Fixed-Bearing Unicompartmental Knee Arthroplasty of the Lateral Compartment: A Series of 246 Cases.

Background: Isolated osteoarthritis of the lateral compartment of the knee is less common than that of the medial compartment, resulting in significantly fewer lateral unicompartmental knee arthroplasties (UKAs) being performed. This study aimed to evaluate results of a fixed-bearing UKA for the treatment of lateral compartment osteoarthritis of the knee. Methods: A prospectively collected cohort of 255 patients undergoing fixed-bearing UKA of the lateral compartment using the Triathlon PKR (Stryker, Warsaw, IND) implant with a minimum 2-year follow-up was reviewed. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, radiographic alignment, complications, reoperations, and revisions were recorded. Patient factors and pre- and post-surgical alignment were assessed for their association with a minimum important change (MIC) of the total WOMAC score. Results: A total of 246 implants with a mean follow-up of 6.6 years (2-10.8 years) were included (4% lost to follow-up). The total WOMAC score increased from 61.3 ± 3.5 to 85.3 ± 7.5, exceeding the MIC in 215 patients (88%). Exceeding the MIC was not associated with age, body mass index, or alignment. The 5-year implant revision rate was 1.6% (3/187). Conclusions: The fixed-bearing Stryker Triathlon PKR implant for lateral UKA resulted in good clinical outcomes with a low revision rate at midterm follow-up. Body mass index, age, and pre- and post-surgical alignment did not correlate with the clinical outcome. Long-term follow-up is necessary to determine if the clinical improvement and low revision rate can be maintained.

Total Hip Arthroplasty in Patients With Neurological Conditions: A Systematic Review.

Background: As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients. Methods: A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included. Results: From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes. Conclusions: THA may be beneficial in the selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.

Does capsular distension and a short period of countertraction improve outcome following manipulation under anesthesia for the treatment of primary adhesive capsulitis of the glenohumeral joint?

BACKGROUND: Despite the fact that primary adhesive capsulitis of the glenohumeral joint is often considered a self-limiting condition, not all patients make a full recovery. Manipulation under anesthesia (MUA) is performed to forcibly rupture the contracted capsule in a controlled manner. However, the technique, timing, and use of additional injections are often debated. In this study, we report the outcomes following the addition of capsular distension and countertraction to MUA as a treatment for adhesive capsulitis. METHODS: We performed a retrospective case-cohort study comparing 3 groups: Group 1 underwent MUA alone (n = 54); group 2, MUA with capsular distension (n = 114); and group 3, MUA with capsular distension and countertraction (n = 167). The re-MUA rate, Constant-Murley shoulder (CMS) score, and visual analog scale (VAS) score (for pain) were measured after 6 weeks and 6 months. RESULTS: The re-MUA rate fell with the addition of both capsular distension and countertraction: 63% in group 1, 39% in group 2, and 18% in group 3. Patients in group 3 recorded the greatest improvement in the CMS score after 6 weeks (+90% vs. +68% in group 2 and +58% in group 1), with all groups showing improvements compared with before treatment. The only independent risk factor identified for re-MUA was smoking. If a second MUA was performed, the CMS (+67%) and VAS (+61%) scores improved, but at 6 months, the CMS score (74.57 ± 7.6 vs. 83.30 ± 5.5) and VAS score (10.57 ± 1.8 vs. 12.96 ± 1.5) remained inferior to those of patients who only needed a single MUA. DISCUSSION AND CONCLUSION: MUA combined with capsular distension and countertraction reduces the need for a second MUA and results in a faster improvement in functional outcome (CMS score) and reduction of pain (VAS score) compared with MUA alone or MUA with capsular distension. The results of this case-cohort study are of clinical relevance because they show that the efficacy of an MUA can be improved through relatively simple adaptations of the treatment protocol.

Focal articular surface replacement as primary treatment for focal chondral defects of the femoral condyles: A series of 157 cases.

BACKGROUND: Focal chondral defects (FCDs) of the femoral condyle are common. Treatment has heretofore primarily consisted of non-surgical and biological treatments. Focal articular surface replacement (FASR) is an emerging technique utilizing small implants to essentially fill the FCD. Here we report functional outcome and re-operation rates following FASR as a primary treatment for FCDs of the femoral condyles. METHODS: Retrospective analysis of a prospectively collected database including 327 FASR procedures was performed to identify patients who underwent FASR of the femoral condyle with a modular cementless metallic implant (HemiCAPTM) as a primary procedure. Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), SF-36 Health Status Survey (SF-36) and Visual Analog Scale (VAS) were collected before and 6 weeks, 6 months, and 4 years after surgery. Implant revision and re-operation rate were recorded. RESULTS: 157 patients were included with a mean follow-up of 9.4 ± 1.3 years (range 7.0 to 11.4 years). The average age was 40.2 ± 5.3 years, 85% involved the medial condyle, and the average defect size was 3.6 ± 0.5 cm2. Primary FASR resulted in functional improvement on the KOOS (+52%), OKS (+69%) and SF-36 (+50%) scores and a reduction in VAS scores (-70%) at 4-year follow-up. Revision rate was 0.64% and the re-operation rate was 11%. CONCLUSION: This retrospective case-series supports primary FASR with HemiCAPTM implants as an alternative to biological procedures to treat medium-sized FCDs (2.5-4 cm2) of the femoral condyle, although long-term follow-up is necessary to determine if the clinical outcome and low revision rate can be maintained.

Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes-A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR. METHODS: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B). RESULTS: Twenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A. CONCLUSION: TKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.

Focal articular surface replacement of knee lesions after failed cartilage repair using focal metallic implants: A series of 132 cases with 4-year follow-up.

BACKGROUND: Focal articular lesions of the knee can be treated using several different techniques with generally good results, but failures are difficult to manage. Focal articular surface replacement (FASR) using metal implants could be a promising technique that allows defect geometry matching, congruency restoration and defect propagation prevention. METHODS: 132 patients were included who underwent FASR between January 2009 and December 2013. Three different implants were used: 1. HemiCAP®; 2. UniCAP® and 3. HemiCAP® PF Classic for trochlear lesions. Primary outcome parameter was knee function assessed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score with a 4-year follow-up, secondary outcomes included survivorship and complications. Statistical analyses were performed using GraphPad Prism. RESULTS: For all 132 surgeries combined (102 HemiCAP®, 11 UniCAP® and 19 HemiCAP® PF Classic implants), WOMAC scores significantly improved from 6 weeks onward until the end of the study (p < 0.001 for all time points). 4-year survival rate was 97.7%, and a re-operation rate of 12.1% was found. The HemiCAP® group revealed a slower WOMAC improvement in patients aged ≥40 years, combined with a trend towards lower final WOMAC scores and a higher re-operation rate in patients with a BMI ≥ 25. CONCLUSIONS: This report shows good to excellent clinical results of FASR as a salvage procedure after failed cartilage repair, with a low re-operation rate and a high survival of 97.7% at 4-year follow-up. Although longer follow-up is required, this could be a valuable treatment option in these challenging cases, without limiting future options for surgical interventions when deemed necessary.

Knee Fix or Replace Trial (KFORT): a randomized controlled feasibility study.

AIMS: The aim of this study was to assess the feasibility of conducting a full-scale, appropriately powered, randomized controlled trial (RCT) comparing internal fracture fixation and distal femoral replacement (DFR) for distal femoral fractures in older patients. PATIENTS AND METHODS: Seven centres recruited patients into the study. Patients were eligible if they were greater than 65 years of age with a distal femoral fracture, and if the surgeon felt that they were suitable for either form of treatment. Outcome measures included the patients' willingness to participate, clinicians' willingness to recruit, rates of loss to follow-up, the ability to capture data, estimates of standard deviation to inform the sample size calculation, and the main determinants of cost. The primary clinical outcome measure was the EuroQol five-dimensional index (EQ-5D) at six months following injury. RESULTS: Of 36 patients who met the inclusion criteria, five declined to participate and eight were not recruited, leaving 23 patients to be randomized. One patient withdrew before surgery. Of the remaining patients, five (23%) withdrew during the follow-up period and six (26%) died. A 100% response rate was achieved for the EQ-5D at each follow-up point, excluding one missing datapoint at baseline. In the DFR group, the mean cost of the implant outweighed the mean cost of many other items, including theatre time, length of stay, and readmissions. For a powered RCT, a total sample size of 1400 would be required with 234 centres recruiting over three years. At six months, the EQ-5D utility index was lower in the DFR group. CONCLUSION: This study found that running a full-scale trial in this country would not be feasible. However, it may be feasible to undertake an international multicentre trial, and our findings provide some guidance about the power of such a study, the numbers required, and some challenges that should be anticipated and addressed. Cite this article: Bone Joint J 2019;101-B:1408-1415.

404 Porous titanium revision shells permit early weight-bearing and rapid rehabilitation in revision hip surgery.

An aging population and younger primary arthroplasty candidates have led to increased demand for acetabular bone deficient revision hip surgery. Seventy consecutive revision arthroplasty porous titanium shells prior to December 2011 were reviewed. We sought to determine evidence of implant instability in a cohort of patients that are mobilised early. Radiological data were analysed for stability. Primary endpoint was revision of implant. Mean age at surgery was 69.9 (±10) years. Median time since primary surgery was 13 years (range: 0.3-37). Forty-nine per cent had Paprosky Type IIb or greater acetabular deficiency. Bone graft and augments were not used. One shell was revised for ingrowth failure. Mean acetabular inclination was 35.4 ̊ (±7.3) post- operatively and 36.9 ̊ (±7.28) at latest follow up. There were no screw fractures. Porous titanium shells in revision arthroplasty are stable and permit rapid rehabilitation.

Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review.

Significant advances in the treatment of Human Immunodeficiency Virus (HIV) have occurred in recent times, with life expectancy now approaching the normal population. Therefore, patients with HIV will increasingly be undergoing joint replacement in the future, however concerns remain regarding the complications and outcome in this patient cohort. The aim was to assess the outcome of total hip and knee arthroplasty in HIV-infected patients. A systematic search of the literature using MOOSE reporting guidelines was performed to assess the outcome of hip and knee arthroplasty in HIV-infected patients. The primary outcome was infection. Secondary outcome was all-cause revision. The search yielded 552 results, of which 19 met the inclusion criteria, comprising 5.819.412 joint replacements. The overall quality of the studies was poor with significant heterogeneity between the studies. Infection and revision appeared to be more likely to occur in HIV positive patients compared to HIV negative patients. A subgroup analysis of four studies revealed a risk ratio of 3.31 and 2.25 for increase in infection and revision respectively in HIV positive patients. This systematic review and meta-analysis demonstrates an increased risk of infection and revision in HIV infected patients undergoing total hip and knee arthroplasty. However, these findings are based on poor quality evidence in a limited number of studies and need to be interpreted with caution. Further research should concentrate on large, well-designed, prospective studies, that control for co-morbidities and employ standardised outcome measures to allow for direct comparison.

Prevalence and impact of low body mass index on outcomes in patients with adolescent idiopathic scoliosis: a systematic review.

Comparatively lower body mass index (BMI) has been reported in patients with adolescent idiopathic scoliosis (AIS)-a feature which may be an unrecognised symptom, or an organic consequence of the condition. The primary aim of this systematic review is to investigate the relationship between low BMI and AIS. A secondary aim is to investigate the effect of low BMI on outcomes of postsurgical correction in this patient group. The Cochrane Library, PubMed, SCOPUS, Web of Science and Ovid MEDLINE databases were searched up to December 2016 for relevant studies that reported prevalence of low preoperative BMI in patients with AIS and/or compared BMI between patients with AIS and healthy controls, as well as those that examined the relationship between low BMI and postoperative outcomes. Forty-five eligible studies were identified from the search strategy. Mean differences (MDs) were used with 95% confidence intervals (CI) in a random effects model to compare BMI in patients with AIS and controls in a pooled analysis of data from nine eligible studies (n = 3747 patients). In the meta-analysis, BMI of patients in the AIS group was significantly lower than those in the control group (MD -1.19, 95% CI -1.78 to -0.60). Low BMI in AIS can impact postoperative outcomes, including increased risk of ileus. This review demonstrates that patients with AIS are significantly more likely to have a low BMI compared to the general population. We advocate that closer attention be paid to AIS patients with low BMI both pre- and postsurgical correction.

Fix and replace: An emerging paradigm for treating acetabular fractures in older patients.

Acetabular fractures in older patients are challenging to manage. The "fix and replace" construct may present a new paradigm for the management of these injuries. We present the current challenge of acetabular fractures in older patients. We present this in the context of the current literature. This invited editorial presents early results from our centre and the ongoing challenges are discussed.

Metal-on-Metal Total Hip Arthroplasty: Quality of Online Patient Information.

Metal-on-metal total hip arthroplasty (THA) has generated much attention in the media because of early failure of certain implant systems. This study assessed the quality, accuracy, and readability of online information on metal-on-metal THA. The search terms "metal-on-metal hip replacement" and "metal hip replacement" were entered into the 3 most popular search engines. Information quality was assessed with the DISCERN score and a specific metal-on-metal THA content score. Accuracy of information was assessed with a customized score. Readability of the websites was assessed with the Flesch-Kincaid grade level score. A total of 61 unique websites were assessed. For 56% of websites, the target audience was patients. Media or medicolegal sources accounted for 44% of websites. As assessed by DISCERN (range, 16-80) and metal-on-metal THA (range, 0-25) scores, quality of the websites was moderate at best (47.1 and 9.6, respectively). Accuracy (range, 0-8) of the information presented also was moderate, with a mean score of 6.6. Media and medicolegal websites had the lowest scores for both quality and accuracy, despite making up the greatest proportion of sites assessed. Only 1 website (2%) had a Flesch-Kincaid grade level at or less than the recommended level of 8th grade. This study found that online information on metal-on-metal THA was of poor quality, often was inaccurate, and was presented at an inappropriately high reading level, particularly for media and medicolegal websites. Health care providers should counsel patients on the quality of information available and recommend appropriate online resources. [Orthopedics. 2017; 40(2):e262-e268.].

Anthropometric characteristics, high prevalence of undernutrition and weight loss: impact on outcomes in patients with adolescent idiopathic scoliosis after spinal fusion.

PURPOSE: Abnormal anthropometry including comparably lower weight and body mass index (BMI) in the adolescent idiopathic scoliosis (AIS) population is increasingly recognised, however, no study has examined postoperative weight loss or its clinical relevance in these relatively thin patients. This study aimed to assess perioperative nutritional status as well as clinically severe involuntary weight loss and its impact on outcomes in patients with AIS undergoing posterior spinal fusion (PSF). A further objective was to compare preoperative anthropometric measurements of the current AIS cohort with healthy controls. METHODS: Seventy-seven consecutive and eligible patients with AIS who underwent PSF were prospectively followed up from hospital admission (January 2010-April 2012). Pre- and postoperative anthropometric measurements were collected (weight, height, BMI), and clinically severe unintentional weight loss computed, defined as loss of >10% body weight from admission to hospital discharge. The effect of weight loss >10% was analysed in relation to radiographic, nutritional and perioperative complication data, and length of hospitalisation. A case-controlled study was then performed to establish potential differences in weight, height and BMI of this AIS cohort with healthy age- and gender-matched controls derived from the National Teens' Food Survey (2005-2006). Anthropometric values were standardised by conversion to age- and gender-specific Z-scores; 'undernutrition' was defined as BMI Z-scores <-2. RESULTS: Mean age of the cohort was 15 years (SD 1.89); 93.5 % of subjects were female. Clinically severe postoperative weight loss >10%, identified in 22 patients (30.6%), was associated with a significantly increased superficial wound infection incidence (13.6 vs. 2%, P = 0.047), as well as lower serum albumin at hospital discharge (25 vs. 28 g/L, P < 0.05). A high prevalence of postoperative undernutrition was observed-over one quarter of patients had a BMI Z-score <-2 at hospital discharge (26.4%); serum albumin, total protein and haemoglobin levels were below normal limits in 98, 66 and 91% of patients, respectively. Significantly lower weight (52 vs. 59.8 kg, P < 0.0001), corrected height (162 vs. 166.3 cm, P < 0.0001) and BMI (19.72 vs. 21.6 kg/m(2), P < 0.0001) measurements were identified in this AIS cohort, in comparison with those recorded in The National Teens' Survey. CONCLUSIONS: This study demonstrated that clinically severe postoperative weight loss >10%, identified in almost one-third of this AIS cohort, was associated with significantly increased wound infection incidence. Early detection and prevention of severe postoperative weight loss in patients with AIS who undergo spinal fusion may be beneficial in reducing wound infection risk. This study confirms a body of literature indicating the significantly lower weight and BMI in patients with AIS compared with healthy controls.

Intramedullary nails for extracapsular hip fractures in adults.

BACKGROUND: Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008. OBJECTIVES: To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014). SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model. MAIN RESULTS: We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81). AUTHORS' CONCLUSIONS: The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Timing and predictors of return to short-term functional activity in adolescent idiopathic scoliosis after posterior spinal fusion: a prospective study.

STUDY DESIGN: Prospective study. OBJECTIVE: To assess the timing and predictors of return to short-term functional activity in patients with adolescent idiopathic scoliosis (AIS) after posterior spinal fusion (PSF). SUMMARY OF BACKGROUND DATA: Few studies have examined the timing and rate of return to short-term functional activity in patients with AIS after PSF. No study has yet evaluated the timing and factors that predict a delayed return to school/college--a topic relevant to patients who have had or anticipate having spinal fusion, and their treating surgeons. METHODS: Seventy-seven eligible subjects with AIS who underwent PSF and correction (January 2010 to April 2012) were followed up until return to the functional outcomes under analysis. Timing of return to school/college and physical activity, as per the patients' preoperative level or better, was assessed. Binary logistic regression analysis was used to determine predictors of delayed return to school/college full-time (>16 wk) and unrestricted physical activity (>32 wk) relative to sociodemographic, anthropometric, radiographical, clinical, and surgical factors. In the present study, a "delayed" return to all the functional outcomes recorded was defined as "greater than the 75th percentile" of the continuous distribution. RESULTS: Mean follow-up was 12.8 months (SD, 5.7). Mean age was 15.04 years (SD, 1.89). The median time to return to school/college full-time (n = 75) was 10 weeks; the majority returned by 16 weeks (77.3%). Preoperative curves greater than 70° (relative risk, 3.38; P = 0.008), postoperative weight loss greater than 5 kg (relative risk, 3.02; P = 0.012), and minor perioperative respiratory complication incidence (relative risk, 2.89; P = 0.024) independently predicted delayed return to school/college full-time. By 24 and 52 weeks, 51.4% and 88.5% of subjects, respectively, returned to unrestricted physical activity. At final follow-up, nonreturn to unrestricted physical activity was identified in only 3 subjects (4.3%) because of chronic back pain. CONCLUSION: The majority of patients with AIS can expect to return to school/college full-time by 16 weeks and unrestricted physical activity by 52 weeks after PSF. Preoperative curves greater than 70°, postoperative weight loss greater than 5 kg, and minor perioperative respiratory complication incidence independently predicted a delayed return to school/college full-time. These findings add to the current knowledge base regarding actual versus anticipated timing of return to short-term functional outcomes in this population. LEVEL OF EVIDENCE: 3.

Dislocation of primary total hip arthroplasty and the risk of redislocation.

6554 primary total hip arthroplasties were reviewed. Risk factors for dislocation were analysed to assess which were important in terms of predicting recurrent instability. The patients risk of having a second dislocation was independently associated with the surgical approach adopted (p = 0.03) and the time to first dislocation from the primary hip replacement (p = 0.002). Early dislocators whose surgery was performed through an anterolateral approach had less recurrence than late dislocators through a posterior or transtrochanteric approach. None of the other risk factors including head size (p = 0.59), modularity (p = 0.54), mechanism of dislocation (p = 0.23), leg length discrepancy (p = 0.69) and acetabular inclination (p = 0.31) were influential. The use of an abduction brace was not useful in preventing a further dislocation with 69.2% of those braced re-dislocating compared to 68.5% who were not braced (p = 0.96).

Minimum ten-year follow-up of acetabular fracture fixation from the Irish tertiary referral centre.

BACKGROUND: Successful outcome from acetabular fracture fixation is multi-factorial. Long-term results are not frequently reported. Pooling such data from high output centres will help progress acetabular fixation. This paper presents the first ten-year data from the Irish tertiary referral centre. AIM: To audit the radiographic and clinical outcome of all patients who had acetabular fracture fixation in the unit a minimum of ten years previously. METHODS: Patients were identified from the unit database. Each patient was contacted and invited to attend the hospital for clinical and radiographic review. Clinical review consisted of examination and three separate scoring systems using both subjective and objective parameters. Radiographic review consisted of a standard AP pelvis and Judet views. RESULTS: Forty-four patients were identified. Follow up of 68% was achieved. Total hip arthroplasty rate was 13.8%. Twenty percent of the remaining native hips had radiographic evidence of established arthritis. Sixty-three percent of functional outcome scores were classified as 'good' or 'excellent'. Radiographic and functional data did not strongly correlate. The strongest correlating factor with poor functional outcome was concurrent injuries, particularly sciatic nerve injury. CONCLUSIONS: These data support the role of operative intervention for acetabular fractures in a tertiary referral centre and allow better counselling of patients on prognosis.

Influence of weather variables on pain severity in end-stage osteoarthritis.

PURPOSE: Patients often attribute increasing pain in an arthritic joint to changing weather patterns. Studies examining the impact of weather on pain severity have yielded equivocal and sometimes contradictory results. The relationship between subchondral pseudocysts and the role they play in this phenomenon has not been explored. METHODS: Fifty-three patients with end-stage osteoarthritis of the hip completed daily pain severity visual analogue scale (VAS) scores over a one month period. Radiographs were reviewed to determine the presence of pseudocysts. Data pertaining to precipitation, atmospheric pressure and temperature were collected from the nearest weather station. A generalised linear mixed model was used to explore the relationship between weather variables, cysts and pain severity. RESULTS: Pain levels increased as a function of absolute change in atmospheric pressure from one day to the next. Precipitation, temperature and the presence of subchondral pseudocysts were not shown to influence pain severity. CONCLUSIONS: This data supports the belief held by many osteoarthritic patients that changing weather patterns influence their pain severity.

Pre-operative traction for hip fractures in adults.

BACKGROUND: Following a hip fracture, traction may be applied to the injured limb before surgery. This is an update of a Cochrane review first published in 1997, and previously updated in 2006. OBJECTIVES: To evaluate the effects of traction applied to the injured limb prior to surgery for a fractured hip. Different methods of applying traction (skin or skeletal) were considered. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2011), the Cochrane Central Register of Controlled Trials (in The Cochrane Library 2011, Issue 4), MEDLINE (1948 to April week 2 2011), EMBASE (1980 to 2011 week 16), and CINAHL (1982 to 1 April 2011), conference proceedings, trials registries and reference lists of articles. SELECTION CRITERIA: All randomised or quasi-randomised trials comparing either skin or skeletal traction with no traction, or skin with skeletal traction for patients with an acute hip fracture prior to surgery. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed trial quality and extracted data. Additional information was sought from all trialists. Wherever appropriate and possible, data were pooled. MAIN RESULTS: One new trial was included in this update. In all, 11 trials (six were randomised and five were quasi-randomised), involving a total of 1654 predominantly elderly patients with hip fractures, are included in the review. Most trials were at risk of bias, particularly that resulting from inadequate allocation concealment, lack of assessor blinding and incomplete outcome assessment. Only very limited data pooling was possible.Ten trials compared predominantly skin traction with no traction. The available data provided no evidence of benefit from traction either in the relief of pain (pain soon after immobilisation (visual analogue score 0: none to 10: worst pain): mean difference 0.11, 95% CI -0.27 to 0.50; 3 trials), ease of fracture reduction or quality of fracture reduction at time of surgery. There were inconclusive data for pressures sores and other complications, including fracture fixation failure. Three minor adverse effects (sensory disturbance and skin blisters) related to skin traction were reported.One of the above trials included both skin and skeletal traction groups. This trial and one other compared skeletal traction with skin traction and found no important differences between these two methods, although the initial application of skeletal traction was noted as being more painful and more costly. AUTHORS' CONCLUSIONS: From the evidence available, the routine use of traction (either skin or skeletal) prior to surgery for a hip fracture does not appear to have any benefit. However, the evidence is also insufficient to rule out the potential advantages for traction, in particular for specific fracture types, or to confirm additional complications due to traction use.Given the increasing lack of evidence for the use of pre-operative traction, the onus should now be on clinicians who persist in using pre-operative traction to either stop using it or to use it only in the context of a well-designed randomised controlled trial.

Traumatic hip dislocation in a 3-year-old girl.

Traumatic hip dislocation in the pediatric patient requires much less energy than in an adult, yet it remains a rare diagnosis. We report the case of a 3-year-old girl who dislocated her right hip when bindings failed to release as she skied downhill. The hip was promptly reduced in the nearest trauma center, and at 18 months after injury, there is no evidence of avascular necrosis. The potential risk of avascular necrosis is significant, and the risk rises greatly when reduction is delayed beyond 6 hours. Reduction can be safely performed in the emergency department, although up to 25% of cases will require open reduction in the operating room. A high index of suspicion is warranted to not miss the "golden window" and achieve satisfactory reduction in a timely fashion.