Healed ORIF in a fibula fracture - Hardware removal or hardware retention for the fibula in a patient with minor symptoms?

HISTORY: - A 31yo female is involved in a fall while climbing on some wet rocks. She was brought into the emergency department and was found to have suffered a closed fracture of the right fibula with a deltoid ligament injury. Distal neurovascular exam was normal. She is otherwise unhurt. She had ORIF of her ankle injury and it has gone onto heal with good results. She comes back at 6 months and complains of vague pain over her lateral ankle and hardware with a normal physical exam. She wonders about hardware removal, (Figs. 1 and 2). PAST MEDICAL HISTORY: - previous history of breast reduction surgery and she has delivered one child vaginally. No chronic diseases and she takes no pills except the birth control pill. SOCIAL HISTORY: - married with one child and works as an administrative assistant for a manufacturing company; she is a social drinker and nonsmoker. Has a history of using some recreational drugs but none for 10 years. She is moderately active.

Management and outcomes of flexor tendon repairs at a peripheral hospital: a New Zealand case series study.

BACKGROUND: Current evidence for flexor tendon repair management and outcomes performed at peripheral centres is unclear. Most studies are based on evidence from specialist hand centres. This study evaluated a peripheral hospital in New Zealand; where all flexor tendon repairs were performed by a generalist Orthopaedic service. The purpose of the study was to benchmark management and outcomes from a peripheral hospital in comparison to international standards. METHODS: A retrospective single-centre consecutive case series of Zones I and II flexor tendon repairs was extracted between 1 January 2014 and 1 January 2018. Medical records were used to evaluate management and outcomes of repairs. Hand therapy notes were used to evaluate rehabilitation protocols provided. The primary objective was to measure re-rupture and re-operation rates. Secondary objectives included auditing operative management and hand therapy compliance. RESULTS: Forty-six patients (76 tendon repairs) were included in our final analysis. Mean follow up time to last clinical appointment was 11.8 weeks, and to last patient episode was 4.9 years. Most patients received timely surgery with a four-core repair using 3-0 or larger suture. All hand therapy followed a controlled active motion protocol. The re-operation rate was 19.6% (P = <0.05) and the re-rupture rate was 8.7% (P = 0.28). CONCLUSIONS: Most flexor tendon injuries at this peripheral centre were managed according to international standards. However, high complication rates including re-operation and re-rupture occurred. Due to a lack of local comparison studies, confounding factors cannot be excluded as a contributor for these results.

Cemented vs. uncemented glenoid fixation in total shoulder arthroplasty for osteoarthritis: a New Zealand Joint Registry study.

BACKGROUND: Total shoulder arthroplasty (TSA) is commonly performed for shoulder osteoarthritis (OA). Uncemented metal-backed (MB) glenoid components were introduced in an attempt to avoid glenoid loosening. New Zealand and Australian Joint Registry studies have shown significantly higher revision rates when uncemented MB glenoids are used. We used the New Zealand Joint Registry (NZJR) to compare all-cause revision rates and functional scores for TSA and investigated the trends of glenoid fixation used in New Zealand. METHODS: The NZJR was accessed for all primary TSA undertaken for OA from January 2000 to December 2017. Patient demographics were collated. All-cause revision rates were reported as rate per 100 component-years. Analysis was repeated excluding the uncemented SMR L2 glenoid (LimaCorporate), as it was a potential confounder. Kaplan-Meier survival analysis was performed. Oxford Shoulder Scores at both 6 months and 5 years were analyzed. RESULTS: A total of 2613 TSAs were performed for OA during the study period, representing 85.0% of all TSAs in New Zealand. Overall, 62.1% of the patients were female. In addition, 69.6% of glenoids were cemented and 30.4% uncemented. The most common uncemented MB glenoid was SMR 86.6% (LimaCorporate), and cemented was Global (DePuy) 49.8%. The revision rate for TSA with uncemented glenoids was significantly higher at 2.03 compared with cemented at 0.41 per 100 component-years (P < .001). Hazard ratio 5.0 for revision of uncemented glenoids. No significant difference was found in Oxford Scores at 6 months (39.7 vs. 40.3, P = .13) or 5 years (42.1 vs. 42.8, P = .22). The most common mode of failure was glenoid loosening in cemented glenoids (44.4%), and component failure in uncemented (34.8%). Revision for rotator cuff, deep infection, and instability were comparable between groups. When excluding SMR L2, uncemented MB glenoid all-cause revision rates remained significantly higher than cemented (1.42 vs. 0.41 per 100 component-years, P < .001). SMR L1 uncemented MB glenoids had a higher revision rate than the non-SMR uncemented glenoids (1.61 vs. 0.18 per 100 component-years, P = .009). Uncemented glenoid use peaked in New Zealand in 2011 at 46.7% of TSAs but declined to 20.1% in 2017. CONCLUSIONS: In the NZJR, primary TSAs undertaken for OA have a significantly higher all-cause revision rate when the glenoid component is uncemented. Uncemented glenoids have a 5.0 times higher revision rate. Excluding SMR L2 glenoids from the analysis, the significantly higher revision rate remained for uncemented glenoids. These data reaffirm that uncemented MB glenoids are associated with higher revision rates.

Early radiological and functional outcomes for a cementless press-fit design modular femoral stem revision system.

AIM:: To assess early radiological and functional outcomes of revision hip surgery with a cementless press-fit design femoral stem. PATIENTS AND METHODS:: A retrospective review of 48 consecutive revision total hip replacements using the RECLAIM revision hip system, between October 2012 and August 2015. Radiographic assessment was undertaken with serial anteroposterior (AP) X-rays of the pelvis. Risk factors for subsidence were evaluated. Prospective clinical follow up was performed on 21 patients to assess functional outcomes. RESULTS:: Mean stem subsidence was 1.1 mm (95% confidence interval[CI]: 0.63-1.57). Median follow up of 12 months. An inverse relationship was observed between level of subsidence and femoral stem diameter r = -0.45, p = 0.001. Subsidence at the time of follow-up assessment was correlated with initial subsidence (correlation coefficient rho 0.69, p = 0.001). The mean Merle d'Aubigne score at the latest follow up was 14.2 (range 8-17). The mean OHS was 34.1 (range 15-48). CONCLUSION:: Early radiological and functional outcomes for the RECLAIM revision system showed very low levels of subsidence and good functional outcomes. There was an association with smaller diameter femoral stems and greater levels of subsidence.

Which is the best bearing surface for primary total hip replacement? A New Zealand Joint Registry study.

INTRODUCTION: We have investigated the revision rates of all bearing surface combinations for primary total hip replacement (THR) registered on the New Zealand Joint Registry (NZJR) to determine which coupling has been the most durable and successful over the last 16 years. METHODS: There were 106,139 primary THRs registered, resulting in 4,960 revisions for any cause. We examined all-cause revision rates, reasons for revision and performed survival analyses. RESULTS: Ceramic-on-highly cross-linked polyethylene (CoPx) had the lowest all-cause revision rate of 0.54/100-component-years (cys) (95% confidence interval 0.48 to 0.61). This was superior to all other hard-on-soft bearing combinations in unadjusted analysis. Furthermore, the age of patients receiving CoPx was significantly lower than for metal-on-polyethylene (mean 62.9; standard deviation [SD] 10.1 vs. 69.1; SD 9.6; p<0.001). Acetabular loosening was the reason for revision in 14.5% of CoPx, compared to 33% of MoP THRs (p<0.001). Metal-on-metal bearings had the highest revision rate of 1.43/100 cys and were significantly inferior to CoPx (p<0.001). Kaplan-Meier analysis and Cox regression analyses were performed and we adjusted the analyses to control for age, femoral head size, surgical approach and fixation. CONCLUSIONS: CoPx remained the most durable and successful coupling used in primary THR in New Zealand irrespective of age, gender or size of femoral head.