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.

Accuracy of Total Hip Arthroplasty Templating Using Set Calibration Magnifications.

Background Templating for total hip arthroplasty has been adopted over recent decades as a reliable and accurate method for pre-operative planning. The use of calibration markers for this process provides a recognised benefit at the expense of cost, availability and error. Many surgeons use a set magnification of 118% to account for calibration errors when templating total hip arthroplasty. This study aims to assess the accuracy of templating with standardised magnifications and assess the effect of BMI on templating accuracy. Materials and methods A retrospective analysis was performed using a single-surgeon series of 119 consecutive total hip arthroplasties. Anteroposterior radiographs were taken pre- or post-operatively without calibration hardware. Pre-operatively, the total hip arthroplasty was templated on TraumaCad (BrainLab Inc, Westchester, IL) using either 118% or 119% calibration magnification. Post-operative magnification was calibrated using the known femoral head diameter. Templated and implanted prostheses were compared for size. Results At 118%, 61.1% of cups matched those templated with 96.3% of cups within two sizes. At 119%, 52.5% of cups used matched their templates with 100% within two sizes. There was no significant difference between 118% and 119% cup size prediction (p=0.49). A trend was noticed in increasing magnification error with increasing BMI. However, BMI had no significant effect on the accuracy of templating cup size within two cup sizes (p=0.58). Conclusion. Templating acetabular cups using a set magnification of 118% or 119% yields accurate results and provides a reliable method to template without calibration equipment. Whilst BMI can affect magnification error, this has no significant effect on the accuracy of implanted cups and stems within two sizes.

Short- and Long-Term Outcomes in Patients With Lower Extremity Amputations Undergoing Total Hip and Knee Arthroplasty.

Background: Joint replacement following amputation is scarcely reported. The primary aim of this study was to evaluate patient-reported outcomes (PROMS) and revision rates among lower extremity amputees undergoing total hip (THA) or knee arthroplasty (TKA). Methods: This was a retrospective cohort analysis of lower extremity amputees undergoing THA/TKA between August 2002 and August 2022 in a single tertiary center. Demographic and clinical data were collected from prospectively populated surgical databases and patient electronic records. PROMS included Oxford Knee Score, Oxford Hip Score, and 5-level EuroQol 5-dimension questionnaires. Twenty-three TKAs and 21 THAs were performed in 38 patients. The mean age at arthroplasty procedures was 59.8 (24-87) years. The mean clinical follow-up duration for THA and TKA was 9.1 and 4.5 years, respectively. Seven TKAs and 6 THAs were ipsilateral to the amputated side. Results: The 10-year revision rates were 9.5% (2/21) and 5.9% (1/17) in the TKA and THA cohorts, respectively. TKA revisions occurred due to aseptic loosening. Six (26%) TKA cases experienced stump complications. Overall PROMS completion was 61.9% (13/21) and 64.7% (11/17) in TKA and THA patients, respectively. The average Oxford Hip Score/Oxford Knee Score of THA and TKA cohorts were 40.8 and 34.2, respectively. EuroQol 5-dimension questionnaire visual analog scores were higher in the THA cohort than those in the TKA cohort without statistical significance (59.1 vs 50.5, P = .214). The overall survival rate for the study was 94.7% at 5 years (36/38). Conclusions: TKA/THA in lower extremity amputees can be successful, with low revision rates and good prosthesis function. Potential pitfalls highlighted include prosthesis malalignment, postprocedural rehabilitation, and stump complications.

Subsidence in Centraliser Sign: A Novel Tool to Help Predict Early Subsidence in Periprosthetic Femoral Fractures Around Polished Tapered Stems Treated With Internal Fixation.

Background When treating periprosthetic femoral fractures (PPF) around polished taper slip stems (PTS), determining which patients can be successfully treated with internal fixation can be challenging. We have described the subsidence-in-centraliser (SINC) sign as a radiographic feature of PPF around PTS stems. We hypothesise that a positive SINC sign can help predict a poorer outcome for the fixation of these fractures. Patients and methods Retrospective identification of PPFs around cemented PTS with an appreciable centraliser on radiographs was conducted at a single centre. A positive SINC sign was defined as a post-injury radiograph demonstrating >50% reduction in the radiographic lucency representing the stem centraliser when compared to pre-injury films or complete obliteration of distal lucency when no pre-injury film was available. The primary outcome was the rate of subsequent stem subsidence on follow-up radiographs comparing SINC-positive and SINC-negative fractures, which were managed with open reduction and internal fixation (ORIF). Results Fifty-four patients were included in the analysis. The mean age was 76.8 years, and the mean follow-up for all patients was 12.7 months. Thirty-five fractures were deemed SINC-positive, and 19 were SINC-negative. 17/17 (100%) SINC-positive fractures managed with fixation underwent further subsidence (mean 5.4 mm, SD 2.8). A positive SINC sign demonstrated a sensitivity of 90.5% and specificity of 100% for subsequent stem subsidence in fractures treated without revision. SINC positive fractures underwent significantly more subsidence compared with SINC negative fractures when fixed (5.4 mm vs. 0.28 mm, U = 6.50, p<0.001) at a mean follow-up of 12.7 months. The SINC sign demonstrated strong inter- (k=0.96) and intra-rater (k=0.86) reliability. Conclusion The SINC sign can serve as a useful adjunct in the decision to fix or revise PPF around PTS. A positive SINC sign may represent a cement mantle that cannot be reconstituted anatomically, leading to subsidence after treatment with ORIF.

Ischial screw fixation can prevent cup migration in 3D-printed custom acetabular components for complex hip reconstruction.

INTRODUCTION: Custom acetabular components have become an established method of treating massive acetabular bone defects in hip arthroplasty. Complication rates, however, remain high and migration of the cup is still reported. Ischial screw fixation (IF) has been demonstrated to improve mechanical stability for non-custom, revision arthroplasty cup fixation. We hypothesize that ischial fixation through the flange of a custom acetabular component aids in anti-rotational stability and prevention of cup migration. METHODS: Electronic patient records were used to identify a consecutive series of 49 custom implants in 46 patients from 2016 to 2022 in a unit specializing in complex joint reconstruction. IF was defined as a minimum of one screw inserted into the ischium passing through a hole in a flange on the custom cup. The mean follow-up time was 30 months. IF was used in 36 cups. There was no IF in 13 cups. No difference was found between groups in age (68.9 vs. 66.3, P = 0.48), BMI (32.3 vs. 28.2, P = 0.11) or number of consecutively implanted cups (3.2 vs. 3.6, P = 0.43). Aseptic loosening with massive bone loss was the primary indication for revision. There existed no difference in Paprosky grade between the groups (P = 0.1). 14.2% of hips underwent revision and 22.4% had at least one dislocation event. RESULTS: No ischial fixation was associated with a higher risk of cup migration (6/13 vs. 2/36, X2 = 11.5, P = 0.0007). Cup migration was associated with an increased risk for all cause revision (4/8 vs. 3/38, X2 = 9.96, P = 0.0016, but not with dislocation (3/8 vs. 8/41, X2 = 1.2, P = 0.26). CONCLUSION: The results suggest that failure to achieve adequate ischial fixation, with screws passing through the flange of the custom component into the ischium, increases the risk of cup migration, which, in turn, is a risk factor for revision.

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.

Shoulder arthroplasty for juvenile idiopathic arthritis.

There is limited literature to guide shoulder surgeons in the management of juvenile idiopathic arthritis (JIA). We aim to help clinicians to formulate an approach to the surgical management of the condition through a review of the available literature on arthroplasty in JIA, general considerations when operating on patients with inflammatory arthropathy and recommendations based on the authors' experience. Four articles report formal data on arthroplasty in JIA with favourable improvements in post-operative pain and function scores after the long-term follow-up. Significant heterogeneity in treatment and a lack of standardisation in quantitative outcomes highlights the need for further larger scale and higher quality research. The aim of this study is to review the evidence and provide information on preoperative evaluation of surgical candidates, operative techniques, choice of implant design and to evaluate functional outcomes in patients who undergo shoulder arthroplasty.

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.

Propofol extravasation: a rare cause of compartment syndrome.

We detail a rare cause of forearm compartment syndrome that occurred in an 18-year-old patient who presented with a Glasgow Coma Scale of 13/15 after a mixed drug overdose and subsequently required intubation. She suffered extravasation of her propofol infusion, which resulted in intrinsic compression within her forearm muscle compartments. Fortunately, the diagnosis of compartment syndrome was made swiftly and the patient was taken to theatre within 3 h where she underwent an emergency forearm fasciotomy. She made an uneventful recovery and at follow-up her wounds had healed well with no associated morbidity or loss of function. The learning points of this study highlight the importance of thoroughly understanding the signs and symptoms of compartment syndrome while maintaining a high index of suspicion. In addition to a thorough history and examination, consideration of the potential underlying causes allows for a swifter diagnosis and a quicker transition to theatre.