Systematic review and meta-analysis on SuperPATH approach versus conventional approaches for hip arthroplasty.

AIM: The SuperPATH approach has been in practice for almost a decade. There is no systematic review to date comparing the novel SuperPATH approach with conventional approaches. Therefore, it is important to conduct an up-to-date review to evaluate the benefits and drawbacks of the SuperPATH approach in comparison to widely accepted traditional approaches.Our primary aim was to compare the newer SuperPATH approach with the traditional approaches to the hip in terms of functional outcome and radiological parameters. We also aimed to identify any potential complications of the SuperPATH approach as it is a new surgical technique lacking any published sytematic reviews. MATERIALS AND METHODS: The review was conducted in accordance with the steps detailed in the Cochrane Handbook for Systematic reviews of intervention and will be reported bearing in mind the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PICO terms were independently searched in multiple databases. Studies that compared SuperPATH with traditional approaches were included in the analysis. RESULTS: 7 studies including a total of 730 patients were available for final analysis. 3 studies were randomised control trials, 2 were prospective cohort studies and 2 were non-randomised case control studies.Patients in the SuperPATH group were discharged earlier (2 days difference in weighted mean). The operative time was 5 minutes longer (84.46 vs. 78.99) and there was a marginal decrease in blood loss (38 ml lesser) in the SuperPATH approach. VAS Score and HHS at the end of 1 year was comparable in both study groups. Cup abduction angle and anteversion angles were acceptable and comparable in both groups. CONCLUSIONS: The SuperPATH approach shows minimal improvement in length of hospital stay and blood loss with no significant improvement in pain or functional outcome score. There are no major complications reported and the radiological parameters are comparable.

Cost analysis on virtual clinic follow-up after primary joint arthroplasty.

BACKGROUND: As previously reported, a virtual clinic (VC) effectively manages the increasing need to review and monitor patients after primary joint replacement. Such procedure is increasing steadily in number, with more than 200,000 procedures performed annually in the UK. Considering that face-to-face review following routine uncomplicated primary joint arthroplasty is costly and time consuming, guidelines suggest reviewing patients at regular intervals through radiographs and patient-reported outcome measures (PROMs). METHODS: We reviewed our VC experience in a large teaching hospital. A single surgeon established the VC, and all primary hip and knee replacements over an 18-month period (January 2016 to July 2017) were included in the study. We evaluated all clinical records, PROMs, patient satisfaction, and outcome of VC at one-year follow-up. Additionally, we conducted a safety and cost analysis. RESULTS: This study included 154 primary joints (70 total knee replacements and 84 total hip replacements) in 148 patients (89 females, 59 males). The mean age at surgery was 65.3 years. Of the patients, 93% completed the postoperative PROMs, whereas <40% completed the PROM during regular clinical follow-up. All the patients had follow-up radiographs. After VC assessment, which included radiographies and PROMs, 59% of the patients were directly discharged. Of the remaining 41% patients who had face-to-face review, one-third were examined for the same arthroplasty issue, and two-thirds were examined for unrelated or other joint problems. Although the postoperative PROM was below the national average, the improvement in PROM (from pre-operative to post-operative scores) was higher than the national average. The cost analysis demonstrated an average cost savings of £10.449 per year and consultant. CONCLUSIONS: VC follow-up after primary joint replacement is a safe and cost-effective option to manage postoperative follow-up visits and identify those patients who require additional face-to-face reviews and who can be safely discharged. The discharge criteria included satisfactory improvement in PROM scores, review of follow-up radiographs, and no concerns raised by patients. Considering the increasing number of primary joint arthroplasty and the financial pressure on the National Health Service, VC offers an excellent alternative to conventional clinics.

Outcome of revision surgery for bisphosphonate related subtrochanteric fracture non-union following failed intramedullary nailing.

BACKGROUND: Bisphosphonates use is a recognised cause of atypical femur fractures. Intramedullary nailing is the first line of treatment for these fractures, but failure is a common problem due to altered biology, resulting in a non-union and a challenging problem. PURPOSE: There is lack of evidence in the literature on revision surgery for the management of non-union after failed nailing in atypical femur fracture. We present our experience of treating this complex problem. PATIENT AND METHODS: A retrospective review of all consecutive cases of revision surgery for non-union of bisphosphonate related subtrochanteric fractures was undertaken. All procedures were performed between 2012 and 2017 by a single surgeon. Revision surgery included removal of failed metalwork, resection of non-union, bone grafting and double plating with a lateral DCS plate and anterior locking compression plate. RESULTS: Ten patients (9 females, 1 male) were included with a mean age of 71.5 years and mean BMI of 34 at the time of revision. All patients received previous Bisphosphonate treatment on average for 6.2 years. One patient was lost to follow up. Mean time for non-weight bearing (NWB) mobilization was 7 months and mean time for union was 14 months. CONCLUSIONS: Fracture healing can be achieved with bone grafting and compression plating in all patients. However, a prolonged time to achieve union and a long follow-up duration should be expected.

Coronavirus infection in hip fractures (CHIP) study.

AIMS: Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. METHODS: This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. RESULTS: The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. CONCLUSION: In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782-787.

Sequential spontaneous compartment syndrome in multiple limbs in a young adult with GYG1 gene mutation.

Compartment syndrome is a surgical emergency requiring immediate intervention. Majority of compartment syndromes are associated with trauma or surgery. Spontaneous compartment syndrome in multiple limbs is rare and alternative diagnosis should be sought. We report a young adult man who developed compartment syndrome in all four limbs sequentially over 4 years. On further evaluation, he was found to have a gene mutation in exon 3 of GYG1 gene. Spontaneous compartment syndrome in patients with GYG1 gene mutation does not appear to have been previously recognised. Although a direct causality cannot be confidently drawn, this gene is involved in muscle energy utilisation and is known to cause metabolic defect. Acute compartment syndrome, once diagnosed, warrants emergency surgical decompression. The subsequent management of spontaneous compartment syndrome demands a thorough medical assessment to identify any underlying metabolic or genetic predisposition.

Second-Generation Ceramic First Metatarsophalangeal Joint Replacement for Hallux Rigidus.

BACKGROUND: Ceramic first metatarsophalangeal (MP) joint replacement has been reported for treatment of hallux rigidus, but there are no published mid- or long-term studies available. We present our midterm results using a second-generation ceramic first MP joint implant. METHODS: A retrospective review of clinical data and radiographs was performed for 31 feet (24 women; mean age at surgery, 55 ± 6 years) who had first MP joint replacement with a second-generation ceramic prosthesis (primary, 29 feet; revision, 2 feet). Mean follow-up was 81 ± 27 months after surgery RESULTS: Mean first MP passive range of motion was 32 ± 17 degrees (dorsi- and plantarflexion). Mean AOFAS score was 72 ± 19 points and Foot Function Index was 27 ± 26 points (all 31 feet). Clinical rating for 29 feet that had surgery as a primary procedure was excellent in 5 feet (17%), good in 8 feet (28%), fair in 3 feet (10%), and poor in 13 feet (45%). Patients were satisfied with the outcome in 24 feet (77%). Follow-up radiographs showed that radiolucency, change in angulation, sinkage, and malalignment of the metatarsal or proximal phalanx components were common. Complications included 1 superficial wound infection, and revision was performed in 5 feet (16%) because of loosening, sinkage, subluxation, pain, or fractured prosthesis. Implant survival was 92% at 5 years, 85% at 7 years, and 68% at 9 years. CONCLUSION: The results of second-generation ceramic first MP joint replacement in our series demonstrated poor clinical and radiological results with a high revision rate. LEVEL OF EVIDENCE: Level IV, case series.

Delayed rupture of flexor tendons in zone V complicated by neuritis 18 years following Galeazzi fracture-dislocation.

We report a rare case of an 84-year-old woman who presented with delayed, complete rupture of superficial (flexor digitorum superficialis) and deep flexor tendons (flexor digitorum profundus) of the third, fourth and fifth digits of the right hand in zone V of the flexor tendons. The patient, who was otherwise healthy, active and independent, incurred a closed fracture of her right wrist 18 years ago, which was treated conservatively. Current X-rays and operative findings confirmed a malunited Galeazzi fracture-dislocation with volar dislocation of the ulna from the distal radioulnar joint. She underwent surgical treatment to improve her hand function and agonising neuritis symptoms, as she was unable to use her middle, ring and little fingers and had developed severe neuritis of the ulnar nerve. Exploration and repair of the flexor tendons, nerve decompressions and Darrach procedure were performed. On follow-up, the patient showed improvement in hand function with the neuritis completely resolved.

Campylobacter fetus sepsis in an immunocompetent patient with haematological complication.

Campylobacter fetus sepsis is rare, especially among young, immunocompetent patients. We present the case of a 43-year-old man with a history of ulcerative colitis who was diagnosed with C fetus bacteraemia with endovascular manifestation. The patient was found to have a low vitamin K level and a high international normalised ratio, and developed deep vein thrombosis. The patient was fully recovered with oral antibiotic treatment, anticoagulation and supportive therapy. Clinicians should be aware that this type of infection, although extremely rare, can occur even in younger, healthy adults and immediate diagnosis and treatment are required to avert life-threatening complications.

The painful shoulder: shoulder impingement syndrome.

Rotator cuff disorders are considered to be among the most common causes of shoulder pain and disability encountered in both primary and secondary care. The general pathology of subacromial impingment generally relates to a chronic repetitive process in which the conjoint tendon of the rotator cuff undergoes repetitive compression and micro trauma as it passes under the coracoacromial arch. However acute traumatic injuries may also lead to this condition. Diagnosis remains a clinical one, however advances in imaging modalities have enabled clinicians to have an increased understanding of the pathological process. Ultrasound scanning appears to be a justifiable and cost effective assessment tool following plain radiographs in the assessment of shoulder impingment, with MRI scans being reserved for more complex cases. A period of observed conservative management including the use of NSAIDs, physiotherapy with or without the use of subacromial steroid injections is a well-established and accepted practice. However, in young patients or following any traumatic injury to the rotator cuff, surgery should be considered early. If surgery is to be performed this should be done arthroscopically and in the case of complete rotator cuff rupture the tendon should be repaired where possible.

The frozen shoulder: myths and realities.

Frozen shoulder is a common, disabling but self-limiting condition, which typically presents in three stages and ends in resolution. Frozen shoulder is classified as primary (idiopathic) or secondary cases. The aetiology for primary frozen shoulder remains unknown. It is frequently associated with other systemic conditions, most commonly diabetes mellitus, or following periods of immobilisation e.g. stroke disease. Frozen shoulder is usually diagnosed clinically requiring little investigation. Management is controversial and depends on the phase of the condition. Non-operative treatment options for frozen shoulder include analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections. Operative options include manipulation under anaesthesia and arthroscopic release and are generally reserved for refractory cases.

Catastrophic failure of ceramic-on-ceramic total hip arthroplasty presenting as squeaking hip.

A 68-year-old woman with osteoarthritis had a ceramic-on-ceramic left total hip arthroplasty, including ceramic femoral head and acetabular liner. At 5 years after surgery, the patient developed onset of a very loud squeaking noise, which could be heard 25 m from her, associated with limited hip movement. Findings at revision surgery included a broken ceramic femoral head component, complete wear of the ceramic acetabular component, and black wear debris. Squeaking hip after ceramic-on-ceramic total hip arthroplasty may be associated with catastrophic failure of the arthroplasty components.

Late Streptococcus bovis infection of total knee replacement complicated by infective endocarditis and associated with colonic ulcers.

Streptococcus bovis is rare cause of late infections after total knee replacement (TKR). This report presents a case of confirmed late septic arthritis following TKR caused by S bovis that was further complicated with infective endocarditis resulting in aortic valve insufficiency in an immunecompetent patient. As an association between S bovis and gastrointestinal malignancies is suggested, a workup for such malignancies was performed that revealed non-malignant ulcers in patient's ascending colon. The patient is currently recovering from his aortic valve replacement surgery and is scheduled to have annual colonoscopies. His knee joint has improved; however, he developed constant pain because of underlying chronic infection in the affected joint and has difficulties mobilising. Therefore, a revision TKR is considered but postponed until he fully recovers from his heart valve surgery.

Fractures of the clavicle: an overview.

Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management. A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.

Periprosthetic metastasis: a rare cause for prosthetic loosening.

Malignant periprosthetic metastasis is a very rare yet important cause of painful joint arthroplasty. This study presents a case in which periprosthetic osteolysis following total hip replacement (THR) occurred as a result of metastatic mesothelioma. After a THR and revision THR, histopathology confirmed the diagnosis of metastatic mesothelioma. Primary lesion was identified using CT scan of the chest. Patient is receiving palliative chemotherapy.