Does the osteonecrotic volume/other factors predict progression to total knee arthroplasty in spontaneous osteonecrosis of the knee? An MRI study.

Background: The aim of this study is to determine whether the volume of the osteonecrotic lesion in spontaneous osteonecrosis of the knee (SONK) or other prognostic factors predict progression to total knee arthroplasty (TKA). The secondary aim is to analyse co-relation of volume of osteonecrotic lesion versus other prognostic factors The authors hypothesize that a greater osteonecrotic volume predicts progression to TKA. Materials and methods: A retrospective study was conducted at a single tertiary hospital. All patients under the care of a single surgeon with magnetic resonance imaging (MRI)-proven SONK were included from the period of January 2011 to January 2018. Survival analysis was conducted to evaluate for progression to TKA based on volume and location of osteonecrotic lesion. Univariate and multivariate analyses were performed to identify potential risk factors for TKA. Results: 42 patients with MRI-proven SONK were evaluated. 9 patients (21.4 %) required TKA. There was no significant association between progression to TKA with volume of the osteonecrotic lesion. Other factors such as age, gender, body mass index, degree of bony edema and cartilage damage, presence of meniscal tear and subchondral fractures and location of osteonecrotic lesion were also not significant. Conclusion: The volume of the osteonecrotic lesion and other evaluated prognostic factors were not predictive of the progression to TKA for patients with SONK.

Current concepts of bone grafting in trauma surgery.

Bone graft in trauma surgery is commonly used in managing bone defects, non-union, fracture related infections, arthrodesis or to provide structural support in fractures. A variety of bone grafts are made available to the treating physician, which includes autograft, allograft and bone graft substitutes. The future of bone grafting in trauma surgery is exciting with the incorporation of technological advancement such as gene therapy, 3D-printing and tissue engineering. Regardless, there are still limitations to what we understand regarding current bone grafting techniques with conflicting literature on their clinical utility and indication. The aim of this review article therefore is to take a step back and critically evaluate the current concepts of bone grafting in trauma surgery, with special emphasis made on reviewing the types of bone graft, biology of bone graft incorporation and indication for its use in various clinical scenarios.

Telemedicine use in orthopaedics: Experience during the COVID-19 pandemic.

INTRODUCTION: With a recent resurgence of the 2019 coronavirus disease (COVID-19) cases globally, an increasing number of healthcare systems are adopting telemedicine as an alternative method of healthcare delivery in a bid to decrease disease transmission. Continued care of orthopaedic patients in the outpatient setting during the coronavirus disease of 2019 era can prove challenging without a systematic workflow, adequate logistics, and careful patient selection for teleconsultation. The aim of this paper is to describe our single-centre experience with the application of telemedicine in our orthopaedic practice, and its effectiveness in maintaining outpatient follow-up of orthopaedic patients. METHODOLOGY: We describe our centre's telemedicine model of care for orthopaedic patients on the outpatient follow-up - which includes workforce assembly, population health and target patients, logistics and communications, and overall workflow - with roles and responsibilities of involved people portrayed in detail. RESULTS: Feedback from both patients and orthopaedic surgeons reflected high satisfaction rates with care provided, noting minimal communication and clinical barriers compared to face-to-face consultations. Whilst not without limitations, our protocol allowed for rapid adoption of telemedicine in line with a national-wide initiative to digitize healthcare. DISCUSSION: The implementation of teleconsultation services at our orthopaedic centre has provided an effective method of healthcare delivery while enforcing social distancing measures - which proves vital in combating the spread of COVID-19 and ushering in a new normal.

A Pragmatic and Evidence-Based Approach to Mallet Finger.

A mallet finger is a common injury that results from a sudden flexion force on an extended distal phalanx or rarely, from hyperextension of the distal interphalangeal joint. Mallet finger can be purely tendinous or bony when associated with an avulsion fracture. The management of this injury is largely conservative with the use of a splint, although surgery may be indicated for select patients. There is little consensus on the indications for surgery or the suitable surgical technique. The aim of this review article is to provide a pragmatic and evidence-based approach to mallet finger that will guide the treating surgeon in providing best care for their patient.

Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore.

Undertreatment of osteoporosis after hip fracture increases the risk of death, disability, recurrent osteoporotic fractures, and financial burden. Only half were compliant with osteoporosis medications. Elderly patients were less persistent and compliant to treatment. Denosumab was associated with a higher proportion of days covered by osteoporosis medications than oral bisphosphonates. PURPOSE: The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications. METHODS: Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated. RESULTS: Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year. CONCLUSION: Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.

Intraoperative periprosthetic femur fracture during bipolar hemiarthroplasty for displaced femoral neck fractures.

INTRODUCTION: We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted. MATERIALS AND METHODS: 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically. RESULTS: There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65-10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47-8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction. CONCLUSION: The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications.

The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture.

INTRODUCTION: Pertrochanteric fractures after low-energy trauma are common among osteoporotic patients. Although the use of intramedullary devices to treat such fractures is becoming increasingly popular, there is a paucity of data comparing the outcomes of the use of short cephalomedullary nails (SCN) with the use of long cephalomedullary nails (LCN). This study aimed to compare the outcomes of treatment using LCN with treatment using SCN for patients with osteoporotic pertrochanteric fractures. METHODS: A retrospective review of 64 patients with osteoporotic pertrochanteric fractures who were treated with either LCN or SCN and had a minimum follow-up of one year was performed. Primary outcome measures include complications, revision surgeries and union rates. Secondary outcome measures include duration of surgery, estimated blood loss, length of hospital stay, and ambulatory and mortality status at one year. RESULTS: There was no significant difference in the clinical and functional outcomes of the patients who were treated with LCN and those who were treated with SCN. However, there was a higher incidence of heterotopic ossification in the latter group, and a slightly greater average estimated blood loss and duration of surgery in the former group. Patients treated with LCN tended to be more osteoporotic. CONCLUSION: Our study found no significant difference in terms of complications, revision surgeries, union rates and ambulatory status between the patients who were treated with LCN and those who were treated with SCN. Both LCN and SCN provided safe and reliable outcomes in the treatment of osteoporotic pertrochanteric fractures.

Cemented hemiarthroplasty in traumatic displaced femoral neck fractures and deep vein thrombosis: is there really a link?

INTRODUCTION: Traumatic displaced femoral neck fractures in the elderly can be treated with cemented or uncemented hemiarthroplasty with good outcomes. Earlier studies reported a higher incidence of deep vein thrombosis (DVT) associated with cemented prostheses in elective total hip or knee arthroplasty. In addition, the hypercoagulable state after a traumatic femoral neck fracture and possible thrombogenic properties of bone cement could put these patients at greater risk for thromboembolism. We aimed to compare the incidence of DVT and progression to pulmonary embolism (PE) or mortality in cemented and uncemented hemiarthroplasty. METHODS: The data of 271 patients treated with cemented or uncemented hemiarthroplasty after a traumatic displaced femoral neck fracture was retrospectively analysed for the incidence of DVT. The level of thrombosis, progression to PE and mortality were compared. RESULTS: There were 133 (49.1%) patients with cemented hemiarthroplasty, while 138 (50.9%) had uncemented hemiarthroplasty. The patients had an average age of 76.6 (range 53-99) years and 11 (4.1%) patients had DVT. There were no significant differences in development of DVT, level of thrombosis, PE and mortality regardless of whether a cemented or an uncemented prosthesis was used. CONCLUSION: Cemented hemiarthroplasty is not associated with higher risks of DVT, PE or mortality in patients with traumatic displaced femoral neck fracture. Cemented prostheses can be safely used for this group of patients.

Forklift-Related Crush Injuries of the Foot and Ankle.

BACKGROUND: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. METHODS: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients' demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. RESULTS: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). CONCLUSION: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. LEVEL OF EVIDENCE: Level IV retrospective case series.

Residual knee pain and functional outcome following total knee arthroplasty in osteoarthritic patients.

PURPOSE: Total knee arthroplasty (TKA) is a successful and safe elective operation in managing patients with severe osteoarthritis of the knee. However, the presence of residual knee pain (RKP) post-TKA can adversely affect patient satisfaction and functional outcome. Hence, the aim of this paper is to identify the incidence, progression of knee pain, functional outcome post-TKA and possible predictive factors for the development of RKP post-TKA. METHODS: A retrospective review of 357 patients was conducted with a minimum follow-up period of 2 years. Predictive factors reviewed include the patients' demographics, co-morbidities, type of implants and patellar management. For functional outcome, the patient's Knee Society Score (KSS) and Western Ontario and McMaster Universities Index of Osteoarthritis scores were analysed. To determine presence and severity of RKP, the sub-score for pain in the KSS was utilised. RESULTS: In total, 31.1 and 28.9% of the patients were found to have RKP at 1 and 2 years, respectively, though their functional outcome scores continued improving from 1 year. Ischaemic heart disease (IHD) patients were more likely to have RKP and poorer functional outcome at 1 year. Males and patients with posterior-stabilised implants were found to have better functional outcome at 1 and 2 years, respectively. CONCLUSIONS: Almost a third of the patients continued to have RKP at 2 years post-TKA, with factors such as gender, presence of IHD and implant type significantly associated with the development of RKP and/or poorer functional outcome scores. By recognising the incidence and predictive factors for RKP, physicians will be able to better manage their patients' expectations and optimise their pre-morbid status pre-operatively. LEVEL OF EVIDENCE: III.

Impact of trimalleolar ankle fractures: how do patients fare post-operatively?

BACKGROUND: We aim to evaluate the clinical and functional outcome of trimalleolar fractures and the ability of patients to return to sporting activities. METHODS: A retrospective review of 31 patients with operatively managed trimalleolar fractures was conducted. Their Olerud and Molander scores and ability to return to sports was analyzed at 1 year postoperatively. RESULTS: Dislocations were more likely to result from trimalleolar fractures (p<0.001). 11 (52.4%) of our patients had residual pain at 1 year. 13 (61.9%) and 10 (47.6%) had persistent ankle stiffness and swelling. Out of 12 patients who were involved in sports pre-operatively, only 4 (33.3%) patients were able to return to sports. 3 (25%) patients were unable to do sports at all. Increasing posterior malleolar fragment size correlates with poorer functional outcome. CONCLUSIONS: Patients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures. Residual deficits affect the majority of our patients and a notable proportion was unable to return to sporting activities.

Functional outcome and limitation of sporting activities after bimalleolar and trimalleolar ankle fractures.

BACKGROUND: Ankle fractures are extremely common. However, the outcomes of operatively treated bimalleolar and trimalleolar ankle fractures remain unclear. We aimed to evaluate and compare the functional outcomes of operatively treated bimalleolar versus trimalleolar ankle fractures and the ability of patients to return to sporting activities. METHODS: A retrospective review of all patients with operatively treated ankle fractures for a period of 2 years was performed. Demographics, fracture pattern, operative details, postoperative radiographs, and complications were extracted and analyzed statistically. Outcome variables were union rates, pain ratings using the visual analogue scale (VAS) and the Olerud and Molander (O&M) score, ability to return to sporting activities, satisfaction with surgery, and surgical complications. RESULTS: Forty-seven patients with bimalleolar and trimalleolar ankle fractures were recruited. At 1 year postoperatively, most patients regained good function and had good to excellent O&M scores. There were no notable differences in terms of VAS and O&M scores for both the bimalleolar and trimalleolar group. However, 26 (55.3%) of 47 patients had residual pain. Twenty-nine (61.7%) patients complained of stiffness, and 21 (44.7%) patients had ankle swelling. Of 33 (70.2%) patients who were involved in sporting activities prior to the ankle injury, 9 of 33 (27.3%) were able to return to preinjury level of sporting activities with no difficulties. Of the 33 patients, 18.2% were unable to do sports activities at all. CONCLUSION: The majority of our patients recovered well in their second year despite some residual deficits. We found no difference in functional outcome between bimalleolar and trimalleolar ankle fractures, although it is of great concern that a notable number of patients will not return to sporting activities. Residual symptoms and functional limitation after ankle fracture must be emphasized to patients to manage postoperative expectations. LEVEL OF EVIDENCE: Level II, retrospective case series.