Functional outcome of direct anterior versus posterior approach in total hip arthroplasty: a propensity-matched Asian study.

INTRODUCTION: The direct anterior approach (DAA) to total hip arthroplasty (THA) is a surgical approach that minimises soft tissue trauma, resulting in faster rehabilitation when compared to a posterior approach (PA). This study aimed to evaluate the difference between the two groups in an Asian cohort using propensity score matching. METHODS: A retrospective review of prospectively collected registry data of 794 primary THAs was performed. The effects on patients with DAA THA versus patients with PA THA were investigated. Propensity scores were generated using logistic regression to adjust for confounding variables of age, gender, body mass index and diagnosis. Data analysis was performed, and statistical significance was defined as a P value < 0.05. RESULTS: The average length of stay (LOS) for the PA group and DAA group was 5.4 days and 2.9 days, respectively (P < 0.001). One (1.9%) patient from the PA group suffered a posterior dislocation 6 months after surgery and subsequently underwent revision surgery 2 years later. No dislocations were detected in the DAA group. The DAA group had better functional outcome, satisfaction and expectation scores at 6 months and 2 years. CONCLUSION: In this study, patients who underwent DAA THA had better functional outcome at 2 years and almost 2 days shorter overall LOS than those who underwent PA THA. Therefore, the DAA to THA is a novel technique that has shown improved functional outcomes, with fewer complications compared to PA THA.

Predictors of 10-year Mortality After Hip Fracture Surgery in a Pre-Pandemic Cohort.

Introduction: Though hip fractures are associated with significant mortality and morbidity, increasing life expectancy in developed countries necessitates an analysis of mortality trends and factors predicting long term survival. The aim of this study is to identify the predictors of 10-year mortality as well as assess the correlation of Age-adjusted Charlson comorbidity index (ACCI) with 10-year mortality in a surgically treated Asian geriatric hip fracture population. Materials and Methods: From January 1, 2007 to December 31, 2009, 766 patients who underwent surgery for hip fracture with a minimum follow up of 10-years were recruited to the study (92% follow-up rate). A review of the patient's electronic hospital records was performed to glean the following data: patient demographics, pre-existing comorbidities, operation duration, length of stay, fracture configuration, as well as mortality data up to 10 years. CCI scores and individual co-morbidities were correlated with inpatient, 30-day, 1-year, 5-year and beyond 10-year mortality. Results: Of the 766 patients, the mortality rate for 30-day, 1-year, 5-year and 10-years was 2.9%, 12.0%, 38.9% and 61.6% respectively. The average ACCI was 5.31. The 10-year mortality for patients with ACCI ≤ 3, ACCI 4-5 and ACCI ≥ 6 are 29.4%, 57.4% and 77.5% respectively. End-Stage-Renal Failure (ESRF), liver failure and COPD were dominant predictors of mortality at 10 years, whereas cancer was the predominant predictor at 1 year. Discussion: ACCI significantly correlates with the 10-year mortality after surgically treated hip fractures with a shift of the dominant predictors from cancer to ESRF and COPD. This could inform future health policy and resource planning. This data also represents recently available pre-pandemic survival trends after hip fracture surgery and serves as a baseline for post-pandemic outcome surveillance of interventions for fragility fractures. Conclusion: This study demonstrates that ACCI correlated with 10-year mortality after surgical treatment of hip fractures.

Perioperative management of open fractures in the lower limb.

An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient's postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.

Perioperative management of distal radius fractures.

Fractures of the distal radius are the most common upper limb fracture and account for over a sixth of all fractures seen in emergency departments. Although most of these fractures are managed non-operatively, a significant number of complex injuries undergo operative management. This educational review of up to date guidelines discusses the perioperative management of distal radius fractures and provides readers with continuing professional development activities.

The accuracy of a hand-held navigation system in total knee arthroplasty.

INTRODUCTION: This study aims to evaluate the effectiveness of a new hand-held navigation system. The authors of this study hypothesize that this navigation system will improve overall lower limb alignment and implant placement without causing a delay in surgery. PATIENTS AND METHODS: Two hundred consecutive patients diagnosed with tricompartmental osteoarthritis and underwent total knee arthroplasty by a senior surgeon were included in this study. One hundred patients underwent TKA using the hand-held navigation system, while the other 100 patients underwent TKA using the conventional technique. The primary outcomes of this study were the overall alignment of the lower limb and the position of the components. This was determined radiologically using the: (1) Hip-Knee-Ankle angle (HKA) for lower limb alignment; (2) Coronal Femoral-Component angle (CFA); and (3) Coronal Tibia-Component angle (CTA) for component position. Normal alignment was taken as 180° ± 3° for the HKA and 90° ± 3° for both the CFA and CTA. RESULTS: For the CFA, the proportion of outliers was 7 and 17% in the hand-held navigation and conventional group, respectively (p = 0.030). For the HKA and CTA, there was no difference in the proportion of outliers between the two groups. The duration of surgery was 73 ± 9 min and 87 ± 15 min in the hand-held navigation and conventional group, respectively (p < 0.001). CONCLUSION: This hand-held navigation system is an effective intraoperative tool for reducing the proportion of outliers for femoral implant placement as well as the duration of surgery. The authors conclude that it can be considered for use to check femoral implant placement intra-operatively. LEVEL OF EVIDENCE: III.

Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia.

PURPOSE: To compare the 6-month outcome of Weil osteotomy with distal metatarsal mini-invasive osteotomy (DMMO) in 33 patients with lesser toe metatarsalgia. METHODS: Records of 33 patients who underwent Weil osteotomy (n=20, 41 toes) or DMMO (n=13, 22 toes) for lesser toe metatarsalgia by a single surgeon were reviewed. 25 of them had a concurrent procedure on the 1st toe. Outcome at 6 months was assessed using the visual analogue score (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal (MTP-IP) score, and the RAND-36 score. RESULTS: The 2 groups were comparable in terms of age, gender, and preoperative MTP joint range of motion (ROM), VAS for pain, AOFAS lesser toe MTPIP score, and RAND-36 scores. At 6 months, the Weil osteotomy group had a higher RAND-36 (mental) score (92 vs. 78, p=0.026), and the DMMO group had a higher percentage of toes with greater MTP joint ROM (p=0.043). All patients achieved bone union within 6 months. Two patients in the DMMO group had prolonged oedema until 3 months post-surgery. CONCLUSION: DMMO is a safe and reliable alternative to Weil osteotomy for metatarsalgia and can preserve ROM of the MTP joints.

Is clinical evaluation alone sufficient for the diagnosis of a Bankart lesion without the use of magnetic resonance imaging?

BACKGROUND: Imaging modalities such as magnetic resonance arthrogram (MRA) offer great utility in diagnosing Bankart lesions but they are associated with a high degree of intra and interobserver variability. This study aims to evaluate the diagnostic accuracy of clinical evaluation and imaging modalities in Bankart lesions such as magnetic resonance imaging (MRI) and MRA of the shoulder. METHODS: Between February 2004 to January 2015, a retrospectively review of the surgical records at a tertiary hospital identified a total of 250 patients treated with a shoulder arthroscopy for Bankart repair. All patients were thoroughly investigated preoperatively in which a detailed history were obtained, relevant physical examinations were performed (Load and Shift/Anterior Apprehension test) and pre-operative radiographs taken. Some patients subsequently underwent either an MRI or an MRA scan if the initial clinical evaluation was equivocal. RESULTS: Anterior Shoulder Apprehension test and the Load and Shift test identified 214 of 227 Bankart tears, with a sensitivity of 94% [95% confidence interval (CI), 90-97%]. MRI correctly identified 23 of 26 Bankart tears, with a sensitivity of 89% (95% CI, 70-98%). Out of the five superior labrum anterior-posterior (SLAP) tears identified on MRI, only three were confirmed during arthroscopic surgery. MRA correctly identified 84 of 89 Bankart tears, for a sensitivity of 94% (95% CI, 87-98%). CONCLUSIONS: In our study, we report that clinical evaluation with focused history-taking and anterior apprehension, load and shift clinical examination can diagnose anterior shoulder instability as reliably as MR imaging. For patients with equivocal clinical findings, MR imaging can aid in the diagnosis.

History of previous knee surgery does not affect the clinical outcomes of primary total knee arthroplasty in an Asian population.

BACKGROUND: Patients with a history of previous knee surgeries, such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO), often have a higher likelihood of requiring a subsequent total knee arthroplasty (TKA). However, there is relatively limited data, especially in the Asian population, on how previous knee surgery could affect the clinical outcomes of TKA. Therefore, this study aims to evaluate the impact of previous knee surgeries on the clinical outcomes of future TKA. METHODS: We reviewed the prospectively-collected data of 303 patients who underwent TKA by a single surgeon from a total joint registry of a tertiary hospital over a period of 5 years. Those with a history of previous knee surgery were identified. The SF-36 Health Survey, Oxford Knee Score (OKS) and Knee Society Score (KSS) were used to evaluate clinical outcomes pre-operatively, at 6 months and 2 years. RESULTS: Previous knee surgery did not have a significant impact on the patients' pre-operative baseline clinical scores and body mass index (BMI). Patients with a history of knee surgery undergo TKA at a significantly younger age (mean of 6.6 years younger). On follow-up, patients with a history of knee surgery have similar post-operative outcome scores as those without previous knee surgery. Also, a high proportion of these patients are satisfied with their post-operative results and feel that their expectations have been met. CONCLUSIONS: Patients with previous knee surgery had TKA at a significantly younger age than those without. But these patients have similar clinical and quality of life outcomes after TKA. In addition, a high proportion of these patients are satisfied with the results of surgery and feel that their expectations of TKA are met. This is important for clinicians when counselling patients pre-operatively.

Preoperative haemoglobin cut-off values for the prediction of post-operative transfusion in total knee arthroplasty.

PURPOSE: The purpose of this study is to determine preoperative haemoglobin cut-off values that could accurately predict post-operative transfusion outcome in patients undergoing primary unilateral total knee arthroplasty (TKA). This will allow surgeons to provide selective preoperative type and screen to only patients at high risk of transfusion. METHODS: A total of 1457 patients diagnosed with osteoarthritis and underwent primary unilateral TKA between January 2012 and December 2014 were retrospectively reviewed. Logistic regression analyses were applied to identify factors that could predict transfusion outcome. RESULTS: A total of 37 patients (2.5 %) were transfused postoperatively. Univariate analysis revealed preoperative haemoglobin (p < 0.001), age (p < 0.001), preoperative haematocrit (p < 0.001), and preoperative creatinine (p < 0.001) to be significant predictors. In the multivariate analysis with patients dichotomised at 70 years of age, preoperative haemoglobin remained significant with adjusted odds ratio of 0.33. Receiver operating characteristic curve identified the preoperative haemoglobin cut-off values to be 12.4 g/dL (AUC = 0.86, sensitivity = 87.5 %, specificity = 77.2 %) and 12.1 g/dL (AUC = 0.85, sensitivity = 69.2 %, specificity = 87.1 %) for age above and below 70, respectively. CONCLUSIONS: The authors recommend preoperative haemoglobin cut-off values of 12.4 g/dL for age above 70 and 12.1 g/dL for age below 70 to be used to predict post-operative transfusion requirements in TKA. To maximise the utilisation of blood resources, the authors recommend that only patients with haemoglobin level below the cut-off should receive routine preoperative type and screen before TKA. LEVEL OF EVIDENCE: IV.

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

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

Low Infection Rates in Total Knee Arthroplasty in End Stage Renal Failure Patients.

End stage renal failure is considered a risk factor for postoperative infection and many surgeons are cautious in offering this group of patients total knee arthroplasty for symptomatic osteoarthritis. In this retrospective study, 16 total knee arthroplasties were performed in 13 patients and each case was followed up for an average of 5.1 years. We report no cases of infection and also an overall improvement in multiple validated outcome measures. There were, however, 2 cases of periprosthetic loosening. As the patients in our series were generally younger and none was diagnosed with stroke or peripheral vascular disease at the time of surgery, we believe that careful patient selection is key to reducing infection rates in this challenging group of patients.

Prevalence of Metatarsus Adductus in Symptomatic Hallux Valgus and Its Influence on Functional Outcome.

BACKGROUND: Metatarsus adductus (MA) increases the risk of developing symptomatic hallux valgus (HV). This study aimed to determine the prevalence of MA in patients with symptomatic HV and to evaluate how it affected the functional outcome after scarf osteotomy. METHODS: Between January 2007 and June 2012, a total of 206 patients who underwent scarf osteotomy for symptomatic HV at a tertiary hospital were included. The metatarsus adductus angle (MAA) was determined using the Modified Sgarlato method, and these patients were categorized into 2 groups: MA (MAA > 20 degrees); and Control (MAA ≤ 20 degrees). The patients were prospectively followed for 2 years. RESULTS: The prevalence of MA was 33% (68/206) with a mean MAA of 24 ± 4 degrees (range = 20-39). There was a 21 ± 12 degrees and 18 ± 9 degrees improvement in hallux valgus angle for the MA and Control groups, respectively (P = .061), whereas there was a 6 ± 4 degrees and 6 ± 3 degrees improvement in intermetartarsal angle for the MA and Control groups, respectively (P = .475). The visual analog scale, AOFAS Hallux Metatarsophalangeal-Interphalangeal Scale, and Physical and Mental Component Scores were comparable between the 2 groups both preoperatively and at 2 years' follow-up (all P > .05). Two patients in the control group required revision surgery for recurrence symptomatic HV. CONCLUSION: The authors conclude that MA did not predispose the patient to poorer functional outcome after scarf osteotomy with the advent of good operative techniques. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Accuracy of endorectal ultrasound for measurement of the closest predicted radial mesorectal margin for rectal cancer.

BACKGROUND: At present, pelvic phased array-coil MR is used as the validated imaging modality for measurement of the closest predicted radial mesorectal margin for rectal cancer. Endorectal ultrasound is also used to assess the clinical stage of the cancer that will determine the recommendation for neoadjuvant chemoradiation, but it has not been used to assess the closest predicted radial margin. OBJECTIVE: We propose to assess endorectal ultrasound identification of mesorectal margins and the measurement of the closest predicted radial tumor-mesorectal margin. PATIENTS AND METHODS: Patients included were those having MRI and endorectal ultrasound for evaluation of primary rectal cancer in 2010 at a tertiary cancer referral colorectal clinic. Clinical data, MRI, and endorectal ultrasound images were assessed. Two independent retrospective measurements of mesorectal dimensions were correlated to evaluate the reproducibility of identifying mesorectal margins. MRI and endorectal ultrasound images were compared for independent measurements of mesorectal dimensions and of the closest predicted radial mesorectal margin. MRI and endorectal ultrasound determination of margin involvement were assessed for agreement. RESULTS: Fifty-two patients were studied with an average rectal cancer distance to the anal verge of 6.8 cm. Interobserver correlation coefficients of endorectal ultrasound mesorectal dimensions ranged from 0.47 to 0.53 (p < 0.01). MR and endorectal ultrasound measurements of the closest predicted radial mesorectal margin were correlated r = 0.56 (p < 0.0001). MR and endorectal ultrasound determination of margin involvement agreed in 81% of cases. CONCLUSION: Endorectal ultrasound has substantial agreement with MR to measure the closest predicted radial tumor-mesorectal margin. Correlations between observers and modalities for identification of mesorectal dimensions are modest. Further assessment is indicated to confirm endorectal ultrasound mesorectal measurements in a larger sample and to understand the advantages and disadvantages relative to MR.

A metastatic colon cancer model using nonoperative transanal rectal injection.

BACKGROUND: This study aimed to develop a noninvasive orthotopic model for metastasis of colon and rectal cancer using a transanal approach. Currently, the most accurate orthotopic representation of metastatic human colon cancer is via a cecal injection. The transanal model allows for further examination of systemic immune responses, tumor take, and onset of metastasis without prior surgical intervention. METHODS: For this study, 60 Balb/c mice were anesthetized and subjected to gentle anal dilation using blunt-tipped forceps at the anal opening. Murine colon cancer parental CT26 or luciferase-labeled CT26 (CT26-luc) cells were injected submucosally into the distal posterior rectum (30 CT26 and 30 CT26 injections) at concentrations of 2.5 x 10(4), 1 x 10(5), and 1 x 10(6) in a volume of 50 microl. Tumor growth and metastatic development was monitored at 5-day intervals for 50 days. All the remaining mice were killed on postinjection day 50. RESULTS: The optimal concentration for metastasis and survival of the mice was 2.5 x 10(4) cells. Higher concentrations of cells yielded higher mortality but did not result in metastasis. The overall success of tumor growth in both experiments using the transanal rectal injection was 65%. Histology showed that all tumors were poorly differentiated adenocarcinomas. Two mice (3.3%) from the 2.5 x 10(4) CT26-luc group showed metastatic colonic adenocarcinoma to the liver on postinjection day 50. CONCLUSION: Transanal rectal injection of colon cancer cells offers a nonoperative orthotopic murine model for colon cancer that may lead to the development of metastasis. By using an orthotopic model, more aspects of metastatic colon cancer can be evaluated without the influence of a previous abdominal incision. These results warrant more investigation.