Trends in incidence and average waiting time for arthroplasty from 1998-2021: an observational study of 282,367 patients from the Scottish arthroplasty project.

BACKGROUND: Current waiting times for arthroplasty are reported as being the worst on record. This is a combination of increasing demand, the COVID-19 pandemic and longer standing shortage of capacity. The Scottish Arthroplasty Project (SAP) is a National Audit that analyses all joint replacements undertaken in the Scottish NHS and Independent Sector. The aim of this study was to investigate the long-term trend in provision and waiting time for lower limb joint replacement surgery. METHODS: All total hip replacements (THR) and total knee replacements (TKR) undertaken in NHS Scotland from 1998 to 2021 were identified. Waiting times data were analysed each year to determine the minimum, maximum, median, mean and standard deviation. RESULTS: In 1998, there were 4,224 THR and 2,898 TKR with mean (range, SD) waiting time of 159.5 days (1-1,685, 119.8) and 182.9 days (1-1,946, 130.1). The minimum waiting times were both in 2013 for 7,612 THR - 78.8 days (0-539, 46) and 7,146 TKR - 79.1 days (0-489, 43.7). The maximum waiting times recorded were in 2021 with 4,070 THR waiting 283.7 days (0-945, 215) and 3,153 TKR waiting 316.8 days (4-1,064, 217). CONCLUSIONS: This is the first robust large-scale national dataset showing trends in incidence and waiting time for THR and TKR over two decades. There was an expansion of activity with a reduction in waiting time, which peaked in 2013, followed by an increase in waiting time with a plateau and modest decline in the number of procedures.

Glenoid track measurement using magnetic resonance imaging arthrography is predictive of recurrent instability following arthroscopic shoulder stabilisation.

PURPOSE: The primary aim of this study was to investigate medium-term survivorship following arthroscopic Bankart repair (ABR) for anterior glenohumeral instability. The secondary aim was to determine whether the pre-operative magnetic resonance (MR) arthrography glenoid track measurement predicted recurrent instability following ABR. METHODS: Over a 9-year period (2008-2017), 215 patients underwent ABR. Median age was 26 years (IQR 22-32.5; range 14-77). There were 173 males (81%). 175 patients (81%) had available pre-operative MR arthrography, which was used to determine the presence of "off-track" bone loss. Retrospective analysis was undertaken to determine recurrence of instability at a median follow-up of 76 months (range 21-125 months). Survivorship analysis was undertaken using Kaplan-Meier methodology: the endpoints examined were repeat dislocation, revision stabilisation, and symptomatic instability. RESULTS: 56 patients (26%) presented with further instability, including 29 patients with recurrent dislocation and 15 patients required revision stabilisation. Cumulative incidence of instability was 10% at 1 year, 27% at 5 years and 28% at 7 years. No significant difference in instability was seen between men and women 7 years after stabilisation (19% vs 17%; p = 0.87). Age at time of surgery did not predict recurrence. "Off-track" lesions were identified in 29 patients (16.1%). The incidence of redislocation was significantly higher in these patients (24% vs 3%; p = 0.01; relative risk 7.2; 95% CI 2.45-20.5; p = 0.001). Recurrent instability without frank redislocation was also significantly higher in this group (60% vs 18%; RR 3.33, 95% CI 2.02-5.20; p < 0.0001). CONCLUSIONS: This study has reported a significant rate of recurrent instability in longer-term follow-up after ABR. It has also identified pre-operative MR arthrography as an important predictor of recurrent instability, which may be used to risk stratify patients with anterior instability in a typical UK population. LEVEL OF EVIDENCE: III (cohort study).

The changing epidemiology of radial head replacement over a 22-year period in Scotland.

BACKGROUND: Radial head replacement is used to confer joint stability in the management of acute unstable elbow fractures and dislocations associated with instability. We determined the annual incidence of radial head replacement over a 22-year period in a defined population. MATERIALS AND METHODS: Hospital episode statistics were collected prospectively at a national level. This database was retrospectively examined to determine the annual incidence of radial head replacement over the study period in adults over 16 years of age. RESULTS: A total of 615 radial head replacements were performed over the 22 years studied. The overall incidence was 0.65/100,000/year (95% confidence interval, CI, 0.50-0.71). The average adult population during the period was 4,270,593. There was a steady and statistically significant increase in the incidence of radial head replacement over the study period (r 2 = 0.816; p < 0.0001). This incidence was significantly greater in women than men (odds ratio 1.46, 95% CI 1.25-1.72; p < 0.001). The peak incidence in men was 0.87/100,000 population/year in the fifth decade of life while in women the peak incidence was in the seventh decade of life (1.38/100,000 population/year). CONCLUSION: The incidence of radial head replacement has increased steadily over 22 years. We hypothesise that this represents an evolving understanding of the role of radial head replacement in acute trauma in the context of emerging literature during the study period.

Hand-arm vibration and outcomes of surgery for Dupuytren's contracture.

BACKGROUND: Dupuytren's contracture was recently designated a prescribed occupational disease when it occurs in patients with previous hand-arm vibration (HAV) exposure. AIMS: The aims of this study were to describe the impact of self-reported HAV exposure on upper limb function and satisfaction following surgery for Dupuytren's contracture. METHODS: Paired pre- and postoperative Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient satisfaction questionnaires were prospectively collected from all patients undergoing surgery for Dupuytren's contracture over a 6-year period. Patients self-reported HAV exposure duration. RESULTS: Results were available for 425 hands (65%) at mean 13 months postoperatively. There were 111 patients (26%) that reported HAV exposure. The prevalence of HAV exposure was significantly greater in male compared with female patients (32% versus 4%; P < 0.001). A statistically significant difference in preoperative (difference 7.47; 95% confidence interval 4.78-10.17; P < 0.001) and postoperative QuickDASH score (difference 6.78; 95% confidence interval 2.69-10.88; P < 0.001) was observed between the two groups, but difference in QuickDASH improvement was not significantly different (difference 1.76; 95% confidence interval -1.58 to 5.10; P > 0.05). No significant difference in satisfaction rate or return to work was observed between the two groups. CONCLUSIONS: Previous HAV exposure influenced the pre and postoperative function in patients undergoing surgery for Dupuytren's contracture, but had no effect on satisfaction or return to work. Further prospective research will be required to determine whether the introduction of a compensatory framework will have a more profound effect on the functional outcomes of surgery.

Comorbid status influences quality of life following carpal tunnel decompression.

The aim of this study was to characterize the change in health-related quality of life following carpal tunnel decompression. Pre- and postoperative Euroqol 5 Dimensions scores were collected prospectively over three years. Outcomes were available for 435 of 563 patients (77%); mean age was 62 years. Comorbid status was described using the Charlson Comorbidity Index. Change in Euroqol 5 Dimensions scores declined with increasing age and Charlson Comorbidity Index: the greatest improvement in quality of life occurred in the youngest group (+0.07 vs. -0.07 in the oldest group; p < 0.001) and patients with the lowest Comorbidity Index (+0.05 vs. -0.07 in the highest comorbidity group; p < 0.001). Charlson Comorbidity Index was an independent predictor of worse change in Euroqol 5 Dimensions scores on regression analysis. Carpal tunnel decompression results in significant improvement in health-related quality of life in younger patients with minimal comorbidities, but not in older patients with more comorbidities. We advise interpreting the Euroqol 5 Dimensions scores with caution in this patient cohort. LEVEL OF EVIDENCE: III (cohort study).

Occupation classification predicts return to work after carpal tunnel decompression.

BACKGROUND: The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear. AIMS: To investigate predictors of RTW following CTD. METHODS: We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010. RESULTS: Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2-6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P < 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9-6.5) and non-manual workers (6.2; 95% CI 4.8-7.6) (P > 0.05). Median pre-operative (difference 15.9; 95% CI 4.5-25) and post-operative (difference 43.2; 95% CI 13.6-43.2) hand function scores were significantly worse in patients who did not RTW (P < 0.05). CONCLUSIONS: Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.

Reporting Discrepancy Resolved by Findings and Time in 2947 Emergency Department Ankle X-rays.

AIMS: To identify common errors in ankle X-ray reporting between initial interpretation and final assessment at the virtual fracture clinic. Also, to assess time of initial reporting as a causative factor for discrepancy. METHODS: Two thousand nine hundred forty-seven final reports were reviewed by standard of agreement to the initial interpretation. Where discrepancy was found, it was classified and collated by specific finding. Comparison was made between reports with discrepancy and the complete dataset, allowing rates of error by finding to be established. The reports containing discrepancy were further classified by time period, this was compared against an expected value to establish if initial reporting outside of routine working hours was as accurate as that conducted within routine working hours. RESULTS: 94.4% of reports were in agreement with the initial interpretation, 2.9% contained minor discrepancy, and 2.7% major discrepancy. In 45.6% of reports there was no radiologically observable injury. 16.4% of reports contained a lateral malleolar fracture, most commonly Weber type B. 40.0% of all navicular fractures, and 33.3% of all cuboidal fractures were not commented upon in the initial reporting. Lower rates of more frequently observed findings were missed with 2.5% of Weber type B fractures not commented upon. An increased proportion of major discrepancy reports were generated from 00:00 to 07:59 (expected = 15.0%, observed = 22.2%; p = 0.07908). Similarly, a greater than expected number of minor discrepancy reports were found between 20:00 and 23:59 (expected = 18.0%, observed = 34.1%, p = 0.00025). CONCLUSIONS: The initial reporting of ankle X-rays in the emergency department is performed to a high standard, however serious missed findings emphasise the need for timely senior review. Reporters should increase their awareness of navicular, cuboid, talar, and Weber A fractures which were missed at disproportionate rates. This study also finds evidence to support increased rates of error in initial reporting of ankle X-rays outside of normal working hours (17:00-07:59), particularly with a significantly increased rate of minor discrepancy seen from 20:00 to 23:59.

Bone penetration of intravenous flucloxacillin and gentamicin as antibiotic prophylaxis during total hip and knee arthroplasty.

AIMS: To investigate the bone penetration of intravenous antibiotic prophylaxis with flucloxacillin and gentamicin during hip and knee arthroplasty, and their efficacy against Staphylococcus (S.) aureus and S. epidermidis. PATIENTS AND METHODS: Bone samples from the femoral head, neck and acetabulum were collected from 18 patients undergoing total hip arthroplasty (THA) and from the femur and tibia in 21 patients during total knee arthroplasty (TKA). The concentration of both antibiotics in the samples was analysed using high performance liquid chromatography. Penetration was expressed as a percentage of venous blood concentration. The efficacy against common infecting organisms was measured against both the minimum inhibitory concentration 50, and the more stringent epidemiological cutoff value for resistance (ECOFF). RESULTS: The bone penetration of gentamicin was higher than flucloxacillin. Relative to ECOFF, flucloxacillin concentrations were effective against S. aureus and S. epidermidis in all THAs and 20 (95%) TKAs. Gentamicin concentrations were effective against S. epidermidis in all bone samples. Gentamicin was effective against S. aureus in 11 (61.1%) femoral neck samples in THA. Effective concentrations of gentamicin against S. aureus were only achieved in four (19%) femoral and six (29%) tibial samples in TKA. CONCLUSION: Flucloxacillin and gentamicin were found to penetrate bone during THA and TKA. Gentamicin was effective against S. epidermidis in both THA and TKA, while levels were subtherapeutic against S. aureus in most TKAs. Bone penetration of both antibiotics was less in TKA than THA, and may relate to the use of a tourniquet. Using this antibiotic combination, effective cover against the two common infective organisms was achieved in all THAs and all but one TKA. Cite this article: Bone Joint J 2017;99-B:358-64.

Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care.

OBJECTIVES: "Virtual fracture clinics" have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a "top-down" analysis of the cost effectiveness of this virtual fracture clinic pathway. METHODS: National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. RESULTS: The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. CONCLUSIONS: The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings.Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33-36. doi: 10.1302/2046-3758.52.2000506.

Interpretation of the QuickDASH score after open carpal tunnel decompression: threshold values associated with patient satisfaction.

UNLABELLED: We studied the correlation between change in the QuickDASH score and the absolute post-operative QuickDASH score with patient satisfaction after open carpal tunnel decompression. Threshold values in the QuickDASH score, the point at which the sensitivity and specificity are maximal in predicting patient satisfaction, were identified. During the study period, outcome data were compiled for 937 carpal tunnel decompressions, which included 219 (23%) male and 718 (77%) female patients with a mean age of 58 years (standard deviation (SD) 14). There was a significant improvement (mean difference 32, 95% confidence interval (CI) 30 to 34) in the QuickDASH from a mean of 54 (SD 20) to 22 (SD 23) at 1 year after surgery. There were 808 (86%) patients who defined their outcome as satisfactory at 1 year. The identified threshold values for the post-operative QuickDASH score (⩽34 points) and the change (⩾20 points) in the score were highly predictive of patient satisfaction. However, these threshold values varied significantly according to the baseline pre-operative score. The threshold values identified in the QuickDASH can be used to interpret the score. However, the influence of the pre-operative baseline score should be taken into account when comparing different cohorts of patients or using the values to power future studies. LEVEL OF EVIDENCE IV: Prognosis, observational cohort study.

Socioeconomic deprivation and age are barriers to the online collection of patient reported outcome measures in orthopaedic patients.

Introduction Questionnaires are used commonly to assess functional outcome and satisfaction in surgical patients. Although these have in the past been administered through written forms, there is increasing interest in the use of new technology to improve the efficiency of collection. The aim of this study was to assess the availability of internet access for a group of orthopaedic patients and the acceptability of online survey completion. Methods A total of 497 patients attending orthopaedic outpatient clinics were surveyed to assess access to the internet and their preferred means for completing follow-up questionnaires. Results Overall, 358 patients (72%) reported having internet access. Lack of access was associated with socioeconomic deprivation and older age. Multivariable regression confirmed increased age and greater deprivation to be independently associated with lack of internet access. Out of the total group, 198 (40%) indicated a preference for assessment of outcomes via email and the internet. Conclusions Internet access was not universal among the patients in our orthopaedic clinic. Reliance on internet collection of PROMs may introduce bias by not including results from patients in older age groups and those from the more deprived socioeconomic groups.

Revisiting the 'bag of bones': functional outcome after the conservative management of a fracture of the distal humerus.

The best method of managing a fracture of the distal humerus in a frail low-demand patient with osteoporotic bone remains controversial. Total elbow arthroplasty (TEA) has been recommended for patients in whom open reduction and internal fixation (ORIF) is not possible. Conservative methods of treatment, including the 'bag of bones' technique (acceptance of displacement of the bony fragments and early mobilisation), are now rarely considered as they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93 years, 72% women) with a fracture of the distal humerus who had been treated conservatively at our hospital between March 2008 and December 2013, and assessed their short- and medium-term functional outcome. In the short-term, the mean Broberg and Morrey score improved from 42 points (poor; 23 to 80) at six weeks after injury to 67 points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford elbow score of 30 points (7 to 48) at four years and a mean Disabilities of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95% reported a functional range of elbow flexion. The cumulative rate of fracture union at one year was 53%. The mortality at five years approached 40%. Conservative management of a fracture of the distal humerus in a low-demand patient only gives a modest functional result, but avoids the substantial surgical risks associated with primary ORIF or TEA.

Outcome at 12 to 22 years of 1502 tibial shaft fractures.

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients' social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome.

Carpal tunnel decompression in the super-elderly: functional outcome and patient satisfaction are equal to those of their younger counterparts.

There is conflicting evidence about the functional outcome and rate of satisfaction of super-elderly patients (≥ 80 years of age) after carpal tunnel decompression. We compiled outcome data for 756 patients who underwent a carpal tunnel decompression over an eight-year study period, 97 of whom were super-elderly, and 659 patients who formed a younger control group (< 80 years old). There was no significant difference between the super-elderly patients and the younger control group in terms of functional outcome according to the mean (0 to 100) QuickDASH score (adjusted mean difference at one year 1.8; 95% confidence interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR) 0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however, more likely to have thenar muscle atrophy at presentation (OR 9.2, 95% CI 5.8 to 14.6). When nerve conduction studies were obtained, super-elderly patients were more likely to have a severe conduction deficit (OR 12.4, 95% CI 3.0 to 51.3). Super-elderly patients report functional outcome and satisfaction rates equal to those of their younger counterparts. They are more likely to have thenar muscle atrophy and a severe nerve conduction deficit at presentation, and may therefore warrant earlier decompression.

Effect of a redesigned fracture management pathway and 'virtual' fracture clinic on ED performance.

OBJECTIVES: Collaboration between the orthopaedic and emergency medicine (ED) services has resulted in standardised treatment pathways, leaflet supported discharge and a virtual fracture clinic review. Patients with minor, stable fractures are discharged with no further follow-up arranged. We aimed to examine the time taken to assess and treat these patients in the ED along with the rate of unplanned reattendance. DESIGN: A retrospective study was undertaken that covered 1 year before the change and 1 year after. Prospectively collected administrative data from the electronic patient record system were analysed and compared before and after the change. SETTING: An ED and orthopaedic unit, serving a population of 300 000, in a publicly funded health system. PARTICIPANTS: 2840 patients treated with referral to a traditional fracture clinic and 3374 patients managed according to the newly redesigned protocol. OUTCOME MEASURES: Time for assessment and treatment of patients with orthopaedic injuries not requiring immediate operative management, and 7-day unplanned reattendance. RESULTS: Where plaster backslabs were replaced with removable splints, the consultation time was reduced. There was no change in treatment time for other injuries treated by the new discharge protocol. There was no increase in unplanned ED attendance, related to the injury, within 7 days (p=0.149). There was a decrease in patients reattending the ED due to a missed fracture clinic appointment. CONCLUSIONS: This process did not require any new time resources from the ED staff. This process brought significant benefits to the ED as treatment pathways were agreed. The pathway reduced unnecessary reattendance of patients at face-to-face fracture clinics for a review of stable, self-limiting injuries.

A comparison of the use of uncemented hydroxyapatite-coated bipolar and cemented femoral stems in the treatment of femoral neck fractures: a case-control study.

We performed a case-control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.

Variability in local pressures under digital tourniquets.

The UK National Patient Safety Agency issued a rapid response report in 2009 following reports of complications related to digital tourniquet use and inadvertent retention. In their guidance, they recommend the use of CE marked digital tourniquets and advise against the use of surgical gloves. There are a number of different commercially available non-pneumatic digital tourniquets, but little clear data relating to their comparable physical properties, clinical efficacy or safety. The aim of this study was to investigate the variability of pressures exerted by non-pneumatic digital tourniquets. A Tekscan FlexiForce(®) force sensor was used to measure applied force and to calculate the surface pressures under: the Toe-niquet™; T-Ring™ and surgical glove 'roll down' tourniquets in finger models. The lowest mean pressures were produced by the larger glove sizes (size 8) (25 mmHg), while the highest pressures were produced by the Toe-niquet (1560 mmHg). There was a significant overall difference in pressures exerted under tourniquets when comparing tourniquet type (p<0.001) and finger size (p<0.001) with these techniques. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Safe limits for application time and surface pressures are difficult to define. Further work is required to model the pressure effects of commercially available digital tourniquets and to identify which are most effective but safe.

Total knee replacement in patients with haemophilia: the Scottish experience.

INTRODUCTION: Patients with haemophilia commonly develop arthropathy secondary to recurrent haemarthroses. Although modern treatment with replacement coagulation factors has reduced the prevalence of end-stage arthropathy, total joint replacement is still required in a small group of patients. These patients may be at higher risk of complications and the outcome of surgery may not be comparable to reports of outcomes of total joint replacement in the general population. The purpose of this study was to describe the change in function in patients undergoing total knee replacement for haemophilic arthropathy. PATIENTS AND METHODS: Patients undergoing total knee arthroplasty in a tertiary centre had prospective evaluations of patient reported outcome measures and range of movement. Their post-operative function was evaluated in a combined orthopaedic-haematology clinic. Eight male patients underwent 13 total knee replacements from 1999 to 2007 and were followed up for a median of 78 months (range 17-116). RESULTS: The median Oxford knee score improved from 45.5 pre-operatively to 28 (p = 0.049). There was a similar improvement in SF-12 physical (p = 0.017) and Knee Society scores (objective p = 0.001; function p = 0.002). Four total knee replacements were performed in patients with inhibitor antibodies and were treated with recombinant activated factor VIIa. These patients had reduced range of movement (p = 0.047). No patients suffered deep infection. CONCLUSIONS: Total knee replacement in patients with haemophiliac arthropathy resulted in improvement in range of movement and function. The presence of factor VIII inhibitors resulted in reduced range of movement, but similar patient reported outcome measures.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.

BACKGROUND: There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment. METHODS: In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed. RESULTS: The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001). CONCLUSIONS: Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.