Distal Femoral Replacement as a Primary Treatment Method for Distal Femoral Fractures in the Elderly.

Distal femoral fractures account for 3-6% of all femoral fractures with a similar demographic as patients suffering from proximal femoral fractures. The mortality risk can be high in such injuries, which has prompted NHS England to extend the scope of the Best Practice Tariff to include all fragility fractures of the femur. Poor bone quality, intra-articular extension, and significant comminution can make these fractures difficult to manage with fixation techniques, while early mobilisation is a key outcome in the treatment of this injury. In this study, a comprehensive literature search was performed based on keywords, and abstracts were reviewed to identify relevant articles. The following factors were analysed: time to surgery, time to full weight-bearing, the average hospital stay, post-operative mobility status, and complications. A total of 233 abstracts were identified using the pre-determined search criteria, and, subsequently, articles were excluded following author review. A total of 10 relevant articles were included in this review, with five used for review and comparison between distal femoral replacement (DFR) and fixation. This resulted in a sample of 200 patients treated with DFR with over 87% ambulatory at follow-up and a re-operation rate of 13.3% compared to 78% and 13.5%, respectively, in those treated with open reduction internal fixation (ORIF) procedure. Despite a limited pool of evidence, the literature suggests that DFR offers an option that potentially allows immediate weight-bearing and leaves most patients ambulatory at follow-up. Although DFR is more costly than other operative techniques, it avoids complications associated with fixation such as non-union and can reduce the risk of further surgery through direct complications or a need for delayed arthroplasty, which is deemed more complex secondary to fixation. Early mobilisation is a key step in reducing morbidity and mortality among this cohort of patients, and a procedure such as DFR should be more widely considered to help achieve this outcome.

Trainee performed total knee arthroplasty is safe and effective: A systematic review and meta-analysis comparing outcomes between trainees and consultants.

BACKGROUND: There are concerns that trainee performed knee arthroplasty (KA) may adversely affect patient outcomes. Demand for KA is projected to increase, and trainees must therefore be competent to perform it. METHODS: A systematic literature search was performed identifying articles comparing outcomes following trainee versus consultant surgeon performed primary KA. Outcomes included rate of revision surgery, rate of infection, operation time, length of stay and functional outcomes. A meta-analysis was conducted using Odds ratios (ORs) and weighted mean differences (WMD). A quality assessment of studies and qualitative analysis was performed. RESULTS: The analysis included 9 studies of 92,309 arthroplasties, 80,655 were performed by consultants, 11,654 by trainees. The mean age was 69.2. There was no significant difference between the two groups' rate of revision (OR 0.79; 95% CI 0.61-1.02; p = 0.07. Trainees were associated with a lower rate of infection (5 studies; OR 0.75; 95% CI 0.58-0.97; p = 0.03). There was no difference in the rate of neurological deficit, transfusion rate or thrombosis. There was no difference in operation time (5 studies; WMD 3.50; 95% CI -3.9-10.89; p = 0.35). The trainee group had less favourable functional outcome scores (7 studies; WMD -1.26; 95% CI -1.44--1.07; p < 0.01). However, this difference was not clinically significant. CONCLUSIONS: The study suggests that supervised trainees can achieve similar outcomes to consultant surgeons andin selected cases, trainee performed supervised KA is therefore safe and effective.

Subtalar arthroereisis for the treatment of the symptomatic paediatric flexible pes planus: a systematic review.

Subtalar arthroereisis has a controversial history and has previously been associated with high failure rates and excessive complications.A database search for outcomes of arthroereisis for the treatment of symptomatic paediatric flexible pes planus provided 24 articles which were included in this review, with a total of 2550 feet operated on.Post-operative patient-reported outcome measures recorded marked improvement. Patient satisfaction was reported as excellent in 79.9%, and poor in 5.3%. All radiological measurements demonstrated improvement towards the normal range following arthroereisis, as did hindfoot valgus, supination, dorsiflexion and Viladot grade.Complications were reported in 7.1% of cases, with a reoperation rate of 3.1%.Arthroereisis as a treatment for symptomatic paediatric flexible pes planus produces favourable outcomes and high patient satisfaction rates with a reasonable risk profile. There is still a great deal of negativity and literature highlighting the complications and failures of arthroereisis, especially for older implants.The biggest flaws in the collective literature are the lack of high-quality prospective studies, a paucity of long-term data and the heterogeneity of utilized outcome measures between studies. Cite this article: EFORT Open Rev 2021;6:118-129. DOI: 10.1302/2058-5241.6.200076.

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures.

AIMS: During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery. METHODS: This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. RESULTS: COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients. CONCLUSION: Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.

A systematic review and meta-analysis of trainee- versus consultant surgeon-performed elective total hip arthroplasty.

Total hip arthroplasty (THA) is one of the most commonly performed orthopaedic procedures. Some concern exists that trainee-performed THA may adversely affect patient outcomes. The aim of this meta-analysis was to compare outcomes following THA performed by surgical trainees and consultant surgeons.A systematic search was performed to identify articles comparing outcomes following trainee- versus consultant-performed THA. Outcomes assessed included rate of revision surgery, dislocation, deep infection, mean operation time, length of hospital stay and Harris Hip Score (HHS) up to one year. A meta-analysis was conducted using odds ratios (ORs) and weighted mean differences (WMDs). A subgroup analysis for supervised trainees versus consultants was also performed.The final analysis included seven non-randomized studies of 40 810 THAs, of which 6393 (15.7%) were performed by trainees and 34 417 (84.3%) were performed by consultants. In total, 5651 (88.4%) THAs in the trainee group were performed under supervision. There was no significant difference in revision rate between the trainee and consultant groups (OR 1.09; p = 0.51). Trainees took significantly longer to perform THA compared with consultants (WMD 12.9; p < 0.01). The trainee group was associated with a lower HHS at one year compared with consultants (WMD -1.26; p < 0.01). There was no difference in rate of dislocation, deep infection or length of hospital stay between the two groups.The present study suggests that supervised trainees can achieve similar clinical outcomes to consultant surgeons, with a slightly longer operation time. In selected patients, trainee-performed THA is safe and effective. Cite this article: EFORT Open Rev 2019;4:44-55. DOI: 10.1302/2058-5241.4.180034.

Mid-term clinical outcome following rotator cuff repair using all-suture anchors.

BACKGROUND: Symptomatic rotator cuff tears can cause significant pain and functional disturbance, with associated financial ramifications. Non-surgical management should always be considered initially, however if recalcitrant to these measures surgical intervention may involve open, arthroscopic-assisted mini-open or arthroscopic rotator cuff repairs. The use of trans-osseous sutures and suture anchors has been reported with good results, with no significant differences if the repair remains intact or recurrent tears occur. The role of traditional suture anchors has been assessed clinically and biomechanically, however there have been reports of pull out, anchor material found within joint and concerns with the amount of bone loss. The all suture anchor (ASA) is proposed to address these concerns with encouraging cadaveric, biomechanical results to date. METHODS: The two senior authors performed 31 arthroscopic rotator cuff repairs using ASA with a double row technique at the two study centres'. The patients were reviewed in clinic at one month, three months, 6 months and a year postoperatively. The patients were assessed with the Constant score and clinical range of motion of the shoulder in abduction, forward flexion, external rotation and internal rotation. The surgical technique and rehabilitation was the same for both surgeons. RESULTS: At a mean follow up of 10.2 months (range 3-12 months) the mean constant score was 77.1 (range 35-90), with a mean abduction of 139.6° (range 30-180°), external rotation of 43.4° (range 20-80°), and internal rotation to lumbar vertebrae 3-4 (range buttock to lumbar vertebra 1). There has been one re-rupture to date. CONCLUSIONS: The functional and clinical results in our study are comparable to those reported in literature using standard anchors.

A systematic review and meta-analysis of platelet-rich plasma versus corticosteroid injections for plantar fasciopathy.

PURPOSE: To determine whether platelet-rich plasma (PRP) injections are associated with improved pain and function scores when compared with corticosteroid injections for plantar fasciopathy. METHODS: A systematic review of published literature was performed for studies comparing PRP injections and corticosteroid injections for plantar fasciopathy. Studies were assessed using the Cochrane Risk of Bias Tool and the Newcastle Ottawa Scale (NOS). The primary endpoint was pain and function score at three and six month follow-up. Sensitivity analysis was performed for high quality studies and randomised studies. RESULTS: Ten studies totalling 517 patients were included. Seven studies were randomised. All studies included patients who had failed conservative measures and excluded patients with systemic illness and other causes of foot pain. Studies reported outcomes using the visual analogue score (VAS) and American Orthopaedic Foot and Ankle Score (AOFAS). At 3-month follow-up, PRP injections were associated with improved VAS scores (standard mean difference [SMD], -0.66; 95% CI, -1.3 to -0.02; p = 0.04) and AOFAS scores (SMD, 1.87; 95% CI, 0.16-3.58; p = 0.03). At 6-month follow-up, there was no difference in VAS score (SMD, -0.66; 95% CI, -1.65 to 0.3; p = 0.17) or AOFAS scores (SMD, 1.69; 95% CI, -1.06 to 4.45; p = 0.23). No studies reported adverse event rates or cost analysis. There was no difference in pain or function score at one, six- or 12-month follow-up. Sensitivity analyses of high-quality studies showed no differences between the PRP and steroid group at any of the follow-up points. CONCLUSIONS: PRP injections are associated with improved pain and function scores at three month follow-up when compared with corticosteroid injections. Information regarding relative adverse event rates and cost implications is lacking. Further, large-scale, high-quality, randomised controlled trials with blinding of outcome assessment and longer follow-up are required.

"Meniscal" scar as a landmark for the joint line in revision total knee replacement.

AIM: To determine whether tissue identified at the joint line was actually remnant "meniscal" scar tissue or not. METHODS: Nine patients undergoing revision knee surgery following informed consent had meniscal scar tissue sent to the histology department for analyses. All revisions were performed where joint line had been raised or lowered at earlier surgery. Although preoperative radiographic evaluations suggested that the joint line had been altered, intraoperatively there was scar tissue at the level of the recreated joint line. This scar tissue has traditionally been described as meniscal scar, and to identify the origins of this tissue, samples were sent for histological analyses. The tissue samples were stored in formalin, and embedded and sectioned before undergoing histochemical staining. All samples underwent macroscopic and microscopic examination by a histopathologist who was blind to the study aims. The specific features that were examined included tissue organisation, surface and central composition, cellular distribution including histiocytes, nuclear ratio and vasculature. Atypical and malignant features, inflammation and degeneration were specifically looked for. A statistical review of the study was performed by a biomedical statistician. RESULTS: The histological findings for the nine patients showing the macroscopic and microscopic findings, and the conclusion are outlined in a Table. The histological analyses were reviewed to determine whether the tissue samples were likely to be meniscal scar tissue. The response was yes (2, 22%), no (6, 67%) and maybe (1, 11%) based on the conclusions. The results were "yes" when on macroscopy, firm cream tissue was identified. In these two "yes" samples, microscopic analyses showed organised fibrous tissue with focal degenerative areas with laminated pattern associated with histiocytes peripherally but no inflammation. The "no" samples were assessed macroscopically and microscopically and were deemed to have appearances representing fibrous synovial tissue and features in keeping with degenerate scar tissue or connective tissue. One sample was indeterminate and microscopically contained fibro-collagenous tissue with synovial hyperplasia. It also contained some degenerate hyalinised tissue that may represent cartilage, but the appearances were not specific. CONCLUSION: Based on our pilot study, we recommend reliance on a number of markers to identify the joint line as outlined above, and to exercise caution in using the "meniscal" scar.

The Role of Wrist Fusion and Wrist Arthroplasty in Rheumatoid Arthritis.

Rheumatoid arthritis is the most common form of inflammatory arthritis with a predilection for the hand and wrist. The aggressive nature of the disease can lead to severe joint destruction causing significant disability. Surgical options for pan-carpal arthritis include total wrist arthroplasty and total wrist fusion both with varying outcomes, yet both have a role in the carefully selected patients. Fusion remains a popular procedure with consistent reliable results with few complications. We present a review of current evidence, indications and guidance for both fusion and arthroplasty in rheumatoid arthritis.

Does a dedicated orthopaedic day surgery list improve delivery of trauma services?

Our aim was to implement a 23-hour pathway for uncomplicated trauma to overcome delays and improve efficiency. A retrospective review of a single surgeon series of 105 consecutive patients operated on between July 2010 and July 2011 was performed. With recently revised trauma tariffs, we believe an efficient day surgery trauma list improves theatre utilisation, reduces inpatient bed demands, prioritises major and sub-specialist trauma and delivers patient satisfaction.

Iatrogenic posterior tibial nerve division during a combined anterior ankle arthroscopy with an additional posterolateral portal.

Ankle arthroscopy is an important diagnostic and therapeutic technique in the management of ankle disorders. Nowadays ankle arthroscopy provides good to excellent results (up to 90%) in the treatment of certain intra-articular disorders. Due to the superficial location of ankle joint and the abundance of overlying neurovascular structures, complications reported in ankle arthroscopy are greater than those reported in other joints. We present the first reported case of a complete division of the posterior tibial nerve during an anterior ankle arthroscopy combined with an additional posterolateral portal. This was due to a poorly controlled use of the arthroscopic instruments.

Analysing the outcome of surgery for chronic Achilles tendinopathy over the last 50 years.

AIM: To determine an association between when the study was performed, the robustness of the study and the outcomes for insertional and non-insertional Achilles tendinopathy surgery. METHODS: We performed a systematic review in accordance with the PRISMA guidelines to assess the methodology of studies investigating the outcome of surgery in chronic Achilles tendinopathy over the last 50 years to identify any trends that would account for the variable results. The Coleman Methodology Scores were correlated with the reported percentage success rates and with the publication year to determine any trends using Pearson's correlation. RESULTS: We identified 62 studies published between 1964 and 2014 reporting on a total of 2923 surgically treated Achilles tendinopathies. The average follow-up time was 40 mo (range 5-204 mo), and the mean reported success rate was 83.5% (range 36%-100%). The Coleman Methodology Scores were highly reproducible (r = 0.99, P < 0.01), with a mean of 40.1 (SD 18.9, range 2-79). We found a negative correlation between reported success rate and overall methodology scores (r = -0.40, P < 0.001), and a positive correlation between year of publication and overall methodology scores (r = 0.46, P < 0.001). CONCLUSION: We conclude that although the success rate of surgery for chronic Acilles tendinopathy described in the literature has fallen over the last 50 years, this is probably due to a more rigorous methodology of the studies.

Chondromyxoid fibroma management: a single institution experience of 22 cases.

BACKGROUND: Several different strategies have been reported for the treatment of chondromyxoid fibromas, all with variable outcomes and high recurrence rates. METHODS: We report on 22 consecutive cases of chondromyxoid fibromas treated by intralesional curettage, four of which had adjuvant cementation at our institution between 2003 and 2010. We assessed the functional outcome using the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS: Nine males and 16 females with a mean age of 36.5 years (range 11 to 73) and a mean follow-up of 60.7 months were included in the study. Local recurrence occurred in two patients (9%) within the first 2 years following the index procedure. This was treated by re-curettage only of the residual defect. Two postoperative complications occurred: a superficial wound infection in one patient and a transient deep peroneal nerve neurapraxia in the other. The mean postoperative MSTS score was 96.7%. CONCLUSIONS: Intralesional curettage and cementation is as an effective treatment strategy for chondromyxoid fibromas, providing satisfactory functional results with a low recurrence rate. Careful case selection with stringent clinical and radiographic follow-up is recommended.

Van Nes rotationplasty as a treatment method for Ewing's sarcoma in a 14-month-old.

INTRODUCTION: In recent years, the rotationplasty procedure has become popular amongst tumour surgeons as an alternative to endoprosthetic replacement or amputation. There are very few documented cases of this technique in young patients with malignancy. PRESENTATION OF CASE: We describe an extremely rare case of Ewing's sarcoma in a 14-month-old boy that involved the entire length of the left femur. At initial presentation, pulmonary metastatic spread had occurred and there was no neurovascular involvement. Complete response to neo-adjuvant chemotherapy was achieved prior to performing the definitive surgical procedure. DISCUSSION: This case highlights the many reconstructive options and difficulties encountered in managing such extremely young patients with aggressive malignant disease. In this case, a complete femoral excision was necessary and various treatment options were explored. These included irradiation and re-implantation, endoprosthetic replacement and manufacturing a custom growing prosthesis. Taking future functional, psychological and social implications into consideration, we performed a total femoral excision and Van Nes rotationplasty of the tibia at our institute. Histological analysis of the tumour resection showed clear tumour margins and at 1 year clinical review, the patient demonstrates good functional outcome with no evidence of disease recurrence. CONCLUSION: Van Nes rotationplasty is a viable reconstructive option in young patients with sarcoma of the femur. We believe this to be the youngest reported case of rotationplasty in current literature.

Patella fracture after medial patellofemoral ligament reconstruction using suture anchors.

The medial patellofemoral ligament (MPFL) acts as a soft tissue restraint to lateral subluxation of the patella, and is frequently damaged following patellar dislocation. A number of techniques for repair or reconstructions of the MPFL have been reported. We report two cases of patellar fracture following MPFL reconstruction utilizing suture anchors and bone tunnels that do not completely traverse the patella. The first case occurred seven months after surgery and the second case was at six weeks following surgery. There have been previous reports of patellar fracture following MPFL reconstruction, particularly when patellar tunnels completely traverse the patella. The authors decided to use suture anchors to reduce the risk of patellar fracture, and they feel that the fractures reported in this paper resulted from surgical error rather than system error. We feel that this is an important learning point when initially using this technique, and should be disseminated to other surgeons who undertake this surgery.

Implant use for primary hip and knee arthroplasty: are we getting it right first time?

Implants used for hip and knee arthroplasties have recently come under increased scrutiny. In England, a large variety of prostheses are currently being used. With the need for savings within the NHS of up to £20 billion over the next five years, we should be 'getting it right first time' by using the most reliable implants with proven survivorship. The 8th Annual Report from the NJR (2011) reporting on prostheses used in 2010 was analysed to determine whether implants had published survivorship data. This study demonstrates that the majority of implants did have long-term results but a small percentage had no published data. The cost of these implants was calculated to see if the implants provided best value for money based on survivorship. Implant choice was also correlated to revision rates published in the NJR report (2011) to help determine whether their continued use was justified.

Repair of osteochondral defects in joints--how to achieve success.

Osteochondral defects in the knee are difficult to repair because intrinsic healing of cartilage is poor and gradual progression to "early-onset" osteoarthritis leads to severe pain and disability. Of all methods tested to achieve regeneration of hyaline cartilage and long-lasting repair, autologous chondrocyte transplantation (ACI-C and MACI) has been the most successful with 80% of good results and graft survival in this unit in a very large series over 10 years. The repair mechanism is unclear but our work shows that the criteria for success are: young patient age, no previous operative procedures on the defect, no obesity, no smoking, defect on femoral condyles or trochlea and no pre-existing degenerative joint changes. Future research is aimed at non-transplantation, single-stage procedures aided by use of new scaffolds and growth factors and the extension of such techniques into arthritic joints.

Intra-articular extraskeletal myxoid chondrosarcoma of the ankle.

We describe an extremely rare case of an intra-articular extraskeletal myxoid chondrosarcoma causing devastating destruction to the ankle joint in a 71-year-old woman, which had been originally excised as a ganglion cyst. Histological analysis of the lesion revealed an extraskeletal myxoid chondrosarcoma. The patient proceeded to curative surgery with a below-the-knee amputation.

The perioperative management of skeletal metastases.

Bone metastasis is a common problem affecting a significant proportion of patients with metastatic cancer. Bone metastasis can present in a number of ways and the patients may need surgical stabilisation of their lesions. There are many important considerations in the care of these patients that need to be borne in mind including their increased anesthetic risks and potential risk of complications. There are continuous developments in the prevention, diagnosis and treatment with advances in imaging, orthopaedic technique and medication, particularly radiopharmaceuticals and cytotoxic, endocrine treatments with newer treatments based around the tumour cell-osteoclast interaction. Having a better understanding of these considerations and developments is important in allowing the optimisation of the care of the patient with bone metastasis.