Severe arthritis predicts greater improvements in function following total knee arthroplasty.

PURPOSE: Although excellent outcomes are routinely reported following total knee replacement, up to 20 % of patients remain dissatisfied. The aim of this study was to determine whether pre-operative radiographic classification was associated with functional outcomes following surgery. METHODS: A retrospective review of a prospective arthroplasty database identified 256 patients that fulfilled the inclusion criteria over an 18-month period. Baseline demographic data on all patients were collected prospectively. All pre-operative radiographs were assessed using the Kellgren and Lawrence (K&L) classification system. Patients were prospectively assessed using the American Knee Society Score pre-operatively and at 1, 3 and 5 years post-surgery. RESULTS: An association was found between the pre-operative radiographic severity of arthritis and the pre-operative American Knee Society Knee (AKSK) scores, with worsening radiographic grade corresponding to worsening AKSK scores (p = 0.020). There was an association between K&L classification and improvement in AKSK scores from pre-operative to 1 year (p = 0.003) and 3 years (p = 0.04), with K&L grades 3 and 4 demonstrating the most significant improvements. On multivariate regression analysis, K&L classification was the only significant predictor of improvement in AKSK at 1 year (p = 0.009). No correlation was found between K&L grade and the American Knee Society Functional Scores at any stage. CONCLUSIONS: The results of this study may help to improve satisfaction rates in total knee replacement by targeting treatment. Patients can be counselled that although radiographic severity of arthritic changes can predict knee-specific functional improvement, the extent of their global functional improvement cannot. LEVEL OF EVIDENCE: IV.

Quantification of radiation exposure in the operating theatre during management of common fractures of the upper extremity in children.

Introduction Surgical procedures to manage trauma to the wrist, forearm and elbow in children are very common. Image intensifiers are used routinely, yet studies/guidelines that quantify expected radiation exposure in such procedures are lacking. Methods Information on demographics, injury type, surgeon grade and dose area product (DAP) of radiation exposure per procedure was collected prospectively for 248 patients undergoing manipulation/fixation of injuries to the elbow, forearm or wrist at a paediatric hospital over 1 year. Results DAP exposure (in cGycm(2)) differed significantly across different procedures (p<0.001): wrist manipulation under anaesthesia (MUA; median, 0.39), wrist k-wiring (1.01), forearm MUA (0.50), flexible nailing of the forearm (2.67), supracondylar fracture MUA and k-wiring (2.23) and open reduction and internal fixation of the lateral humeral condyle (0.96). Fixation of a Gartland grade-3 supracondylar fracture (2.94cGycm(2)) was associated with higher exposure than grade-2 fixation (1.95cGycm(2)) (p=0.048). Fractures of the wrist or forearm necessitating metalwork fixation resulted in higher exposure than those requiring manipulation only (both p<0.001). For procedures undertaken by trainees, trainee seniority (between year-5 and year-8 and clinical fellow, p≥0.24) did not affect the DAP significantly. Conclusions The spectrum of radiation exposures for common procedures utilised in the management of paediatric upper limb trauma were quantified. These findings will be useful to surgeons auditing their practice and quantifying radiation-associated risks to patients. Our data may serve as a basis for implementing protocols designed to improve patient safety.

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.

Proximal humeral fractures due to blunt trauma producing skin compromise.

We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management.