Shall We Not Pressurise It? Effects of Bone Cement Pressurisation on Mortality and Revision Following Hip Hemiarthroplasty for Neck of Femur Fracture Patients: A Comparative Cohort Study.

OBJECTIVES: This study aimed to compare 30-day post-operative mortality, and revision for aseptic femoral component loosening and all-causes following hip hemiarthroplasty performed with or without pressurisation of the bone cement in neck of femur fracture patients. METHODS: Design: Retrospective cohort study. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from 10th December 2007 (database inception) to 15th November 2023 (search date) were reviewed.Outcome Measures and Comparisons: Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurisation of the bone cement for outcomes 30-day post-operative mortality, revision for aseptic femoral component loosening, and revision for all-causes. RESULTS: 406 procedures among 402 patients, and 722 procedures among 713 patients were performed with and without pressurisation of the bone cement respectively. Mean ages were 83.1 and 84.3 years (p=0.018), with 72.2% and 68.6% (p=0.205) females in the pressurised and non-pressurised cement patient groups respectively. There were no differences in 30-day post-operative mortality (7.2% versus 8.2%; HR 0.89, 95%CI 0.46-1.73, p=0.727). There were no differences in all-cause revision (HR 1.04, 95%CI 0.27-4.04, p=0.953). No revisions were performed for aseptic loosening. Survival at 10 years post-operatively was 15.3% (95%CI 11.46-19.64) and 12.6% (95%CI 7.67-18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurisation respectively. CONCLUSIONS: There were no differences in 30-day post-operative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurisation. Bone cement pressurisation did not confer any advantages for revision outcomes which may be attributed in part to patients' high mortality rate and low survival beyond 10 years post-operatively. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating: A systematic review and meta-analysis of current evidence.

BACKGROUND: Supracondylar periprosthetic fractures, when amenable to fixation, can be treated by either retrograde intramedullary nailing (RIMN) or plating. There is paucity of evidence regarding the superiority of one fixation method over the other. This review aims to determine which fixation method leads to better functional outcomes and perioperative complications. HYPOTHESIS: Superiority of intramedullary nailing in terms of fracture healing and surgical complications when compared to distal femoral plating. MATERIALS AND METHODS: Using PRISMA guidelines, a systematic search was performed. Studies which reported comparative outcome data following the two interventions were included. Qualitative data analysis and narrative synthesis were reported. Pooled comparisons were conducted when similar quantifiable outcomes were reported in a minimum of three studies. RESULTS: A total of 151 records were generated by the search. Eight studies met the eligibility criteria so were included in the final analysis. The studies comprised a total of 407 cases, with a follow up period ranging from 1 to 15 years. 252 cases were treated with plate fixation and 155 with RIMN. All studies were mitigated by heterogeneity and methodological limitations. The review showed marked variation in descriptive fracture classifications. Narrative data synthesis was conducted. Although guarded by the methodological limitations of individual studies, outcomes showed that mean time to union was equivalent; 5.88 months for RIMN compared to 6.75 months in plating, standardised mean difference=0.28 (95% CI -0.02-0.58). Similarly, no statistically significant differences were reported between RIMN and plating for deep infection (OR:1.41 95%CI 0.40-5.00) and revision surgery (OR: 0.74, 95%CI 0.39-1.41). DISCUSSION: Clinical outcomes showed a tendency that favours intramedullary nailing; however, generalisation of results was not possible. Future priority must be awarded to higher quality research in the form of a collaborative multicentre observational studies to delineate appropriate major diagnostic categories, ultimately informing a large comparative trial using condition specific validated outcome measures. LEVEL OF EVIDENCE: III, meta-analysis.

Distal femoral fractures: A comparison between single lateral plate fixation and a combined femoral nail and plate fixation.

OBJECTIVES: Distal femoral fractures occur in patients with osteoporotic bone and also as a consequence of high energy trauma. The recognised treatment options include closed or open reduction of the fracture and fixation using a locking plate or a femoral nail. Both these fixation modalities have some drawbacks. There is a risk of metalwork failure with single lateral locking plates and limited distal fixation with intramedullary nails. Since January 2018, we started using augmented fixation of distal femoral fractures using a combination of a retrograde femoral nail and a lateral locking plate. This study compares the outcomes of single lateral femoral plating (SLP) and combined nail-plate fixation (NPF). METHODS: This is a single centre retrospective case control study including all patients who sustained distal femoral fractures (OTA 33-A2, 33-A3, 33-C, 33-V3B and 33-V3D) over the study period. Outcomes for SLP were compared to NPF. The principal outcome measure was fracture union. Secondary outcome measures were reoperation rate, mortality and post-operative weight bearing status. RESULTS: 67 distal femoral fractures were included in the study. 19 patients had peri­prosthetic fractures. 40 were treated by SLP, 27 were managed with NPF.  23 (58%) patients in the SLP group were given instructions to non-weight bear or Toe touch weight bear for 6 weeks post-surgery compared to 1 (4%) in the NPF group (p = 0.000004). 7 (18%) patients treated with SLP had metalwork failure due to a non-union compared to none treated with NPF (p = 0.04). 11 fractures in the SLP group failed to unite compared to no non-unions in the NPF group (p = 0.01). These differences were magnified when assessing older (>50 years old) patients. CONCLUSIONS: Augmented fixation of distal femoral fractures using a nail plate fixation provided significantly higher union and enabled early weightbearing compared to single plate fixation. We recommend nail plate fixation for the treatment of distal femoral fractures, particularly in osteoporotic fractures.

UK trial of the Osseointegrated Prosthesis for the Rehabilitation for Amputees: 1995-2018.

BACKGROUND:: Amputation of a limb impacts on patients' self-perception and quality of life. Prostheses directly anchored to the skeleton are being investigated, aiming to avoid soft tissue complications. OBJECTIVES:: We report outcome data for the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees Implant System with a minimum of 9-year follow-up. METHODS:: Eighteen transfemoral amputees received unilateral implants between 1997 and 2008. Five were implanted before a formalised protocol, called Osseointegrated Prosthesis for the Rehabilitation of Amputees, was developed. Mean follow-up of the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group is 11.4 years (1.8-18.6 years), while for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group it is 12.3 years (2.9-15.9). RESULTS:: The Kaplan-Meier cumulative survivorship is 40% for the Pre-Osseointegrated Prosthesis for the Rehabilitation of Amputees group and 80.21% for the Post-Osseointegrated Prosthesis for the Rehabilitation of Amputees group. Five implants (28%) have been removed, three (17%) for deep infection, one (5.6%) for chronic pain, later proven to be infected and one (5.6%) due to implant fracture secondary to loosening due to infection. Two patients (11%) have peri-implant infections suppressed with oral antibiotics. Eleven cases (61%) of superficial infection were successfully treated with antibiotics. 36-Item short-form health survey and Questionnaire for persons with a Transfemoral Amputation showed significant improvements in quality of life up to 5 years after implantation. CONCLUSION:: This small cohort of patients demonstrates osseointegrated prosthesis allows prolonged usage and improves patients' quality of life compared to conventional prostheses. CLINICAL RELEVANCE: These prostheses may provide a future gold standard for amputees and this study provides the first outcome data over such a time period to be reported from outside of the developers group.

Does it really spin? Intra-medullary nailing of segmental tibial fractures--a cadaveric study.

This study aims to quantify the effect of intra-medullary reaming on rotational displacement of both long diaphyseal segmental tibial fractures (Melis Type III) and short (Melis Type IV) in a cadaveric model with differing degrees of soft tissue stripping. Eighteen fresh-frozen cadaveric specimens (9 matched pairs), median age at death was 85 years (68-92) were used to perform a standardized reaming procedure for an intra-medullary tibial nail and the rotational displacement of the segmental fracture fragment (long and short diaphyseal fractures) was recorded. Rotational displacement was recorded using a goniometer and K-wires positioned in the proximal, segmental and distal fracture fragments. Type III fractures rotate more than Type IV fractures (p<0.0001). In Type III fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 11.7 SD 12), 13 (SD 16.5) and 307.3 (SD 118.1) degrees respectively. In Type IV fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 8.5 (SD 5.5), 12.7 (SD 9.9) and 135.3 (SD 147.1) degrees respectively. The use of a pointed reduction clamp or unicortical plate eliminated rotational displacement. Reaming is a major risk factor for rotational displacement of segmental tibial fractures irrespective of the degree of soft tissue stripping. Long diaphyseal segmental fractures rotate more than shorter segmental fractures. We recommend always clamping the fracture during reaming to avoid rotational displacement.

Minimally invasive reduction and fixation of displaced calcaneal fractures: surgical technique and radiographic analysis.

PURPOSE: The optimal treatment of calcaneal fractures is controversial. A specific subgroup of healthy patients has good outcomes with open reduction and internal fixation using an extensile lateral approach. However, there are many patients who do not fit into this category. Consequently, they are either denied surgical intervention or put at significant risk of developing complications as a result of open surgical intervention. Minimally invasive reduction and fixation (MIRF) of calcaneal fractures can restore the height, width, length and shape of the hindfoot in addition to restoring the orientation of the posterior facet of the calcaneus (Böhler's angle). METHODS: We present a series of 31 patients treated with minimally invasive reduction and fixation technique using threaded K wires and Steinmann pins as an alternative treatment method in patients who are not suitable for open reduction and internal fixation. RESULTS: The mean time to surgery from injury was six days (range one to ten days). The mean duration of surgery was 35 minutes (range 11-52 minutes). The mean followup was 14.9 months (range of seven to 30 months). The mean change in Böhler's angle and length of the calcaneus from intra-operative fixation to final followup were 18.7° and 4.7 mm, respectively. The complication rate was low and there was one case of a superficial wound infection and no cases of deep infection or peroneal impingement in this series. CONCLUSION: The MIRF technique with the use of threaded K wires has not been previously described in the literature. In our experience, the operative time is short and can be safely performed even in the presence of extensive soft tissue swelling in the immediate period following injury. The infection risk is low and calcaneal morphology was improved and maintained in terms of Böhler's angle. This technique is suitable to be considered in patients who have significant medical co-morbidities (smokers, diabetics, peripheral vascular disease) and in those patients who are not suitable for an extensile lateral approach and internal fixation.

Early failure of a mobile-bearing unicompartmental knee replacement.

Concerned by a perceived high revision rate, we retrospectively reviewed the survivorship of a series of 43 cemented, medial, mobile-bearing Preservation unicompartmental knee replacements implanted during a 2-year period at a single institution. The initial post-operative AP and lateral radiographs were independently assessed to test the hypothesis that suboptimal implantation of the prosthesis was responsible for early failure. An X-ray scoring system based on the criteria for assessing the Oxford mobile-bearing unicompartmental knee replacement was devised. The components of this score included assessment of prosthesis alignment, sizing and cementation. Nine (21%) LCS Preservation mobile-bearings prostheses had required revision at a mean of 22 months post-implantation. The commonest causes for failure were pain (44%) and tibial component loosening (33%). Analysis of post-operative radiographs showed no difference (n.s.) between the compound error scores for the revised and the surviving prostheses. No particular surgical error was identifiable leading to subsequent need for revision. The high failure rates shown in this study have led us to cease using this implant. The clinical relevance of this study is that the captive running track of the LCS mobile-bearing prosthesis may over constrain the meniscal component leading to early failure.

Detecting patient allergy: beware the LIE.

INTRODUCTION: Allergy detection is important in surgical patients. Historically, the focus has been on drug allergies. There is increasing focus on non-drug allergy, specifically latex, iodine and elastoplast. PATIENTS AND METHODS: The practice and knowledge of 24 pre-registration house officers was evaluated, with regard to patient allergy. For the second phase of the study, the cohort of 367 consecutive patients presenting to the orthopaedic pre-assessment clinic was prospectively assessed. RESULTS: This prospective study demonstrates that standard history-taking misses a large number (38%) of such allergies. CONCLUSIONS: With regard to allergy detection, we are living a LIE (by ignoring latex, iodine, elastoplast allergy). We suggest junior doctors should employ the mnemonic LIED (latex, iodine, elastoplast and drugs) when taking a medical history.

The relationship between gastro-oesophageal reflux symptoms and achalasia.

BACKGROUND AND AIMS: Patients with achalasia can experience heartburn, which may be misinterpreted as gastro-oesophageal reflux disease (GORD), leading to a delay in diagnosis and subsequent treatment. We investigated the relationship between gastro-oesophageal reflux (GOR) and reflux symptoms in a large cohort of patients with achalasia. METHODS: The symptoms of all patients with a manometric diagnosis of achalasia made over the past 15 years were studied. The types of treatment, onset and pattern of heartburn, lower oesophageal sphincter pressure (LOSP) and 24-h oesophageal pH studies were compared. RESULTS: A total of 110 out of 225 untreated (48.9%) and 57 out of 99 treated (57.6%) patients experienced heartburn. An oesophageal pH study was performed on 80 patients and GOR was found in only six out of 57 untreated (10.5%) and 10 out of 23 treated (43.5%) patients. A low LOSP (<10 mmHg) was associated with an increased risk of GOR [odds ratio (OR) 14.2; 95% confidence interval (CI) 1.6-128.7; P<0.02). Treated patients were also more likely to develop GOR (OR 7.9; 95% CI 2.0-32.1; P<0.005). Neither the LOSP nor previous treatment was, however, a predictor of heartburn. The timing of the onset of dysphagia and heartburn was categorized in 111 patients. There was no significant difference in mean (or median) LOSP between these three groups, indicating that the LOSP is unlikely to predict the occurrence of symptoms. CONCLUSIONS: Heartburn is common in patients with untreated and treated achalasia, but is a poor predictor of GORD. Such patients should always be investigated with a 24-h oesophageal pH study to clarify the presence of GORD.