Total Knee Arthroplasty in Hemophilia: Survivorship and Outcomes-A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with hemophilia (PWHs) may experience spontaneous or traumatic bleeding episodes. Recurrent bleeding can lead to end-stage hemophilic arthropathy and total knee replacement (TKR) provides an effective treatment. The aim of this study is to investigate outcomes in PWHs who undergo TKR. METHODS: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study outcomes included patient-reported functional outcomes, implant survivorship, and complications. Subgroup analysis was performed assessing the effect of recombinant prophylaxis medication by comparing studies that included only TKRs performed after the year 2000 (period A), to those that included TKRs before 2000 (period B). RESULTS: Twenty-eight studies were included, with a total of 1210 TKRs performed in 917 PWHs. The mean age of patients was 38.5 years (standard deviation 5.1) with a mean length of follow-up of 7.1 years (standard deviation 2.9). The total complication rate was 28.7%, with 19.3% requiring a further procedure. Hospital for Special Surgery Knee Score improved by 44.6 points (confidence interval 38.9-50.4) and Knee Society Score function improved by 35.9 points (confidence interval 30.1-41.8). Total range of motion improved by 22.3°. The most common complication was post-operative hemarthrosis (7.6%, 92 TKRs). Deep infection (6.2% vs 3.9%) and aseptic loosening (3.8% vs 2.1%) rates fell between period B and period A. CONCLUSION: TKR in PWHs is a successful procedure improving function, reducing pain, and improving range of motion. PWHs undergo TKR at a younger age and have a higher risk of complications, though contemporary treatment has reduced these risks. PWHs can expect similar survivorship to the general population.

Trabecular Metal Augments for Severe Acetabular Defects in Revision Hip Arthroplasty: A Long-Term Follow-Up.

BACKGROUND: Paprosky type IIIa and IIIb acetabular defects remain technically challenging during revision hip arthroplasty. Numerous surgical options exist to counter extensive acetabular bone loss with high postoperative complication and revision rates reported. Our aim was to report comprehensive long-term outcomes of our experience with Trabecular Metal (TM) augments for these difficult cases. METHODS: 38 patients underwent revision total hip arthroplasty at our institution from 2009 to 2014 where a TM augment was used for acetabular deficiency. Prospective radiographic and Patient-Reported Outcome Measures were recorded and analyzed to a mean of 7.3 years (range: 5.4 to 10.8). RESULTS: No patient was excluded or lost to follow-up. Complications included 3 intraoperative fractures, 1 early infection requiring washout with implant retention, 1 early revision due to allograft resorption, and 6 patients who required late repeat revision surgery: 3 for late infection, 2 for aseptic loosening with augment fracture or dislocation, and 1 for recurrent dislocation. The estimated mean implant survivorship was 8.99 years. 93.5% of augments remaining were well osseointegrated while 97% of the acetabular shells were osseointegrated. Hip center of rotation was restored by a mean of 14 mm inferiorly without significant medialization. Short Form-12 (SF-12) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were significantly reduced postoperatively to a level comparable to the average individual. CONCLUSION: This long-term study details our experience of TM augments for the most severe acetabular defects. For such cases, no excellent surgical solution exists; in comparison to alternative methods, we advocate that this technique is reasonably safe and effective.

A single centre experience of pre-contoured clavicle plates by an anterior approach.

AIM: In recent years there has been increasing evidence that comminuted and shortened clavicle fractures should be treated surgically. The aim of this study was to assess the outcome of patients who had their clavicle fracture fixed using a pre-contoured, clavicle specific plate from an anterior approach. METHOD: A retrospective analysis was carried out of all patients treated with pre-contoured clavicle plates from an anterior approach between May 2014 and June 2016.Medical records were analysed, and a phone survey was carried out to assess patient function and note any complications. RESULTS: Thirty-five eligible patients were identified. Post-operative complications included: 3 patients experienced altered sensation of the anterior chest wall, 2 suture granulomas, 1 incidence of prominent metalwork. In addition, 2 patients suffered peri-implant fractures due to secondary trauma after union. Patients who had Open Reduction and Internal Fixation (ORIF) for acute fractures had a mean qDASH of 8.93 and those who had a ORIF and bone grafting for non-union had an mean qDASH of 34.38. CONCLUSION: Although there are 6 complications listed for 33 procedures, these would be considered minor. Patients appear to do better if treated for an acute fracture. Anterior approach for clavicle ORIF using an anatomically shaped pre-contoured plate appears to be a safe and effective procedure.

Differentiated Thyroid Cancer: How Do Current Practice Guidelines Affect Management?

BACKGROUND: International best-practice guidelines recommend completion thyroidectomy and radioiodine remnant ablation (RRA) for patients with differentiated thyroid cancer (DTC) > 4 cm or with specific risk factors. Patients with DTC < 1 cm without risk factors are recommended for lobectomy alone. Indications for aggressive surgery and RRA are less clearly defined for tumours measuring 1-4 cm. A personalised approach to decision-making is recommended. OBJECTIVES: This study assesses therapeutic approaches to DTC as compared to the current British Thyroid Association (BTA) clinical practice guidelines. We ascertained the effect of equivocal guidance in the 1-4 cm tumour cohort on contemporary practice patterns. METHODS: Data were obtained from a prospectively maintained thyroid cancer database of patients treated for DTC in a tertiary referral centre at the University Hospital Galway. Consecutive patients attending a dedicated thyroid cancer clinic between August 2014 and August 2017 were included. Clinicopathological characteristics and management strategies were assessed. RESULTS: Ninety-four percent (n = 168/178) of patients were surgically managed in adherence with guidelines. A minority (n = 10) received surgery not aligned with guidelines. Ninety-seven percent (n = 172/178) of RRA treatment decisions were in accordance with guidelines. The BTA guidelines recommended a personalised decision-making approach for 18.0% (n = 32) and 44.9% (n = 80) of surgery and RRA treatment decisions, respectively. The more aggressive, treatment-driven approach was typically favoured by the multidisciplinary team, with 97% (n = 31/32) undergoing completion thyroidectomy and 100% (n = 80) proceeding to RRA. CONCLUSIONS: Management of DTC at our institution closely adheres to contemporary clinical practice guidelines. The finding of more aggressive management in those requiring a personalised decision-making approach highlights the requirement for improved risk stratification in this cohort to ratio-nalise management strategies.