Evolution in the Management of Patella Fractures.

Patella fractures usually occur as a result of direct trauma to the anterior knee joint, indirect injury as a result of eccentric muscle contraction, or rapid knee flexion against a contracted quadriceps muscle. The patella functions as part of the extensor mechanism of the knee, where large forces are transmitted, and its subcutaneous nature has made treatment of patella fractures a challenge. In this review article, we evaluate how the management of these fractures has evolved over time and the advantages associated with the various treatment techniques. There are few comparative studies looking at the different treatment types for fractures of the patella, with the goal of achieving a functional extensor mechanism with low rates of post-traumatic arthritis and metal-work irritation.

Severe obesity in total knee arthroplasty occurs in younger patients with a greater healthcare burden and complication rate.

BACKGROUND: Knee osteoarthritis in the presence of severe obesity (BMI ≥ 40) is becoming an increasing presentation to healthcare services. When progressing to arthroplasty, this group is known to have higher complication rates. METHOD: A retrospective cohort study at a tertiary referral centre (UK) with all sequential patients undergoing TKA between 2019 and 2020 included following identification from the UK National Joint Registry. Patients were divided by BMI < 40 and BMI ≥ 40 (86, 16.3%). Analysis of BMI with pre-operative parameters including age, ASA, and blood parameters was performed. Primary outcome was re-operation rate. Secondary outcomes included length of stay, complications, and re-admission. RESULTS: Five hundred and twenty-eight sequential TKA patients were included. The BMI < 40 group (442 patients, 83.7%) were mean 5.4 years younger (p < 0.001), had a higher ASA grade (p < 0.001) lower albumin (p < 0.001) and higher HbA1c (p < 0.001) than the BMI ≥ 40 group (86 patients, 16.3%). The BMI ≥ 40 group had a higher rate of re-operation (8% vs 2%, p = 0.012), and longer length of stay (mean 1.2 days longer p < 0.001), most commonly due to wound discharge, which alongside dehiscence was significantly higher (11.6% vs 4.3% p = 0.02). Overall, re-admission rates were also higher (18.6% vs 6.1% p = 0.06) with wound dehiscence, superficial infection, and deep infection the most common causes. CONCLUSIONS: Those patients undergoing TKA with a BMI ≥ 40 are younger and have higher reoperation rates, greater length of stay, higher re-admission rates and more postoperative complications, providing a target for the development of pre-operative optimisation programmes.

Incidence, Management, and Hospital Costs of Orthopaedic Injuries of E-Scooter Riders in Western Australia.

The use of electric scooters (e-scooters) is increasing in Australia and internationally. The increasing availability of e-scooters has led to a rise in the number of injuries, with most patients sustaining orthopaedic injuries. This retrospective case series describes the incidence, management, and hospital costs of the orthopaedic injuries, which presented to the emergency department (ED) of the major trauma center in Western Australia. Data on demographics, ED dispatch destination, management, follow-up clinics, and hospital costs were collected between 2017 and 2022. Since June 2020, there have been 61 e-scooter crashes, which resulted in orthopaedic injuries, with more than half of the crashes occurring after the introduction of regional e-scooter sharing schemes. Thirty-two patients (52%) were admitted to the hospital. The most common orthopaedic fracture was to the upper limb (44%), followed by the lower limb (41%) and the axial skeleton (15%). Fourteen (23%) patients sustained more than one fracture. Twenty-two patients (36%) required operative management. The median number of outpatient clinic attendances per patient was 3 (interquartile range (IQR): 1-5), with inpatients requiring twice the number of clinics as compared to those discharged from the ED. The median cost per presentation was AU$5880.60 (IQR: AU$1283.10-AU$21,150.90) with inpatient costs exceeding those discharged from the ED. The range of the total costs was AU$413.80 to AU$100,239.80. The rise in the accessibility of e-scooters in Western Australia has led to a rise in ED presentations with orthopaedic injuries. Considering the recent implementation of e-scooter sharing schemes in metropolitan areas, ongoing surveillance of e-scooter injuries by clinicians and policy makers is warranted to inform harm minimization strategies.

Repeat Anterior Cruciate Ligament Injury and Return to Sport in Australian Soccer Players After Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft.

BACKGROUND: Soccer is the most commonly played team sport in the world and a high-risk sport for anterior cruciate ligament (ACL) injury and subsequent ACL reconstruction (ACLR). PURPOSE: To assess the rate of further ACL injury in patients who have undergone ACLR with hamstring tendon autograft after soccer injuries in Australia and to determine factors associated with repeat ACL injury and return to soccer. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: From a prospectively collected database, a series of 1000 consecutive ACLRs using hamstring autografts performed in soccer players were identified. Patients were surveyed at a minimum 5 years after reconstruction, including details of further ACL injuries to either knee, return to soccer or other sports, and psychological readiness per the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale. RESULTS: Of the 862 participants reviewed, ACL graft rupture occurred in 85 (10%) and contralateral ACL rupture in 68 (8%) within 5 years after the reconstruction. The 5-year ACL graft survivorship was 94% for females and 88% for males. The survivorship of the contralateral ACL was 92% for males and 90% for females. When compared with those aged >25 years, the odds of ACL graft rupture was increased by 4 to 5 times in those aged 19 to 25 years and 3 to 7 times in those ≤18 years. Further ACL injury to the graft or contralateral knee occurred in 44% of males aged ≤18 years. Risk factors for further ACL injury were younger age at time of surgery, male sex, and return to soccer. Graft diameter did not influence ACL graft rupture rates, and 70% of patients returned to soccer after ACLR. The mean ACL-RSI score was 59, and patients who reported more fear of reinjury on this scale were less likely to have returned to soccer. CONCLUSION: The prevalence of ACL graft rupture (10%) and contralateral ACL rupture (8%) was near equivalent over 5 years in this large cohort of mostly recreational Australian soccer players. ACLR with hamstring autograft is a reliable procedure, allowing 70% of patients to return to soccer in this high-risk population. Risk factors for further ACL injury are progressively younger age at time of surgery, male sex, and return to soccer. Graft diameter was not a factor in ACL graft rupture, indicating that other factors, particularly age, are of primary importance.

Two-Year Prospective RSA Measured Migration of a Third-Generation Taper Wedge Cementless Femoral Stem.

INTRODUCTION: Implant migration is a concern with newly designed cementless femoral stems for total hip arthroplasty. Radiostereometric analysis (RSA) is the most accurate technique available to measure implant migration following total hip arthroplasty (THA). The objective of this study was to establish the migration pattern of a cementless tapered wedge stem during the first two years after implantation using RSA as well as assess clinical results. MATERIALS AND METHODS: Thirty patients underwent a primary THA with a morphometrically designed cementless stem. RSA was completed immediately after surgery and at three-, six-, 12- and 24-month intervals. Subsidence after two years was compared to the migration thresholds, and survivorship and clinical outcome scores were obtained. RESULTS: After two years, the mean subsidence (distal migration) of the stem within the canal was 0.08mm (standard deviation [SD] 0.036mm), the mean retroversion was 0.301mm (SD 0.362), and the maximal total point motion was 0.764mm (SD 0.195). All stems demonstrated stable motion patterns beyond six months (p=0.99). Patient outcome data highlighted a statistical and clinically significant improvement (p<0.05) after hip arthroplasty at six months, and then there were modest changes at subsequent follow ups. CONCLUSION: The femoral stem tested in this study was designed to provide adequate implant stability in total hip arthroplasty patients in the short term. We found stable fixation of the third-generation tapered wedge stem two years postoperatively and clinical improvements in patient-reported outcomes.

Does Partial Knee Replacement Allow Return to High-Demand Activities?

Purpose  The purpose of this study was to assess postoperative partial knee replacement (PKR) functional improvement using the postoperative Oxford Knee Score for Activity and Participation Questionnaire (OKS-APQ). PKR includes medial, lateral, and patellofemoral knee arthroplasty. Methods A search of a National Health Service hospital database was made to identify eligible candidates for a survey of Patient-Reported Outcome Measure (PROM). Database records were collected for patients who had medial, lateral, and patellofemoral knee arthroplasty. The first author, an orthopaedic surgery resident, retrospectively reviewed the data and selected 318 patient records for inclusion in a questionnaire survey. The inclusion criteria were: patients who had PKR within three years from the time of the study and patients who don't have medical problems that may affect their mobility; for example, balance problems. The survey used the postoperative Oxford Knee Score for Activity and Participation Questionnaire (OKS-APQ), Tegner Activity Score (TAS), and four questions were added to the present study, namely, three free-text questions and one visual analogue score (VAS). The survey was sent by post seeking the patients' responses. Results  Two-hundred five responded to the survey out of 318; a 64% response rate. The ceiling and floor effects were determined from patients' answers. Survey questions included: What is the most demanding activity you routinely do every month on your new knee? The patients' answers were divided into four groups. First, 29% were limited to low functional demand activities, for example, light walking for less than a mile. Second, 43% were involved in domestic work and sports activities, for example, golf, skittles, bowling, squatting, swimming, and gardening. Third, 21% had progressed to higher demand activities, for instance, dancing, racquet sports, cycling, and yoga. Fourth, 7% were performing higher demand activities involving impacts, for example, skiing, heavy gym workout, and marathon running. Conclusion The postoperative questionnaire demonstrated activities ranging from high-impact activities, for example, skiing, and from higher demand activities, for example, dancing to low function activities, for example, light walking.

Prolonged operative time increases risk of blood loss and transfusion requirements in revision hip surgery.

INTRODUCTION: Revision hip surgery is well documented to have a high association with substantial blood loss and the associated need for a blood transfusion. This exposes the patient to increased risk of transfusion reaction and blood borne infection. There are many strategies to minimize allogeneic transfusion rates in revision surgery such as pre-operative autologous donation, peri-operative tranexamic acid, thrombin sealants, normovolaemic haemodilution, intra-operative blood salvage and the use of post-operative autologous drains. PATIENTS AND METHODS: We prospectively looked at 177 consecutive cases performed at one centre by a single surgical and anaesthetic team to identify which patient and operative factors were most significant in minimizing the requirement for an allogeneic blood transfusion. RESULTS: Our results identified the duration of surgery as being the only significant variable affecting the level of blood loss. We noted a 3% increase in the probability of massive blood loss (> 2000 mls) for every minute of increased surgical time in our series. CONCLUSIONS: We conclude that measures to minimize the duration of surgery would be beneficial in reducing blood loss and the risks of requiring blood transfusions in revision hip surgery.

Cable plating with a single strut allograft in the treatment of periprosthetic fractures of the femur.

BACKGROUND:: Hip arthroplasties are increasing worldwide resulting in an increasing number of periprosthetic fractures. These fractures are difficult to treat with various the different fixation or revision options described, many of which have high complication rates. PURPOSE:: To investigate whether our described method of treating periprosthetic fractures is an effective, safe and reproducible method of treating patients. METHODS:: We describe the largest series of a cable plate fixation system combined with a single cortical strut allograft to treat patients with periprosthetic fractures of the hip (Unified Classification System B1 and selected B2, C and D). RESULTS:: Between July 2006 and March 2015, 28 patients were treated using this method. The mean follow-up was 2.2 years (3 months to 9 years). The mean Oxford Hip Score (OHS) at final follow-up was 32 and the mean modified Harris Hip Score (mHHS) 67. There were 3 complications including 1 failure that required revision surgery, 1 case of infection successfully treated with debridement, antibiotics and retention, and a case of discomfort from the metalwork which we managed conservatively. CONCLUSION:: This method of anatomical restoration of the femur with dual-plane fixation is a highly effective method of treating this complex group of patients, and should be considered as a first line of treatment. It shows that there is a role for successful treatment with internal fixation of certain B2, C and D fractures with this technique.

Mid-term clinical results of the cementless R3 cup and Polarstem total hip arthroplasty.

BACKGROUND: There has been a shift from cemented to uncemented hip arthroplasty. One popular uncemented combination is the R3 acetabular cup with Polarstem, having the lowest revision rate in the UK National Joint Registry. However, there are no medium-term clinical outcomes on this combination in the literature. The aim of this study is to review our centre's outcomes with this combination using conventional bearings with a minimum of 7-year follow-up. METHODS: Using our centre's arthroplasty database, we identified all patients that underwent a total hip arthroplasty using these implants from August 2009 to December 2010. One hundred and forty-four procedures were performed. The primary outcome was revision rate, and the secondary outcomes were clinical and radiological evaluation. RESULTS: The mean cohort age at surgery was 68.3 years. There were three revisions, of which only one underwent a cup revision. The mean Oxford Hip Score at 7-year follow-up was 38. Radiological evaluation of both acetabular and stem component did not show any radiolucency at 7-year follow-up. Kaplan-Meier survivorship analysis showed an implant survival rate of 97.69% at 7 years using revision for all causes as endpoint. The risk of revision was 1.47% at 7 years. CONCLUSION: Our revision rates are comparable to the UK's National Joint Registry, with excellent clinical and radiological outcome. Our results correlate with the allocated rating of 7A* by the Orthopaedic Data Evaluation Panel for both R3 acetabular cup and Polarstem.

Management of shoulder pain after a cerebrovascular accident or traumatic brain injury.

BACKGROUND: Shoulder pain after a cerebrovascular accident or traumatic brain injury is a common but often under-recognized problem. It is due to a number of causes including inferior subluxation, spasticity, adhesive capsulitis, and heterotopic ossification. Many of these are amenable to surgical intervention. METHODS: Literature review of current evidence. RESULTS: This article shows that there are multiple treatment options in this group of patients, and it is important to understand these as clinicians in delivering quality care to this complex group of patients. CONCLUSION: This review article describes how careful clinical assessment can differentiate between causes of shoulder pain and guide best management.

Back-carrying infants to prevent developmental hip dysplasia and its sequelae: is a new public health initiative needed?

BACKGROUND: Developmental dysplasia of the hip (DDH) is rarely encountered in the native sub-Saharan African population. We present a retrospective review of the incidence of symptomatic DDH in Malawi and a systematic review of the role of back-carrying as a potential influence of prevalence in this population group. METHODS: We retrospectively reviewed the diagnosis and management of all infants seen at the Beit CURE International Hospital, Malawi and its mobile clinics, from November 2002 to September 2012. In addition, methodical review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and algorithm was performed. RESULTS: A total of 40,683 children aged less than 16 years were managed at our institute over a 10-year period, of which 9842 children underwent surgery. No infant presented with, or underwent surgical intervention, for symptomatic DDH. CONCLUSIONS: The majority of mothers in Malawi back-carry their infants during the first 2 to 24 months of life, in a position that is similar to that of the Pavlik harness. We believe this to be the prime reason for the low incidence of DDH in the country. In addition, there is established evidence indicating that swaddling, the opposite position to back-carrying, causes an increase in the incidence of DDH. There is a need for the establishment of a large clinical trial into back-carrying and prevention of DDH in non-African population groups. LEVEL OF EVIDENCE: Level II.