BACKGROUND: Acute leg compartment syndrome is a well-known orthopedic emergency associated with potentially devastating consequences if not treated immediately. Multiple compartments are usually involved with a clear history of trauma and classic symptoms and signs. However, isolated lateral leg compartment syndrome is relatively rare and is often misdiagnosed due to the atypical presentation of no trauma and the lack of pathognomonic signs. CASE SUMMARY: A 31-year-old male patient presented to our emergency room with excruciating left calf pain and inability to mobilize one-day after participating in a football match despite no clear history of preceding trauma. The patient went to another hospital before presenting to us where he was diagnosed to have a soft tissue injury and was discharged home on simple analgesics. On clinical examination, the left leg showed a tense lateral compartment with severe tenderness. The pain was aggravated by dorsiflexion and ankle inversion. Neurovascular examination of the limb was normal. We suspected a compartment syndrome but as the presentation was atypical and an magnetic resonance imaging (MRI) was readily available in our institution, we immediately performed an MRI and this confirmed a large hematoma in the lateral compartment with a possible partial proximal peroneus longus muscle tear. The patient was taken immediately for an emergency open fasciotomy. The patient is now 18 mo postoperatively having recovered completely and engages fully in sports with no restrictions. CONCLUSION: Atypical presentation due to the lack of pathognomonic signs makes the diagnosis of isolated lateral leg compartment syndrome difficult. Pain on passive inversion and dorsiflexion and weak active eversion may be suggested as sensitive signs.
Periprosthetic joint infection (PJI) is a well-known serious complication following joint replacement surgeries and is responsible for high failure rates of implanted devices. Any delay in the diagnosis can compromise treatment success, putting a huge burden on the patients' wellness and healthcare systems. Diagnosing PJIs is quite complex as there is still no gold standard test to reach the definitive diagnosis in a timely manner. A number of laboratory tests and radiological imaging inventions have evolved in the past few years, requiring consistent updates of the available guidelines to keep up with the latest advances in the field. This article highlights the recent advances in diagnosing PJIs and discusses their validity for use in clinical practice.
Periprosthetic joint infection (PJI) following total knee arthroplasty is one of the most catastrophic and costly complications that carries significant patient wellness as well as economic burdens. The road to efficiently diagnosing and treating PJI is challenging, as there is still no gold standard method to reach the diagnosis as early as desired. There are also international controversies with respect to the best approach to manage PJI cases. In this review, we highlight recent advances in managing PJI following knee arthroplasty surgery and discuss in depth the two-stage revision method.
Background The use of circular frames in correcting lower limb deformity is well-established and has evolved dramatically over the years. Three new frames have been introduced recently, and this study is set to compare them in terms of accuracy and efficiency in correcting a similar long bone deformity. These frames are the Taylor Spatial Frame (TSF; Smith & Nephew, London, United Kingdom), the Truelok Hexapod System (TL-HEX; Orthofix, Lewisville, Texas), and Orthex (OrthoPediatrics, Warsaw, Indiana). Methods This is a biomechanical study comparing the above three types of circular frames to correct similar deformities in Sawbones models. The deformities that are compared were: (1) 30° valgus deformity of the distal femur; (2) 30° varus deformity of the proximal tibia. Each frame was applied to the deformed bone in the standard way that we apply to normal bone. X-rays were taken before and after the deformity correction. The frames' software was used to estimate the deformities. The variations between the software's estimations and the known bone deformities were compared. Residual deformity after initial correction and the number of re-programmings was compared among these three frames. The least residual deformity and re-programming is the favorable outcome. Results All the Sawbones models had a 30° actual coronal angulation. The Orthex software estimated the deformity at around 25.35° (SD 4.6), TSF 25.6° (SD 2), and TL-HEX 29.87° (SD 2.1). One-way analysis of variance (ANOVA) showed a significant difference in the findings (P-value 0.014). Accuracy was measured by comparing the residual deformity in angulation in the coronal plane after the first and second correction. The Orthex median residual deformity was 1°, TSF was 2.5°, and TL-HEX was 3° with a range of less than 5° for all of them. The independent samples Kruskal-Wallis test shows that there is no significant difference between the three groups (P=0.549). The frequency of strut changes required throughout the correction was not significant among the three frames using the Fisher exact test (P=0.336). TSF struts are not designed to be readjusted. Conclusion The three frames were comparable in terms of accurate correction of the two deformities, strut changes, and strut adjustments. The TL-HEX frame software was superior to other frames in terms of analyzing the deformity but the difference, although statistically significant clinically, was not.
BACKGROUND: Allogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA). METHODS: A systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted. RESULTS: We identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference -0.02, 95%, confidence interval CI -0.04 to -0.00, P = 0.01, Heterogeneity I2 = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups. CONCLUSION: TXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs.
Arthroplasty, Replacement, Hip/adverse effects , Postoperative Complications/prevention & control , Pulmonary Embolism/prevention & control , Tranexamic Acid/pharmacology , Antifibrinolytic Agents/pharmacology , Humans , Postoperative Complications/etiology , Pulmonary Embolism/etiology
Learning and change are key elements of clinical governance and are responsible for the progression of our specialty. Although orthopaedics has been slow to embrace quality improvement, recent years have seen global developments in surgical education, quality improvement, and patient outcome research. This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered. Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure. Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data. With various organisations promoting centralisation of care, learning curve analysis is more important than ever before. The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide. Patient outcome research is rapidly changing, with an increased focus on quality of life measures. These are key to patients and their care. Cost-utility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care. Large-scale international, multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread. A global lack of surgeon equipoise will need to be addressed. Quality improvement projects frequently employ interrupted time-series analysis to evaluate change. This technique's limitations must be acknowledged, and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur. Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability, validity, and importance of the conclusions drawn from orthopaedic research.
Dissociation of the polyethylene liner from the acetabular shell is a rare but catastrophic complication of total hip arthroplasty (THA). There have been reports of polyethylene liner dissociation (PLD) as well as ceramic liner dissociation (CLD) in the literature. Amongst the commonly used implants, liner dissociation has been reported with the Pinnacle (DePuy), Harris-Galante (Zimmer) and Trident (Stryker) acetabular components. To the best of our knowledge, this is the first case report of PLD in an R3 (Smith & Nephew) acetabular component. This case report highlights the implant choice for treatment of the liner dissociation and the role of constrained implants in such cases.
BACKGROUND: Triclosan-coated vicryl plus suture (Ethicon, Inc.) was developed to reduce microbial colonisation during surgical procedures. However, its effect on wound healing and surgical site infections remain unclear after hip and knee arthro-plasty surgery. AIM: To determine the effect of triclosan-coated sutures (TCS) vs non-coated sutures on wound healing, following primary hip and knee arthroplasties. METHODS: A single-centred, double-blind randomised controlled trial (RCT) was undertaken. We randomly allocated patients to receive either the triclosan-coated sutures (TCS vicryl plus) or non-coated sutures (NCS vicryl) during the closure of unilateral primary hip and knee arthroplasties. We utilised the ASEPSIS wound scoring system to evaluate wound healing for the first 6 weeks post-operatively. RESULTS: One hundred and fifty patients undergoing primary total hip or knee arthroplasty over a one-year period were included. Eighty-one were randomised to the TCS group and 69 to the NCS group. Despite no statistically significant difference in the ASEPSIS scores among the study groups (P = 0.75), sensitivity analysis using the Mann Whitney test (P = 0.036) as well as assessment of the wound complications at 6 weeks follow up, demonstrated significantly higher wound complication rates in the TCS group (8 vs 1, P = 0.03). CONCLUSION: No clear advantage was demonstrated for using the TCS. However, larger multi-centred RCTs are required to validate their use in hip and knee arthroplasty surgery.
An algorithm for managing periprosthetic joint infections (PJIs) after total hip replacement (THR) surgery using a multidisciplinary approach and a clearly defined protocol may improve infection eradication rates. In this article, we present an algorithm for the management of different types of PJIs including the acutely infected cemented and cementless THRs where the components are well-fixed postoperatively and when the infection is secondary to haematogenous spread in previously well-functioning and well-fixed implants. For chronic PJIs where the components are often loose, the standard treatment includes a two-stage revision procedure. However, in a highly selected subset of patients, a single-stage approach has been utilised with high rates of eradicating infections.
BACKGROUND: Proponents of the direct anterior approach (DAA) for THAs suggest earlier recovery with no increased complications whereas opponents suggest higher complication rates. METHODS: We conducted a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of the DAA versus other surgical approaches in primary THAs. RESULTS: We identified 18 RCTs suitable for detailed extraction of the data. The RCTs included a total of 1661 patients with a mean age of 62 years (range 55-69). Using the DAA led to a significant improvement in the Harris Hip score by a mean of 5.6 points (95% confidence interval (CI) 4.3 to 6.8, p < 0.01, heterogeneity I2 18%) and the WOMAC score by a mean of -3.1 points (95% CI -4.1 to -2.1, p < 0.001, I2 0%) at 6 weeks postoperatively, reduction in the analgesic requirements on the day of surgery (Morphine Equivalents -3.6 95% CI -6.5 to -0.7, p = 0.02, I2 50%) and pain scores on day one postoperatively (VAS -1.3 95% CI -1.5 to -1.1, p < 0.01, I2 91%). DAA was associated with a smaller incision (-3.2 cm 95% CI -3.3 to -3.1, p < 0.01, I2 99%) and there was no significant difference in complication rates (P = 0.20) among the study groups. CONCLUSION: Based on the available studies, the DAA offers superior functional outcomes over other approaches in the immediate postoperative period after primary THA with no increased risk of complications. However, there was no evidence to support the superiority of any approach beyond 6 weeks postoperatively.
Arthroplasty, Replacement, Hip/methods , Humans , Randomized Controlled Trials as Topic
This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.
Compartment syndrome is a rare complication of total knee replacement (TKR) surgery that needs prompt diagnosis and treatment as it may be associated with high morbidity and mortality. We have found very few reports in the literature describing compartment syndrome after TKRs and therefore, present a relevant case which occurred in the immediate postoperative phase and was treated with fasciotomy and subsequent operations to close the soft tissue defects.
Anterior cruciate ligament injury, a common soft tissue injury of the knee joint, is increasing in incidence particularly in young active people. It causes instability of the knee that leads to meniscal tears, cartilage defects and early osteoarthritis. This review summarizes aspects of anterior cruciate ligament injury management.
Anterior Cruciate Ligament Injuries , Knee Injuries/physiopathology , Knee Injuries/therapy , Disease Management , Humans
Anterior cruciate ligament injury is among the most common soft tissue injuries of the knee joint and reconstruction of the anterior cruciate ligament is the gold standard treatment for young active symptomatic patients. This review summarizes the surgical treatment of anterior cruciate ligament injury.
Anterior Cruciate Ligament Injuries , Anterior Cruciate Ligament Reconstruction/methods , Anterior Cruciate Ligament/surgery , Knee Injuries/surgery , Adult , Humans
BACKGROUND: Periprosthetic joint infection (PJI) continues to be one of the leading causes of failure following hip and knee surgery. The diagnostic workflow of PJI includes detailed clinical examination, serum markers, imaging and aspiration/biopsy of the affected joint. The goals of treatment are eradication of the infection, alleviation of pain, and restoration of joint function. Surgical management of PJI consists of debridement, antibiotics and implant retention (DAIR) and single or two-stage revision procedures. Two-stage revision remains the gold standard for treatment of PJIs. We aim to discuss the two stage procedure in this article and report the outcomes. METHODS: The first stage of the two stages consists of removal of all components and associated cement with aggressive debridement and placement of an antibiotic-loaded cement spacer. Patients are then treated with variable periods of parenteral antibiotics, followed by an antibiotic free period to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest infection control, then the second stage can be undertaken and this involves removal of the cement spacer, repeat debridement, and placement of a new prosthesis. RESULTS: Common themes around the two-stage revision procedure include timing of the second stage, antibiotics used in the interim period, length of the interim period before consideration of reimplantation and close liaising with microbiologists. CONCLUSION: Successful eradication of infection and good functional outcome using the two stage procedure is dependent on a multidisciplinary approach and having a standard reproducible startegy.
BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. In an aging population of the developed world, the increasing numbers of hip and knee replacements will inevitably lead to increasing incidence of PJI, carrying with (it) significant patient morbidity and cost to the health care system. Two-stage exchange arthroplasty is currently the gold standard but it is associated with multiple operations, prolonged hospitalization and impaired functionality. One-stage exchange arthroplasty is similar to the two-stage procedure but the interval between removal of the prosthesis and reimplantation of a new one is only a few minutes. It has the theoretical benefits of a single anesthetic, shorter hospitalization, less cost and improved function. METHODS: We reviewed the current literature regarding the outcomes of one-stage exchange arthroplasties focusing on re-infection rates and functional outcomes. RESULTS: Current themes around the one-stage exchange procedure include the indications for the procedure, definition of re-infection, surgical techniques used to provide fixation and differences in approach for hip and knee replacements. CONCLUSION: The current literature on one-stage exchange procedure is promising, with comparable results to two-stage revisions for hips and knees in selected patients. However, there is a great need for a large multi-centred randomized control trial, focusing on re-infection rates and functional scores postoperatively, to provide concrete guidelines in managing this complex condition.
BACKGROUND: The increasing load placed by joint replacement surgery on health care systems makes infection, even with the lowest rates, a serious concern that needs to be thoroughly studied and addressed using all possible measures. METHODS: A comprehensive review of the current literature on salvage procedures for recurrent PJIs using PubMed, EMBASE and CINAHL has been conducted. RESULTS: Prolonged suppressive antibiotic therapy (PSAT), resection arthroplasty and arthrodesis were the most common procedures performed. Suppressive antibiotic therapy is based on the use of well tolerated long term antibiotics in controlling sensitive organisms. Resection arthroplasty which should be reserved as a last resort provided more predictable outcomes in the hip whereas arthrodesis was associated with better outcomes in the knee. Various methods for arthrodesis including internal and external fixation have been described. CONCLUSION: Despite good union and infection control rates, all methods were associated with complications occasionally requiring further surgical interventions.
Periprosthetic Joint infection (PJI) following hip and knee replacements is an important complication causing major concern for patients, operating surgeons and healthcare systems. Therefore, a standardized definition of PJI is required to improve communication and allow for valid comparisons of various diagnostic and treatment strategies. This review summarizes the most commonly used definitions for PJI and the current consensus. It also highlights the economic burden related to PJIs and the importance of a multidisciplinary approach to managing those infections.
BACKGROUND: Periprosthetic Joint Infection Remains a Dreaded Complication After Hip and Knee Replacement Surgery. Treatment Options for Acute Postoperative and Acute Hematogenous Infections Include Arthroscopic or Open Debridement With Retention or Exchange of the Prostheses. This Review Article Aims to Summarize the Evidence for Management of Acute Postoperative And Acute Hematogenous Infections. METHODS: A Systematic Literature Search Was Performed Using a Computer-based Search Engine Covering Medline (OvidSP), PubMed Database (U.S. National Library of Medicine, National Institutes of Health), Embase, Web of Science, Cochrane and Google Scholar for Relevant Articles. RESULTS: Common Themes Around Treatment of Acute Postoperative and Acute Hematogenous Infections Discussed in this Review Include the Timing of Intervention, Description of the Optimal Procedure and How we Perform it at our Institution, the Role of Arthroscopic Debridement, Most Commonly Isolated Micro-organisms and Prognostic Factors for Infection Control. CONCLUSION: Success in Treating Acute Postoperative and Acute Hematogenous Infections Depends on Early Diagnosis and Aggressive Surgical Debridement Combined With Effective Antibiotic Therapy.
