This retrospective study compared injury patterns among PMD and bicycle users. 140 patients were admitted between November 2013 and September 2018. Parameters studied included patients' demographics (e.g. age, gender and body mass index), type of PMD, nature of injury, surgical intervention required, duration of hospitalisation and time off work. Results: Of 140 patients, 46 (32.9%) patients required treatment at the department of orthopaedic surgery. 19 patients were PMD users while 27 were bicycle riders. 16 (84.2%) patients with PMD-related injuries were men. PMD users were significantly younger (mean age 45 ± 15 years) when compared to bicycle riders (mean age 56 ± 17 years; P <0.05). A quarter (n = 5, 26.3%) of PMD users sustained open fractures and over half (n = 10, 52.6%) required surgical intervention. Among 27 bicycle users, 7.4% (n = 2) of patients sustained open fractures and 70.4% (n = 19) required surgical intervention. Both groups had comparable inpatient stay duration and time off work. Conclusion: PMD-related orthopaedic traumas are high-energy injuries, with higher rates of open fractures, when compared to bicycle injuries. In addition, PMD users are significantly younger and of economically viable age. Prolonged hospitalisation and time off work have socioeconomic implications. Caution should be exercised when using PMDs.

Kinematic aligned femoral rotation leads to greater patella tilt but similar clinical outcomes when compared to traditional femoral component rotation in total knee arthroplasty. A propensity score matched study.

PURPOSE: External rotation of femoral component in total knee arthroplasty (TKA) with reference to the posterior condyles is recommended in mechanical alignment (MA) to ensure optimum patella tracking. In kinematic knee alignment (KA) technique, femoral component is more internally rotated as the femoral resection is based on flexion-extension axis. This study aims to investigate the clinical and radiological outcomes of the patellofemoral joint in patients who underwent TKA using KA versus mechanical alignment. METHODS: A review of prospectively collected registry data of 378 consecutive cruciate retaining primary TKAs (P.F.C.® Total Knee System, DePuy Synthes, Massachusetts, United States) was performed. Propensity scoring was performed matching patients who received KA TKA (n = 93) to MA TKA (n = 93). Oxford Knee Score (OKS), Knee Society Score (KSS), Short-Form 36 (SF-36), range of motion as well as radiographs assessing patella tilt were compared at 6 months and 2 years after surgery. All patients received the same implant and had their patella resurfaced. RESULTS: OKS, KSS, physical component of SF-36 and satisfaction rates were comparable at both 6 months and 2 years after surgery. There was moderate association between preoperative and postoperative patella tilt in KA TKA (Cramer's V = 0.260, p < 0.05). Postoperatively, KA group had a greater number of patients with lateral patella tilt compared to the mechanical group (12 [12.9%] vs 1 [1.1%], p < 0.001). Patella tilts, however, resolved two years after surgery. CONCLUSION: The relative internal rotation of the femoral component in KA TKA results in greater incidence of lateral patella tilt postoperatively. Nevertheless, patella tilt resolution was noted at 2 years. LEVEL OF EVIDENCE: Level III Evidence-Retrospective Cohort Study.

Clinical and Radiological Outcomes Comparing Percutaneous Chevron-Akin Osteotomies vs Open Scarf-Akin Osteotomies for Hallux Valgus.

BACKGROUND: Minimally invasive surgeries have gained popularity due to less soft tissue trauma and better wound healing. To date, limited studies have compared the outcomes of percutaneous and open osteotomies. This study aims to investigate the clinical and radiological outcomes of percutaneous chevron-Akin osteotomies vs open scarf-Akin osteotomies at 24-month follow-up. METHOD: We reviewed a prospectively collected database in a tertiary hospital hallux valgus registry. Twenty-nine feet that underwent a percutaneous technique were matched to 58 feet that underwent open scarf and Akin osteotomies. Clinical outcome measures assessed included visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal score (AOFAS Hallux MTP-IP), and Short Form 36 (SF-36) Health Survey. Radiological outcomes included hallux valgus angle (HVA) and intermetatarsal angle (IMA). All patients were prospectively followed up at 6 and 24 months. RESULTS: Both groups showed comparable clinical and radiological outcomes at the 24-month follow-up. However, the percutaneous group demonstrated less pain in the perioperative period ( P < .001). There were significant differences in the change in HVA between the groups but comparable radiological outcomes in IMA at the 24-month follow-up. The percutaneous group demonstrated shorter length of operation ( P < .001). There were no complications in the percutaneous group but 3 wound complications in the open group. CONCLUSIONS: We conclude that clinical and radiological outcomes of third-generation percutaneous chevron-Akin osteotomies were comparable with open scarf and Akin osteotomies at 24 months but with significantly less perioperative pain, shorter length of operation, and less risk of wound complications. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Does obesity influence early outcome of fixed-bearing unicompartmental knee arthroplasty?

Obesity is a known major contributing risk factor for knee osteoarthritis (OA). It is also believed that obese unicompartmental knee arthroplasty (UKA) patients tend to have poorer outcome and possible early failure. The purpose of this study is to investigate the early outcome of obese UKA patients in a single institution. Patients who underwent fixed bearing medial UKA in between year 2005 and 2010 were included in this study. They were divided into four groups based on Body Mass Index (BMI): 25 kg/m2 (Control); 25-29.9 kg/m2 (Overweight); 30-34.9 kg/m2 (Obese); >35 kg/m2 (Severely Obese). Functional outcome was assessed using Knee Society Score (KSS), Oxford Knee Score (OKS) and Short-form 36 (SF-36). One-way ANOVA with Bonferroni post-hoc test was used to compare the four groups for quantitative variables. There were 673 patients in this study, no significant difference between the four BMI groups for gender and side of operated knee ( p > 0.05). The functional outcome of all four groups at 2 years were comparable (all p > 0.05). At a mean follow up of 5.4 (range 2.5, 8.5) years, 9 revision surgeries (1.3%) were identified. The mean duration from initial surgery to revision surgery was 49 months (Range 6, 90). Patients' pre-operative BMI did not influence the early outcome of UKA patients. However, patients with higher BMI had relatively lower functional score prior to the surgery and tended to be younger. This did not translate to early failure and the functional improvement was similar among all four groups.

Routine pre-operative group cross-matching in total knee arthroplasty: A review of this practice in an Asian population.

BACKGROUND: Routine pre-operative group cross-match (GXM) and post-operative haemoglobin level measurements are performed for all total knee arthroplasty (TKA) patients in many institutions. We aimed to determine whether this practice is justified, and to identify predictors for post-operative transfusion. MATERIALS AND METHODS: A retrospective review was performed on 226 TKA procedures performed between Jan. 2011 and Dec. 2013. Patients' demographics and clinical details including co-morbidities, pre-operative laboratory results, type of anaesthesia, surgery duration, post-operative haemoglobin level and transfusion requirement were reviewed. RESULTS: Overall transfusion rate was 10.6% (n=24). Cross-match to transfusion ratio was 6.5. The cross-match to transfusion ratio (C:T ratio) was measured as the ratio of number of units of blood cross-matched to units of blood transfused. In females, relative risk of transfusion between patients with pre-operative haemoglobin below 12.0 and those above or equal to 12.0 was significant at 4.53 (Confidence interval (CI) 2.16 to 9.53). The relative risk of transfusion between patients above 65 years of age compared to those below 65 years of age was 1.13 (CI 1.03 to 1.23). Multivariate analysis revealed advancing age (p=0.044) and lower preoperative haemoglobin (p<0.001) as significant variables associated with post-operative transfusion. CONCLUSION: Post-operative transfusion rates are low and excessive pre-operative GXM and post-operative haemoglobin checks are contributing to unnecessary medical costs. Predictors of blood transfusion risk in unilateral TKA in our cohort of Asian population were advancing age and lower pre-operative haemoglobin level. Type and screen tests should be performed for all other patients. LEVEL OF SCIENTIFIC EVIDENCE: 3.

Fixed Flexion Deformity After Unicompartmental Knee Arthroplasty: How Much Is Too Much.

BACKGROUND: The detrimental impact of postoperative fixed flexion deformity (FFD) after unicompartmental knee arthroplasty (UKA) is manifold. This study aims to define the amount of postoperative FFD that is clinically relevant after UKA. METHODS: Between 2005 and 2012, 803 patients who underwent a primary UKA at a tertiary hospital were prospectively followed up. They were categorized into 3 groups based on the amount of postoperative FFD: (1) 0° (control); (2) 1°-10° (mild FFD); and (3) >10° (severe FFD). RESULTS: There were 26 patients (3%) with severe FFD at 2 years after UKA. The Knee Society Function Score and Knee Score in the severe FFD group were 10 ± 4 and 10 ± 2 points lower than in the control group, respectively (P = .017 and P = .001). Similarly, the Oxford Knee Score and Physical Component Score in the severe FFD group was 5 ± 1 and 7 ± 2 points lower than in the control group, respectively (P = .033 and P < .001). CONCLUSION: This study suggests that postoperative FFD of >10° after UKA is associated with significantly poorer functional outcomes.