Impact of Pronator Quadratus Muscle Tear in Distal Radius Fractures on Patient Outcomes: Analyses of 55 Patients in a Volar Locking Plate Arm of a Randomized Clinical Trial.

Background The advantage of pronator quadratus (PQ) repair following internal fixation via the volar approach in distal radius fracture (DRF) surgery remains unconfirmed in the literature. The aim of this study was to compare grip strength, patient-reported outcomes, and functional results between patients with an intact PQ and those with a ruptured PQ before undergoing surgery with a volar locking plate for dorsally displaced unstable extra-articular DRFs. Methods A total of 120 patients aged 55 years and older were included in a randomized controlled trial comparing a volar locking plate with a dorsal nail plate. Of the 60 patients randomized to the volar plate group, the integrity of the PQ muscle was recorded during surgery for 55 patients, who were included in this study. The outcomes measured were the Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE) score, the EQ-5D index, the visual analog scale (VAS) score, grip strength, and range of motion (ROM). Results The median age was 67 years (range 55 to 88), and the one-year follow-up rate was 98%. Patients with an identified intact PQ (28/55) before surgical release had better QuickDASH scores after one year (2.5 vs 8.0, mean difference 5.5, 95% CI: 1.3 to 9.8, p=0.028). Patients in the intact group also had better EQ-5D Index scores after one year (0.94 vs 0.85, mean difference 0.089, 95% CI: 0.004 to 0.174, p=0.031), and demonstrated better grip strength throughout the trial; after one year: 24 kg vs 20 kg (mean difference 3.9; 95% CI: 0.3 to 7.6, p=0.016). After one year, the intact group had regained 96% of their grip strength and the nonintact group had regained 93% of their grip strength compared to the uninjured side. The observed differences may be of questionable clinical importance, as they were lower than those of previously proposed minimal clinically important differences (MCIDs). Conclusions Patients with a DRF and a ruptured PQ prior to surgery exhibited higher QuickDASH scores and lower EQ-5D index scores after one year. The integrity of the PQ should be reported in future studies.

Non-operative versus operative treatment of suprasyndesmotic ankle fractures: protocol for a prospective, multicentre, randomised controlled trial.

INTRODUCTION: Surgery is widely recognised as the treatment of choice for suprasyndesmotic ankle fractures, because of the assumption that these injuries yield instability of the ankle joint. Stability assessment of ankle fractures using weightbearing radiographs is now used regularly to guide the treatment of transsyndesmotic and infrasyndesmotic ankle fractures. Patients with a congruent ankle joint on weightbearing radiographs can be treated non-operatively with excellent results. Weightbearing radiographs are, however, rarely performed on suprasyndesmotic fractures due to the assumed unstable nature of these fractures. If weightbearing radiographs can be used to identify suprasyndesmotic fractures suitable for non-operative treatment, we may save patients from the potential burdens of surgery.Our aim is to compare the efficacy of operative and non-operative treatment of patients with suprasyndesmotic ankle fractures that reduce on weightbearing radiographs. METHODS AND ANALYSIS: A non-inferiority randomised controlled trial involving 120 patients will be conducted. A total of 120 patients with suprasyndesmotic ankle fractures with an initial radiographic medial clear space of <7 mm will be subjected to weightbearing radiographs. If the tibio-talar joint is completely reduced, we will randomise in a 1:1 ratio to either operative treatment including reduction and fixation of the syndesmosis or non-operative treatment with an orthosis. The primary study outcome is patient-reported ankle function and symptoms as measured by the Olerud-Molander Ankle Score at 2-year follow-up. Secondary outcomes include the Manchester-Oxford Foot Questionnaire, range of motion, radiographic results and rates of adverse events. ETHICS AND DISSEMINATION: The Regional Committee for Medical and Health Research South East, group A (permission number: 169307), has granted ethics approval. The results of this study will provide valuable insights for developing future diagnostic and treatment strategies for a common fracture type. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION NUMBER: NCT04615650.

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme.

INTRODUCTION: Hip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for early surgery of hip fractures, no assessment of other evidence-based measures existed. We wanted to assess, test, implement and measure the impact of a quality improvement (QI) programme consisting of key elements proven to be important in the treatment of hip fractures. METHODS: We formed a multidisciplinary QI team, consisting of several specialists in different fields. The QI team assessed multiple possible process measures for inclusion in the programme and selected six measurable interventions for implementation: early surgery, correct administration of prophylactic antibiotics, surgery using proven methods and expertise, a multidisciplinary patient pathway and secondary fracture prevention. The improvement process was monitored by a statistical process control chart (SPC). Complications, reoperations and mortality were compared before (n=293) and after (n=182) the intervention. RESULTS: The SPC analyses indicated increasing adherence with all interventions throughout the improvement programme, and sustainability 7 years later. The last four periods showed a stable adherence above 90%. We found 60% reduction in major complications after the implementation of the improvement programme, from 19.1% to 7.7% (HR: 0.38 (95% CI: 0.23 to 0.61, p=0.0007). The need for reoperations due to complications fell from 12.6% to 4.9% (HR: 0.37 (95% CI: 0.21 to 0.67, p=0.0054). We did not find a difference in post-operative mortality after the implementation of the QI programme (HR: 0.95 (95% CI: 0.74 to 1.2, p=0.645). CONCLUSION: Our multiprofessional improvement programme achieved almost full adherence within 2 years and was sustainable 7 years later. The quality and safety of the care process were improved and led to a substantial and sustainable decrease in complications and reoperations.

Total Hip Arthroplasty Leads to Better Results After Low-Energy Displaced Femoral Neck Fracture in Patients Aged 55 to 70 Years: A Randomized Controlled Multicenter Trial Comparing Internal Fixation and Total Hip Arthroplasty.

BACKGROUND: The optimal treatment of displaced femoral neck fractures in patients 55 to 70 years old remains controversial. The aim of the present study was to assess the effect of closed reduction and internal fixation with cannulated screws (IF) compared with total hip arthroplasty (THA) on hip pain and function, with use of data for outcome measures, complications, and reoperations. METHODS: This multicenter randomized controlled trial included all patients 55 to 70 years old who presented with a low-energy displaced femoral neck fracture between December 2013 and December 2018. Patients were randomly allocated to undergo either IF or THA. The primary outcome was the Harris Hip Score (HHS) at 12 months postoperatively. Secondary outcomes were the HHS at 4 and 24 months postoperatively, Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), health-related quality of life (EQ-5D-3L [EuroQol 5 Dimensions 3 Levels] index score and EQ-VAS [visual analogue scale]), VAS for pain, and VAS for patient satisfaction at 4, 12, and 24 months postoperatively. Complications and reoperations were continuously monitored. The primary analyses were performed according to the intention-to-treat principle. RESULTS: A total of 102 patients with a mean (± standard deviation) age of 63.7 ± 4.2 years were allocated to IF (n = 51) or THA (n = 51). The mean difference in the primary outcome, the HHS at 12 months postoperatively (5.3; 95% confidence interval, 0.9 to 9.7; p = 0.017), was below the predefined minimal clinically important difference of 10 points. However, patients who underwent THA had a significantly higher HHS at 4 and 12 months, better OHS at 4 and 12 months, and better HOOS at 4, 12, and 24 months postoperatively. Patients who underwent THA also reported better health-related quality of life at 4 months postoperatively and reported greater satisfaction and less pain at 4 and 12 months postoperatively. A total of 26 patients in the IF group (51%; 95% confidence interval, 37% to 65%) and 2 patients in the THA group (4%; 95% confidence interval, 0.5% to 13%) underwent a major reoperation. CONCLUSIONS: In this randomized controlled trial, we showed that patients between 55 and 70 years old who underwent THA for a low-energy displaced femoral neck fracture experienced better outcomes than those who underwent closed reduction and internal fixation. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Dorsally Displaced Unstable Extra-Articular Distal Radial Fractures: Functional and Radiographic Results from a Randomized Controlled Trial.

The use of low-profile dorsal and volar locking plates for distal radial fracture surgery has improved results and lowered the complication rate compared with older plate designs. The purpose of the present randomized controlled trial was to compare patient-reported outcomes as well as radiographic and functional results between patients who underwent stabilization with a volar locking plate or a dorsal locking nail-plate for the treatment of dorsally displaced unstable extra-articular distal radial fractures. METHODS: One hundred and twenty patients ≥55 years of age were randomized to surgery with either a volar locking plate or a dorsal locking nail-plate and were assessed at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The primary outcome was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes were the Patient-Rated Wrist Evaluation (PRWE), EuroQol 5 Dimensions (EQ-5D) index and visual analog scale (VAS), range of motion, grip strength, radiographic measurements, and complication rate. RESULTS: The median age was 66 years (range, 55 to 88 years). The rate of follow-up was 97%. There was no clinically important difference between the groups at any point during follow-up. Patients in the volar locking plate group had better mean QuickDASH scores at 6 weeks, 6 months, and 1 year. However, the differences were small (5.8 vs. 11.3 points at 1 year; mean difference, -5.5 points [95% confidence interval (CI), -9.9 to 1.2]; p = 0.014), which is lower than any proposed minimum clinically important difference (MCID). The difference in PRWE scores was also lower than the MCID (1.0 vs. 3.5 at 1 year; mean difference, -2.5 [95% CI, -4.4 to 0.6]; p = 0.012). The dorsal locking nail-plate group had slightly better restoration of volar tilt (p = 0.011). EQ-5D index, EQ-5D VAS, range of motion, grip strength, and complication rates were similar. CONCLUSIONS: We found no clinically relevant difference between the volar locking plate and dorsal locking nail-plate groups after 1 year or in the time period up to 1 year. A dorsal locking nail-plate can therefore be an alternative method for the treatment of these unstable fractures or in cases in which a dorsal approach is preferable over a volar approach. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Randomized trial comparing suture button with single 3.5 mm syndesmotic screw for ankle syndesmosis injury: similar results at 2 years.

Background and purpose - Better outcomes are reported for suture button (SB) compared with syndesmotic screws (SS) in patients treated for an acute ankle syndesmotic injury. One reason could be that screws are more rigid than an SB. A single tricortical 3.5 mm syndesmotic screw (TS) is the most dynamic screw option. Our hypothesis is that 1 SB and 1 TS provide similar results. Therefore, in randomized controlled trial, we compared the results between SB and TS for syndesmotic stabilization in patients with acute syndesmosis injury. Patients and methods - 113 patients with acute syndesmotic injury were randomized to SB (n = 55) or TS (n = 58). The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was the primary outcome measure. Secondary outcome measures included Manchester Oxford Foot Questionnaire (MOXFQ), Olerud-Molander Ankle score (OMA), visual analogue scale (VAS), EuroQol- 5D (EQ-5D), radiologic results, range of motion, complications, and reoperations (no implants were routinely removed). CT scans of both ankles were obtained after surgery, and after 1 and 2 years. Results - The 2-year follow-up rate was 84%. At 2 years, median AOFAS score was 97 in both groups (IQR SB 87-100, IQR TS 90-100, p = 0.7), median MOXFQ index was 5 in the SB group and 3 in the TS group (IQR 0-18 vs. 0-8, p = 0.2), and median OMA score was 90 in the SB group and 100 in the TS group (IQR 75-100 vs. 83-100, p = 0.2). The syndesmotic reduction was similar 2 years after surgery; 19/55 patients in the SB group and 13/58 in the TS group had a difference in anterior syndesmotic width ≥ 2 mm (p = 0.3). 0 patients in the SB group and 5 patients in the TS group had complete tibiofibular synostosis (p = 0.03). At 2 years, 10 TS were broken. Complications and reoperations were similar between the groups. Interpretation - We found no clinically relevant differences regarding outcome scores between the groups. TS is an inexpensive alternative to SB.

Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial.

BACKGROUND: The evidence supporting rifampin combination therapy in prosthetic joint infections (PJI) is limited due to the lack of controlled studies. The aim of this study is to evaluate the effect of adding rifampin to conventional antimicrobial therapy in early staphylococcal PJIs treated with debridement and retention of the implant (DAIR). METHODS: In this multicenter randomized controlled trial, 99 patients with PJI after hip and knee arthroplasties were enrolled. They were randomly assigned to receive rifampin or not in addition to standard antimicrobial treatment with cloxacillin or vancomycin in case of methicillin resistance. The primary endpoint was no signs of infection after 2 years of follow-up. RESULTS: Forty-eight patients were included in the final analyses. There were no differences in patient characteristics or comorbidities between the two groups. There was no significant difference in remission rate between the rifampin combination group (17 of 23 (74%)) and the monotherapy group (18 of 25 (72%), relative risk 1.03, 95% confidence interval 0.73 to 1.45, p = 0.88). CONCLUSION: This trial has not proven a statistically significant advantage by adding rifampin to standard antibiotic treatment in acute staphylococcal PJIs. TRIAL REGISTRATION: The Regional Ethics Committee and the Norwegian Medicines Agency approved the study (EudraCT 2005-005494-29), and the study was registered at ClinicalTrials.gov at Jan 18, 2007 ( NCT00423982 ).

Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register.

OBJECTIVE: We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013. DESIGN: The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines. SETTING: All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016. PARTICIPANTS: We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture. MAIN OUTCOME MEASURE: Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines. RESULTS: Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals. CONCLUSIONS: The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial.

AIMS: In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. METHODS: A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years. RESULTS: The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (-0.1 mm vs 1.2 mm; p = 0.016). CONCLUSION: Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212-219.

Importance of Syndesmotic Reduction on Clinical Outcome After Syndesmosis Injuries.

OBJECTIVES: To evaluate the relationship between syndesmosis reduction and outcome. DESIGN: Retrospective cohort study. SETTING: One Level 1 and 1 Level 3 Trauma Center. PATIENTS: Ninety-seven patients with syndesmosis injury. INTERVENTION: Stabilization of syndesmosis injury. Open reduction and internal fixation of malleolar fracture, if present. MAIN OUTCOME MEASUREMENTS: Anterior, central, and posterior measures of syndesmosis width on computed tomography scans, Olerud-Molander Ankle score, American Orthopaedic Foot and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, and range of motion measurements. RESULTS: Eighty-seven patients completed 2 years of follow-up. The difference in anterior tibiofibular distance (aTFD) between the injured and noninjured ankle postoperatively had a significant effect on the Olerud-Molander Ankle score after 6 weeks [b = -2.6, 95% confidence interval (CI), -4.8 to -0.4; P = 0.02], 1 year (b = -2.7, 95% CI, -4.7 to -0.8; P < 0.001), and 2 years (b = -2.6, 95% CI, -4.6 to -0.6; P = 0.009) and on American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score after 6 weeks (b = -2.2, 95% CI, -3.7 to -0.7; P = 0.004), 1 year (b = -1.7, 95% CI, -3.0 to -0.4; P = 0.04), and 2 years (b = -1.9, 95% CI, -3.2 to -0.5; P = 0.006). The effect of computed tomography measurements on range of motion was inconsistent. Receiver operating characteristic (ROC) curves demonstrated that aTFD had adequate discriminatory performance (area under the ROC curve ≥ 0.7) 1 and 2 years after surgery and the central measurement at only 2 years after surgery. ROC analyses indicate a cutoff value for syndesmosis malreduction of 2 mm. The postoperative rate of malreduction was 32%. CONCLUSIONS: The aTFD correlated with clinical outcome. A 2-mm difference in aTFD seems to predict poorer clinical outcome. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Knee sliced open by skate blade: complete patellar tendon rupture in an elite long track speed skater.

A long track speed skater sustained a deep horizontal cut to the right knee just distally to the patella, after he got hit by the skate blade of the pair mate. The injury included a complete patellar tendon rupture from the apex of the patella, a 1 mm deep transverse cut in the femoral condyle and a partial rupture of the anterior cruciate ligament. The tendon rupture was repaired with transosseous suture repair without augmentation. A knee brace was used for 8 weeks, with a gradual decrease in flexion restraints. A rehabilitation programme was overseen by a dedicated physiotherapist. At 6 months, he started a gradual return to skating sessions. After 1 year, he had symmetrical single-legged hop performance, but quadriceps weakness due to pain. The patient returned to competition speed skating at national levels after 11 months, and within the first postoperative year, he was breaking new personal records on the ice.

Randomized Trial Comparing Suture Button with Single Syndesmotic Screw for Syndesmosis Injury.

BACKGROUND: This study compared clinical and radiographic results between patients who underwent stabilization of an acutely injured syndesmosis with a suture button (SB) and those treated with 1 quadricortical syndesmotic screw (SS). METHODS: Ninety-seven patients, 18 to 70 years old, with an ankle injury that included the syndesmosis were randomized to 2 groups: SB (48 patients) and SS (49). The main outcome measure was the score on the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The secondary outcome measures were the Olerud-Molander Ankle (OMA) score, visual analog scale (VAS), and EuroQol-5D (EQ-5D) Index and VAS. Computed tomography (CT) scans of both ankles were obtained at 2 weeks and 1 and 2 years after surgery. Both groups were allowed partial weight-bearing at 2 weeks and full weight-bearing at 6 weeks. The mean time for SS removal was 85.9 days (range, 39 to 132 days) after surgery. The patients were followed at 6 weeks, 6 months, and 1 and 2 years. Two years of follow-up were completed for 87 (90%) of the patients (46 in the SB group and 41 in the SS group). RESULTS: The SS group had more injuries to the posterior malleolus than the SB group. At 2 years, the median AOFAS score was higher in the SB group than in the SS group (96 [interquartile range, or IQR, 90 to 100] versus 86 [IQR, 80 to 96]; p = 0.001), as was the median OMA score (100 [IQR, 95 to 100] versus 90 [IQR, 75 to 100]; p < 0.001). The SB group reported less pain during walking at 2 years than the SS group (median VAS score, 0 [IQR, 0 to 1] versus 1 [IQR, 0 to 2]; p = 0.008) and less pain during rest (median VAS score, 0 [IQR, 0 to 0] versus 0 [IQR, 0 to 1]; p = 0.04). There was no difference between treatments groups with regard to pain at night or during daily activities at 2 years. The SB group had a higher median EQ-5D Index score at 2 years (1.0 [IQR, 1 to 1] versus 0.88 [IQR, 0.8 to 1.0]; p = 0.005). Twenty of 40 patients in the SS group had a difference in the tibiofibular distance of ≥2 mm between the injured and uninjured ankles at 2 years, compared with 8 of 40 in the SB group (p = 0.009). Seven patients in the SS group had symptomatic recurrent syndesmotic diastasis during the treatment period compared with none in the SB group (p = 0.005). CONCLUSIONS: The patients treated with an SB had higher AOFAS scores, OMA scores, and EQ-5D Index scores as well as lower (better) VAS scores for pain during walking and pain during rest. Also, the SB group had less widening seen radiographically at 2 years than did the patients in the SS group. No differences in the scores for pain at night or during daily activities were identified. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Posterior versus lateral approach for hemiarthroplasty after femoral neck fracture: Early complications in a prospective cohort of 583 patients.

AIM: To compare early complications after the posterior and the direct lateral (transgluteal) approach, when using hemiarthroplasty in the treatment of displaced femoral neck fractures in the elderly. PATIENTS AND METHODS: A prospective clinical study from four Norwegian hospitals, consisting of 583 patients with 1year follow-up. All the hospitals used the same uncemented femoral stem and bipolar heads. Data were collected for gender, age, surgical approach, prosthetic dislocation, postoperative infection, perioperative fracture, duration of surgery, ASA score, diabetes, alcoholism, cognitive failure, BMI, 30-day mortality and 1-year mortality. RESULTS: Mean age was 83 years (SD 7.8) and 434/583 (74%) were female. There were no relevant differences between the treatment groups. A higher risk was found for prosthetic dislocation in the posterior group compared to the lateral group (15/186 (8%) vs. 4/397 (1%); RR=8.0, 95% CI 2.7-23.8, p-value<0.001), both as a one-time event and for the risk of recurrent dislocations (9/186 (5%) vs. 2/395 (0.5%); RR 9.6, 95% CI 2.1-44.0, p-value=0.001). 11/19 patients with dislocation had recurrent dislocations. 10/11 patients with more than one dislocation needed further open surgery. Of those 6/10 needed more than one additional open procedure. Three patients had a resection arthroplasty and one patient had a chronic infection as final result after a dislocation. No other risk factor for dislocation than surgical approach was identified. There were no differences between the approach groups for other complications. CONCLUSION: There was an 8-fold increased risk for prosthetic dislocations after the posterior approach compared to lateral approach. There was a high risk for recurrent prosthetic dislocations and a subsequent risk for further surgeries and a poor end result. The potential advantages of the posterior approach have not been demonstrated after femoral neck fractures and we advise against its continued use.

Physical Functioning and Prediction of Physical Activity After Total Hip Arthroplasty: Five-Year Followup of a Randomized Controlled Trial.

OBJECTIVE: To examine whether the 1-year effects from a previous walking skill training program on walking and stair climbing still persist 5 years following total hip arthroplasty (THA), to examine recovery of physical functioning from before to 5 years after surgery, and to identify predictors of physical activity 5 years after THA from preoperative measures. METHODS: We performed a 5-year followup of a randomized controlled trial and a longitudinal study. Sixty participants with a mean age of 70 years (range 50-87 years; 95% confidence interval 68, 72 years) were assessed. Outcome measures were the 6-minute walk test, the stair climbing test (SCT), active hip range of motion (ROM), self-efficacy, Hip Dysfunction and Osteoarthritis Outcome Score (HOOS), and University of California, Los Angeles (UCLA) activity scale. Data were analyzed by Student's t-tests, generalized linear model, and multivariate regression analyses. RESULTS: The training and control groups were approximately equal on outcome measures of physical functioning, pain, and self-efficacy at 5 years (P > 0.05). In the total group, the recovery course was unchanged from 1 to 5 years (P > 0.05), except for 9% improvement in ROM (P < 0.001) and an increase in time on SCT of 18% (P = 0.004). Preoperative HOOS pain (P = 0.022) and HOOS sport (P = 0.019) predicted UCLA activity scale 5 years after THA. CONCLUSION: At 5 years after THA, the control group had caught up with the training group on physical functioning, and the participants led an active lifestyle. Those with worse preoperative scores on pain and physical functioning in sport were at risk of being less physically active in the long term following THA.

Effectiveness of gentamicin-containing collagen sponges for prevention of surgical site infection after hip arthroplasty: a multicenter randomized trial.

BACKGROUND: Surgical site infection (SSI) is a feared complication in hip arthroplasty, especially following femoral neck fracture in the elderly, associated with substantially increased morbidity, mortality, and costs. Gentamicin-containing collagen sponges are widely used for prevention of SSIs, but their effectiveness in joint replacement surgery remains unclear. METHODS: We performed a multicenter, randomized trial between February 2011 and July 2013. Eligible patients with femoral neck fracture undergoing hemiarthroplasty were randomly assigned to receive either intravenous antimicrobial prophylaxis alone or with the addition of 2 gentamicin-containing collagen sponges into the hip joint perioperatively. The primary end point was SSI according to the Centers for Disease Control and Prevention criteria within 30 days after surgery. RESULTS: Seven hundred thirty-nine patients were randomly assigned, 684 of whom were included in the modified intention-to-treat analysis. There was no statistical significant difference in SSI between the gentamicin-collagen group (16 of 329 patients [4.9%]) and the control group (19 of 355 patients [5.4%]) (relative risk [RR], 0.91 [95% confidence interval, .48-1.79]; P = .77). No significant differences were observed between the groups in superficial SSI (2 of 329 [0.6%] vs 3 of 355 [0.8%]; P = .99) and deep SSI (14 of 329 [4.3%] vs 16 of 355 [4.5%]; P = .87). There were no significant differences between the groups regarding type of bacteria isolated. CONCLUSIONS: Locally administered gentamicin-collagen sponges did not reduce the incidence of SSI in elderly patients treated with a hemiarthroplasty because of femoral neck fracture. CLINICAL TRIALS REGISTRATION: NCT01287780.

Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: 5-year followup of a randomized trial.

BACKGROUND: Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important. QUESTIONS/PURPOSES: In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup. METHODS: We present followup at a median of 5 years after surgery (range, 56-65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup. RESULTS: Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9-17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16-74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82-1.7). CONCLUSIONS: Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures. LEVEL OF EVIDENCE: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Dolosigranulum pigrum causing biomaterial-associated arthritis.

Dolosigranulum pigrum is a gram-positive, catalase-negative bacteria rarely associated with disease. We report a case of biomaterial-associated arthritis in an immunocompetent patient caused by D. pigrum. The organism was isolated from a synovial biopsy specimen and its identity confirmed by 16S rRNA gene sequencing.

Clinical outcome after reconstruction for isolated posterior cruciate ligament injury.

Fifty-one patients were operated with reconstruction for an isolated PCL injury from 1997 to 2005. Forty-three of these patients were followed during a median period of 48 months (17-109). Median time from injury to surgery was 18 months (2-368). Five patients were operated within the first 6 months after the injury. Nineteen patients had a BPTB autograft, 24 had a hamstring tendon autograft, and seven patients in the hamstring group had a double-bundle femoral fixation. Clinical assessment included Lysholm knee score, International Knee Documentation Committee 2000 (IKDC) scores, Cincinnati score, Tegner score, KOOS score, VAS score, stress radiographs, and a functional test. The median Lysholm score at follow-up was 80 (32-95). Median Tegner score before injury was 7 (1-10) and at follow-up 6 (0-9). Median Cincinnati and IKDC 2000 scores were 74 (12-100) and 63 (24-100), respectively. The mean VAS for subjective assessment of knee function was 67.6 (SD = 22.9). The radiologically measured difference in posterior tibial translation between operated and non-injured knees was mean 8.4 mm (SD =4.8). Four different functional tests showed function of the operated leg from 92% (25-128) to 95% (15-124) compared to the opposite leg. This study shows good functional outcome after reconstruction for isolated rupture of the posterior cruciate ligament. However, pain and instability are still a problem, as only three patients reported full Lysholm subscore indicating full stability, and only four patients reported full subscore indicating no knee pain.

Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures.

Hemiarthroplasty is the most commonly used treatment for displaced femoral neck fractures in the elderly. There is limited evidence in the literature of improved functional outcome with cemented implants, although serious cement-related complications have been reported. We performed a randomized, controlled trial in patients 70 years and older comparing a cemented implant (112 hips) with an uncemented, hydroxyapatite-coated implant (108 hips), both with a bipolar head. The mean Harris hip score showed equivalence between the groups, with 70.9 in the cemented group and 72.1 in the uncemented group after 3 months (mean difference, 1.2) and 78.9 and 79.8 after 12 months (mean difference, 0.9). In the uncemented group, the mean duration of surgery was 12.4 minutes shorter and the mean intraoperative blood loss was 89 mL less. The Barthel Index and EQ-5D scores did not show any differences between the groups. The rates of complications and mortality were similar between groups. Both arthroplasties may be used with good results after displaced femoral neck fractures.

Conversion from failed hemiarthroplasty to total hip arthroplasty: a Norwegian Arthroplasty Register analysis of 595 hips with previous femoral neck fractures.

BACKGROUND AND PURPOSE: Conversion total hip replacement (THR) is a common procedure after failed hemiarthroplasty, but there have been few reports describing the long-term outcome of this procedure. PATIENTS AND METHODS: Between 1987 and 2004, 595 THRs were reported to the Norwegian Arthroplasty Register as conversion THR for failed hemiarthroplasty after a femoral neck fracture in patients aged 60 years and older. 122 operations left the femoral stem intact, whereas 473 were converted with exchange of the femoral stem. RESULTS: We found a lower risk of failure (revision surgery for any reason) for the conversion procedures with stem exchange (RR=0.4; 95% CI: 0.25-0.81) than for the conversion procedures that retained the femoral stem. For the 473 conversion arthroplasties with exchange of the stem, we found no difference in risk of failure compared to all revision stems in the register, either for the complete prosthesis (RR=0.8; CI: 0.50- 1.20) or for the stem (RR=0.9; CI: 0.53-1.59). However, for the 122 conversion procedures in which the femoral stem was retained, we found a significantly increased risk of failure for both the complete prosthesis (RR=4.6; CI: 2.8-7.6) and for the acetabular cup (RR=4.8; CI: 2.3-10) compared to primary hip arthroplasties. INTERPRETATION: Our findings indicate that the seemingly easy operation of implanting an acetabular cup to convert a hemiarthroplasty to a total hip arthroplasty is an uncertain procedure and that the threshold for replacing the stem should be low.