Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up: A Pilot case series with a review of the literature.

INTRODUCTION: Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg's disease. METHODS: Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. RESULTS: No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics. CONCLUSION: Modified Weil osteotomy is an effective treatment for advanced Freiberg's disease with good outcomes and few complications.

Acute Hindfoot Nailing for Ankle Fractures: A Systematic Review of Indications and Outcomes.

OBJECTIVES: To assess the complication rate of hindfoot nailing of acute fractures involving the tibiotalar joint, and mortality, patient-reported outcome measures, and return to preinjury activities. DATA SOURCES: MEDLINE; EMBASE. STUDY SELECTION: A systematic literature search for articles in English was completed using MEDLINE and EMBASE databases on April 23, 2020. Original research articles that assessed patients with acute intra-articular fractures of the ankle joint (malleolar ankle fractures and/or pilon fractures) that were treated with a locked hindfoot intramedullary nail, inserted retrograde through the plantar surface of the foot, were selected for inclusion. Case reports (≤4 patients), studies with nonlocked implants, and non-English studies were excluded. DATA EXTRACTION AND SYNTHESIS: A validated data extraction form was used, which included study demographics (authors, journal, date of publication, and study design), patient characteristics, implant type, and reported outcomes. Risk of bias for each included study was evaluated using the Institute of Health Economics Quality Appraisal Checklist for case series and the Risk of Bias in randomized trials tool, where appropriate. The best evidence was summarized and weighted mean values were provided when appropriate. RESULTS: Ten case series and one randomized controlled trial were included. The overall quality of studies was poor with considerable bias. The majority of studies included elderly patients (weighted mean age 75.5 years) with diabetes (42% of patients). Overall complication rate was 16% with an 8% major complication rate (deep infection, malunion, nonunion, implant failure) and an overall infection rate of 6.2%. Pooled mortality rate was 27% with fracture union rates from 88% to 100%. Mean proportion of patients able to return to preinjury level of activity was 85%. CONCLUSIONS: Hindfoot nailing of acute ankle and pilon fractures in elderly patients and patients with diabetes is associated with complication rates comparable with other methods of fixation. Issues with elimination of subtalar joint motion and implant complications secondary to poor implant fixation persist. The literature to date has composed of primarily Level IV studies with considerable bias. Further research is necessary to clarify the role of hindfoot nailing of acute ankle and pilon fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do psychiatric disorders affect patient reported outcomes and clinical outcomes post total hip and knee arthroplasty?

INTRODUCTION: The purpose of this study is to evaluate the role of major psychiatric illness on patient outcomes after total joint arthroplasty. METHODS: Patients with a diagnosis of a major psychiatric disorder undergoing total joint arthroplasty were retrospectively matched one-to-one with a cohort without such a diagnosis. Major psychiatric disorder in the registry was identified by diagnosis of anxiety, mood, or a psychotic disorder. Primary outcome of interest included perioperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included EuroQol-5D, adverse events, length of stay, 30-day readmission, and discharge destination. RESULTS: Total number of patients were 1828. The total hip arthroplasty (37.80 ± 17.91, p = 0.023) and the total knee arthroplasty psychiatric group (43.38 ± 18.41, p = 0.050) had significantly lower pre-operative WOMAC scores. At 3 months, the total hip arthroplasty (76.74 ± 16.94, p = 0.036) and total knee arthroplasty psychiatric group (71.09 ± 18.64, p < 0.01) again had significantly lower 3-month post-operative WOMAC score compared to the control groups. However, outcomes at 1 year were difficult to interpret, as patients with major psychiatric conditions had an extremely high loss to follow-up. Compared to the control groups, the total hip arthroplasty and total knee arthroplasty psychiatric group had an increased length of stay by 1.43 days (p < 0.01) and 0.77 days, respectively (p = 0.05). Similarly, the psychiatric groups were discharged directly home less often (total hip arthroplasty 86.9%, p = 0.024 and total knee arthroplasty 87.6%, p = 0.022) than the control groups. CONCLUSION: Patients with the diagnosis of a major psychiatric illness have an increased length of stay and are more likely to require a rehabilitation facility, compared to the control groups. Arguably, of utmost importance, there is a very high rate of loss to follow-up within the psychiatric groups. As such, we recommend these patients should be treated for their diagnosis prior to total joint arthroplasty. Furthermore, importance of clinical follow-up should be emphasized carefully.

Two-Year Outcomes After Total Ankle Replacement With a Novel Fixed-Bearing Implant.

BACKGROUND: The Integra Cadence total ankle replacement (TAR) is a fourth-generation anatomic, fixed-bearing implant requiring minimal tibial and talar resection, which has been in clinical use since June 2016. The primary purpose of this study is to assess its short-term clinical and radiographic outcomes after TAR using this prosthesis. METHODS: This is a prospective case series of consecutive patients that underwent TAR using this novel fourth-generation prosthesis between June 2016 and November 2017. The primary outcome of interest was the Ankle Osteoarthritis Scale (AOS). Secondary outcomes included Short Form Health Survey-36 (SF-36) scores, radiographic alignment, complications, reoperations, and revisions. RESULTS: In total, 69 patients were included in our study. Fifty-one patients (73.9%) required a total of 91 ancillary procedures. Postoperatively, AOS pain scores decreased significantly by an average of 17.8±30.1 points from 45.9±18.2 to 28.4±27.3 (P < .001). AOS disability scores also decreased significantly following surgery by an average of 22.0±30.5 points from 53.9±18.5 to 32.5±27.9 (P < .001). The SF-36 physical component summary score improved 10.4±9.8 points from 33.1±9.1 to 42.6±9.1 (P < .001). Radiographic analysis demonstrated significant improvement to neutral coronal plane alignment, which was achieved in 97% of patients (P < .01) with no cyst formation at 2 years. There was 1 reported complication, 9 reoperations, and no metal or polyethylene component revisions. Overall, the 2-year implant survivorship was 100% in our cohort. Eighteen patients (26.1%) demonstrated fibrous ingrowth of the tibial component. However, outcome scores for these patients did not demonstrate any negative effects. CONCLUSION: In our hands, this TAR system demonstrated excellent early clinical and radiographic outcomes. Patients reported improved physical health status, pain, and disability in the postoperative period. Total ankle instrumentation allowed for accurate and reproducible implantation with correction of coronal and sagittal plane deformities. Early results for the clinical use of this TAR system are promising, but further long-term prospective outcome studies are necessary. LEVEL OF EVIDENCE: Level IV, case series.

Does a Delay in Anterior Cruciate Ligament Reconstruction Increase the Incidence of Secondary Pathology in the Knee? A Systematic Review and Meta-Analysis.

OBJECTIVE: Previous systematic reviews looking at timing of anterior cruciate ligament reconstruction (ACLR) examined the functional outcomes and range of motion; however, few have quantified the effect of timing of surgery on secondary pathology. The goal of this study was to analyze the effects of early ACLRs versus delayed ACLR on the incidence of meniscal and chondral lesions. DATA SOURCES: We searched MEDLINE, EMBASE, and CINAHL on March 20, 2018, for randomized control trials (RCTs) that compared early and delayed ACLR in a skeletally mature population. Two reviewers independently identified trials, extracted trial-level data, performed risk-of-bias assessments using the Cochrane Risk of Bias tool, and evaluated the study methodology using the Detsky scale. A meta-analysis was performed using a random-effects model with the primary outcome being the total number of meniscal and chondral lesions per group. RESULTS: Of 1887 citations identified from electronic and hand searches, we included 4 unique RCTs (303 patients). We considered early reconstruction as <3 weeks and delayed reconstruction as >4 weeks after injury. There was no evidence of a difference between early and late ACLR regarding the incidence of meniscal [relative risk (RR), 0.98; 95% confidence interval (CI), 0.74-1.29] or chondral lesions (RR, 0.88; 95% CI, 0.59-1.29), postoperative infection, graft rupture, functional outcomes, or range of motion. CONCLUSIONS: We found no evidence of benefit of early ACLR. Further studies may consider delaying surgery even further (eg, >3 months) to determine whether there are any real benefits to earlier reconstruction.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA. METHODS: This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results. RESULTS: In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA. CONCLUSIONS: The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.Level of Evidence: Level IV, case series.

The Relationships between the Rotational Axes of the Distal Femur in the Arthritic Caucasian Knee: A Magnetic Resonance Imaging Analysis.

Four distal femoral axes have been described to aid in the accuracy of transverse plane component alignment in total knee arthroplasty (TKA). These include the surgical epicondylar axis (SEA), the posterior condylar axis (PCA), and the anteroposterior (AP) axis. Therefore, the primary purpose of this study is to identify the axial femoral relationship with the least variation in a Caucasian population awaiting TKA for osteoarthritis. Secondarily, we further plan to determine if these femoral axis relationships differ with respect to sex or preoperative coronal alignment. These anatomic relationships were measured using preoperative magnetic resonance imaging, which was performed within 2 months of the planned operation date for patient specific instrumentation templating. In terms of our primary outcome, the mean SEA/AP angle was 92.8 degrees (standard deviation [SD]: 2.5 degrees), the mean PCA/AP angle was 95.7 degrees (SD: 2.8 degrees), and the mean PCA/SEA angle was 3.4 degrees (SD: 1.8 degrees). Overall, the PCA/SEA relationship had the smallest variance, while the PCA/AP had the most variance for all comparisons. In terms of our secondary outcome, there was no statistical difference between femoral axis relationships based on preoperative coronal plane alignment. In terms of sex differences, the PCA/SEA was significantly higher in female knees compared with males. Females had a PCA/SEA relationship of 4.7 degrees (SD: 1.3 degrees) compared with 2.6 degrees (SD: 1.2 degrees) for males (p < 0.05). By using the PCA/AP axes, the AP axis was externally rotated by 96.7 degrees (SD: 2.3 degrees) in females, compared with 93.2 degrees (SD: 2.1 degrees) in males, from the PCA. In conclusion, our results demonstrate that the PCA/SEA relationship should be used to determine axial rotation in TKA as it shows the least variation. When using the PCA, approximately 5 degrees of external rotation for Caucasian women and 3 degrees of external rotation for the Caucasian men should be dialed into the femoral cutting block to restore anatomic axial rotation. Further evaluation is needed to determine to role of preoperative coronal alignment on distal femoral axial alignment.

Outcomes of total hip arthroplasty using dual mobility components in patients with a femoral neck fracture.

AIMS: Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA). METHODS: We performed a systematic review of all English language articles on THA-DMC published between 2010 and 2019 in the MEDLINE, EMBASE, and Cochrane databases. After the application of rigorous inclusion and exclusion criteria, 23 studies dealing with patients who underwent treatment for a femoral neck fracture using THA-DMC were analyzed for the rate of dislocation. Secondary outcomes included reoperation, periprosthetic fracture, infection, mortality, and functional outcome. The review included 7,189 patients with a mean age of 77.8 years (66.4 to 87.6) and a mean follow-up of 30.9 months (9.0 to 68.0). RESULTS: THA-DMC was associated with a significantly lower dislocation rate compared with both THA (OR 0.26; 95% CI 0.08 to 0.79) and HA (odds ratio (OR) 0.27; 95% confidence interval (CI) 0.15 to 0.50). The rate of large articulations and of intraprosthetic dislocation was 1.5% (n = 105) and 0.04% (n = 3) respectively. CONCLUSION: THA-DMC when used in patients with a femoral neck fracture is associated with a lower dislocation rate compared with conventional arthroplasty options. There was no increase in the rates of other complication when THA-DMC was used. Future cost analysis and prospective, comparative studies are required to assess the potential benefit of using THA-DMC in these patients. Cite this article: Bone Joint J 2020;102-B(7):811-821.

Waste and recycling among orthopedic subspecialties.

Background: It is estimated that one-quarter to half of all hospital waste is produced in the operating room. Recycling of surgical waste in the perioperative setting is uncommon, even though there are many recyclable materials. The objective of this study was to determine the amount of waste produced in the preoperative and operative periods for several orthopedic subspecialties and to assess how much of this waste was recycled. Methods: Surgical cases at 1 adult and 1 pediatric tertiary care hospital in Calgary, Alberta, were prospectively chosen from 6 orthopedic subspecialties over a 1-month period. Waste was collected, weighed and divided into recyclable and nonrecyclable categories in the preoperative period and into recyclable, nonrecyclable, linen and biological categories in the intraoperative period. Waste bags were weighed using a portable hand-held scale. The primary outcome was the amount of recyclable waste produced per case. Secondary outcomes included the amount of nonrecyclable, biological and total waste produced. An analysis of variance was performed to test for statistically significant differences among subspecialties. Results: This study included 55 procedures. A total of 341.0 kg of waste was collected, with a mean mass of 6.2 kg per case. Arthroplasty produced a greater amount of recyclable waste per case in the preoperative (2017.1 g) and intraoperative (938.6 g) periods as well as total recyclable waste per case, resulting in a greater ratio of waste recycling per case then nearly all other subspecialties in the preoperative (86%) and intraoperative (14%) periods. Arthroplasty similarly produced a greater amount of nonrecyclable waste per case (5823.6 g) than the other subspecialties, most of which was produced during the intraoperative period (5512.9 g). Overall an average of 27% of waste was recycled per case. Conclusion: Among orthopedic subspecialties, arthroplasty is one of the largest waste producers and it has the highest potential for recycling of materials. Effective recycling programs in the operating room can reduce our ecological footprint by diverting waste from landfills, as our study revealed that nearly three-quarters of this waste is recyclable.

Contexte: On estime qu'un quart à la moitié de tous les déchets produits en hôpital proviennent des salles d'opération. Le recyclage des déchets produits en contexte opératoire est assez rare, bien que de nombreux matériaux soient recyclables. Cette étude visait à déterminer la quantité de déchets produits pendant les périodes préopératoire et peropératoire pour plusieurs surspécialités orthopédiques, et à évaluer la quantité de déchets recyclés. Méthodes: Pour y arriver, on a étudié de façon prospective pendant 1 mois les chirurgies effectuées dans 2 hôpitaux de soins tertiaires de Calgary (Alberta), 1 hôpital pédiatrique et 1 hôpital pour adulte, pour 6 surspécialités orthopédiques. Nous avons recueilli les déchets, les avons pesés et les avons répartis dans les catégories « recyclable ¼ et « non recyclable ¼ pour la période préopératoire, et « recyclable ¼, « non recyclable ¼, « textile ¼ et « biologique ¼ pour la période peropératoire. Les sacs de déchets ont été pesés à l'aide d'une balance portative. L'issue principale était la quantité de déchets produits par cas, et l'issue secondaire, la quantité de déchets non recyclables et biologiques et la quantité totale de déchets. On a ensuite procédé à une analyse de la variance pour déterminer la présence de différences statistiquement significatives entre les surspécialités. Résultats: Au total, 55 opérations ont été étudiées, et 341,0 kg de déchets ont été recueillis, pour une moyenne de 6,2 kg par cas. Les arthroplasties produisaient une plus grande quantité de déchets recyclables par cas dans les périodes préopératoire (2017,1 g) et peropératoire (938,6 g) ainsi qu'une plus grande quantité totale de déchets recyclables par cas, ce qui leur donne un meilleur ratio de recyclage par cas que pratiquement toutes les autres surspécialités dans les périodes préopératoire (86 %) et peropératoire (14 %). De même, les arthroplasties produisaient une plus grande quantité de déchets non recyclables par cas (5823,6 g) que les autres surspécialités, et la plupart de ces déchets étaient produits pendant la période peropératoire (5512,9 g). En moyenne, 27 % de l'ensemble des déchets étaient recyclés. Conclusion: Parmi les surspécialités orthopédiques, l'arthroplastie est l'une de celles qui produisent le plus de déchets et qui ont le plus grand potentiel de recyclage. Notre étude a révélé que près des trois quarts des déchets sont recyclables; ainsi, des programmes de recyclage efficaces en salle d'opération peuvent réduire notre empreinte écologique en empêchant l'enfouissement de certains déchets.

Ipsilateral Deltoid and Hand Compartment Syndrome: A Case Report and Review of the Literature.

CASE: We present the unique case of deltoid and hand compartment syndrome in a young man after prolonged syncope because of polysubstance use. The patient was subsequently treated with urgent deltoid and hand compartment fasciotomies which resulted in full recovery of his shoulder function. CONCLUSIONS: Patients suspected of deltoid compartment syndrome should have a thorough physical examination, followed by repeat examinations. Invasive compartment monitoring should be used in equivocal cases, in patients with decreased level of consciousness, and in patients with distracting injury. Once diagnosed, deltoid compartment syndrome (± other compartments) should be taken for emergent fasciotomy, ensuring adequate decompression of all 3 deltoid compartments.

Impact of 3D Printed Calcaneal Models on Fracture Understanding and Confidence in Orthopedic Surgery Residents.

OBJECTIVE: To determine if three-dimensionally printed (3Dp) fracture models can improve orthopedic trainee education. DESIGN: A prospective comparison study of orthopedic trainees and attending surgeons was performed, where a range of calcaneal fractures were used for creating anonymized 3Dp models. Study participants rotated through workstations viewing computed tomography images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. Diagnosis, time for evaluation, confidence of fracture understanding, perceived model accuracy, and proposed treatment were compared using a standardized questionnaire. PARTICIPANTS: Sixteen resident trainees and 5 attending surgeons participated in this study. Attending surgeons were required to have fellowship training in trauma or foot and ankle surgery and manage calcaneal fractures as part of their current practice. RESULTS: Junior residents had the slowest time of assessment (mean = 121 ± 54 seconds) and lowest percentage of correct diagnoses (69%), although these findings did not reach significance compared to the other residency years. Residents displayed higher levels of confidence in fracture understanding with increasing residency year of training (p < 0.0001), and this confidence was greater for cases that included a 3Dp model (p < 0.03). Perceived accuracy of cases with 3Dp models was significantly higher than cases without 3Dp models (7.0 vs 5.5 p < 0.001). CONCLUSIONS: This study found that 3Dp models increase the perceived accuracy of fracture assessment, though no statistically significant improvement in diagnostic accuracy was observed. The 3Dp models did improve trainee confidence, although this effect diminished with increasing residency year. In orthopedic residency training programs, 3Dp models of complex fractures can be a valuable educational tool, especially for junior trainees.

Conservative treatment of cubital tunnel syndrome: A systematic review.

Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available. Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS. There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.

The effect of subscapularis repair on dislocation rates in reverse shoulder arthroplasty: a meta-analysis and systematic review.

BACKGROUND: Reverse total shoulder arthroplasty is an effective treatment for patients with rotator cuff arthropathy; however, complication rates are relatively high (19%-50%), with implant instability and infection being particularly devastating to overall outcomes. The objective of this study was to analyze the highest level of data comparing dislocation rates and outcomes in reverse total shoulder arthroplasty with and without the subscapularis tendon repaired. METHODS: The databases MEDLINE, Embase, and CINAHL were searched using a sensitive search strategy for this meta-analysis/systematic review. Eligibility included any studies in which patients were treated with a reverse total shoulder arthroplasty in which the status of the subscapularis tendon could be determined. A data extraction form was developed to collect select data from the included studies. A meta-analysis was performed on pooled data of 5 studies comparing dislocation rates and 3 studies comparing postoperative forward elevation, rate of infection, overall complication rates, and fractures. RESULTS: Two independent researchers reviewed 1008 studies. Seven studies met inclusion criteria. A meta-analysis was performed on all level III studies, resulting in 1306 patients being analyzed. Results demonstrated lower dislocation rates in the subscapularis repair group (odds ratio, 0.19; P < .001). However, in patients without a subscapularis repair, lateralized center of rotation (COR) resulted in a significantly lower dislocation rate compared with medialized COR (odds ratio, 0.24; P < .001). CONCLUSION: The results of our meta-analysis of the available data demonstrated a decrease in dislocation risk when the subscapularis tendon was repaired in medialized and lateralized designs. When subscapularis repair is not performed, lateralized COR, regardless of humeral socket design, may reduce the dislocation rates.

Development of a simple multidisciplinary arthroplasty wound-assessment instrument: the SMArt Wound Tool

Background: There are currently no validated instruments in the orthopedic literature for assessing the healing of acute surgical wounds. The creation of a simple wound-assessment tool would provide a standardized method of reporting wound outcomes. The objective of this study was to systematically develop a wound-assessment tool that can be used to assess the early healing of arthroplasty incisions. Methods: The databases MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane reviews and CINAHL were searched. Articles that described objective assessment of acute incisional wounds were included. Items for the wound-assessment tool were then extracted from eligible studies based on the frequency of reporting. A multidisciplinary panel of wound experts compiled the items into an initial tool to assess key domains of wound healing. The items were reduced through several iterations of panel discussion. Results: Our search strategy yielded 3743 results, which were screened by title and abstract. Thirty-four studies were included in the systematic review for the development of the wound-assessment tool, and 10 domains were extracted based on frequency of reporting. After item reduction, the final version of the wound-assessment tool, the SMArt Wound Tool, contained 3 major domains: blistering, peri-incisional skin colour and exudate type. Conclusion: There is currently a need for a standardized tool to assess the healing of orthopedic surgical incisions. The SMArt Wound Tool provides a simple, objective method of assessing arthroplasty incisions for the presence of early complications.

Contexte: Il n'existe actuellement aucun instrument validé dans la littérature orthopédique pour évaluer la cicatrisation des plaies chirurgicales récentes. La création d'un outil d'évaluation simple des plaies offrirait une méthode standard pour suivre leur évolution. L'objectif de cette étude était de concevoir un outil d'évaluation systématique des plaies pouvant être utilisé pour vérifier la bonne cicatrisation des incisions d'arthroplastie. Méthodes: Les bases de données MEDLINE, Embase, CINAHL, le registre central Cochrane des essais contrôlés et la base de données Cochrane des revues systématiques ont été interrogés. Les articles qui décrivaient une évaluation objective des plaies d'incision récentes ont été inclus. Les paramètres d'évaluation des plaies ont ensuite été extraits à partir des études retenues en fonction de la fréquence à laquelle ils étaient rapportés. Un comité multidisciplinaire d'experts des plaies a compilé les paramètres pour créer un outil initial d'évaluation des domaines clés de la cicatrisation des plaies. Des discussions successives du comité ont ensuite permis de réduire le nombre de paramètres d'évaluation. Résultats: Notre stratégie d'interrogation a généré 3743 résultats qui ont été triés par titre et résumé. Trente-quatre études ont été retenues pour la revue systématique en vue de la création de l'outil d'évaluation des plaies et 10 domaines ont été extraits en fonction de la fréquence à laquelle ils étaient rapportés. Après la réduction du nombre de paramètres, la version finale de l'outil d'évaluation des plaies, appelé SMArt Wound Tool, comprenait 3 domaines principaux : formation de vésicules, couleur de la peau au pourtour de l'incision et type d'exsudat. Conclusion: On déplore actuellement l'absence d'outils standards pour évaluer la cicatrisation des plaies en chirurgie orthopédique. L'outil SMArt offre une méthode simple et objective d'évaluation des incisions d'arthroplastie pour déceler rapidement la moindre complication, le cas échéant.

A scoping review on the surgical management of metastatic bone disease of the extremities.

BACKGROUND: Management of metastatic bone disease of the extremities (MBD-E) is challenging, and surgical directions pose significant implications for overall patient morbidity and mortality. Recent literature reviews on the surgical management of MBD-E present a paucity of high-level evidence and global inconsistencies in study design. In order to steer productive research, a scoping review was performed to map and assess critical knowledge gaps. METHODS: The Arksey and O'Malley framework for scoping studies was followed. A comprehensive literature search identified a large body of literature pertaining to the surgical management of MBD-E. Study data and meta-data was extracted and presented using descriptive analytics and a thematic framework. Literature gaps were identified and analyzed. RESULTS: Three hundred eighty five studies from 1969 to 2017 were included. Studies were categorized into 11 separate themes, with the majority (63%) falling into the "surgical fixation strategies" theme, followed by "complications" at 7% and "prognosis and survival" at 6.2%. Less than 3% of studies were categorized in "patient related outcomes" or "epidemiology" themes. 89% of studies were retrospective and only 6 studies were of level 1 or 2 evidence. We identified a temporal increase in publication by decade, and all studies published on interventional radiology techniques or economic analyses were published after 2007 or 2009, respectively. 64.9% of studies were published in Europe and 20.3% were published in North America. Average patient age was 62 (± 5.2 years), and breast was the most common primary tumour (28%), followed by lung (17%) and kidney (15%). In terms of surgical location, 75% of operations involved the femur, followed by the humerus at 22% and tibia at 3%. CONCLUSIONS: We present a descriptive overview of the current published literature on the surgical management of MBD-E. Critical knowledge gaps have been identified through the development of a thematic framework. Consolidation of literary gaps must involve bolstered efforts towards patient and family-engaged research initiatives and assessment of patient-related surgical outcomes. Multi-disciplinary engagement in developing prospective research will also help guide evidence-based personalized practice for these patients. By building on existing comprehensive patient databases and registries, knowledge on survival and prognostic parameters can be greatly improved.

Exertional Supraspinatus Syndrome: A Report of Two Cases.

CASE: We present 2 unique cases of exertional supraspinatus syndrome related to overexertion in 2 young men. In both cases, the diagnosis was delayed because the symptom was nonspecific shoulder pain; however, progressive pain, an elevated creatine kinase (CK) level, and either increased compartmental pressures or findings on magnetic resonance imaging eventually led to the appropriate diagnosis. CONCLUSION: The terms "supraspinatus compartment syndrome" and "supraspinatus rhabdomyolysis" are inappropriately used interchangeably. We believe that both conditions are part of a spectrum of pathology called exertional supraspinatus syndrome. It is important to differentiate between these conditions because a patient with supraspinatus compartment syndrome, which is distinguished by elevated compartment pressures, requires an immediate fasciotomy.

Bicompartmental knee arthroplasty vs total knee arthroplasty for the treatment of medial compartment and patellofemoral osteoarthritis.

BACKGROUND: Interest in bicompartmental knee arthroplasty (BKA) for the treatment of medial patellofemoral osteoarthritis (MPFOA) has grown in recent years because BKA offers a bone and ligament-preserving alternative to total knee arthroplasty (TKA). BKA only resurfaces the diseased compartments, while preserving proprioception and native knee kinematics. Therefore, the objective of this study is to assess knee function, perioperative morbidity, and implant survivability in patients undergoing BKA vs TKA for MPFOA. METHODS: The databases MEDLINE, PUBMED, and EMBASE were systematically searched. Randomized controlled trials and nonrandomized comparative studies comparing BKA with TKA for the treatment of MPFOA were included for further analysis. The primary outcome of interest was knee function. Secondary outcomes included range of movement, operation length, intraoperative blood loss, hospital length of stay, postoperative complications, and rate of revision length. The quality of evidence was evaluated using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies when possible. RESULTS: Six studies were selected for inclusion (4 prospective studies and 2 retrospective cohort studies). In total, 274 patients and 277 knees were included for analysis. There were no significant differences between the 2 groups at any time points in terms of knee function, length of stay, complication rate, or revision rate, when monolithic BKA designs were controlled for. BKA did result in significantly decreased intraoperative blood loss, at the expense of increased operative length compared with TKA. CONCLUSIONS: The use of modular BKA for MPFOA is comparable with TKA in terms of short-term function, complication rate, and revision rate. BKA reduces intraoperative blood losses, but it is also more technically demanding, resulting in increased operation length. The use of modular BKA has acceptable short-term outcomes, but more long-term data are needed before it can be recommended for routine use in the treatment of MPFOA. The selection of modular BKA should be determined on a patient-specific basis. Currently, there is no evidence to suggest the use of monolithic BKA designs because of their high revision and failure rate.

Periprosthetic total knee fracture after remote reconstruction of the anterior cruciate ligament: a case report.

BACKGROUND: Distal femoral fracture is a rare, but significant, postoperative complication of anterior cruciate ligament reconstruction. However, there has not been a reported case of periprosthetic total knee arthroplasty fracture associated with a previous anterior cruciate ligament repair. CASE PRESENTATION: We report the case of a 51-year-old white man with a history of total knee arthroplasty and remote anterior cruciate ligament reconstruction, who presented with a distal femoral periprosthetic fracture at the site of a previous anterior cruciate ligament augmentation staple. CONCLUSIONS: Based on these findings, it may be important to consider removal of previous anterior cruciate ligament hardware prior to total knee arthroplasty to reduce risk of periprosthetic fracture, which should be determined on a patient-specific basis.

The Effect of Synovectomy in Total Knee Arthroplasty for Primary Osteoarthritis: A Meta-Analysis.

The objective of this study is to assess pain, function, and morbidity in patients undergoing synovectomy during primary total knee arthroplasty (TKA) for osteoarthritis (OA). A meta-analysis, which included randomized controlled trials comparing TKA with and without synovectomy for OA, was completed. The primary outcome was postoperative knee pain. Secondary outcomes included performance, perioperative complications, validated functional scores, operation length, and hospitalization length. A literature search produced 487 unique references, of which 3 randomized controlled trials were selected for inclusion. A total of 304 patients (354 knees) were included, with an average age of 67 years. Follow-up intervals between studies ranged from 26 weeks to 12 months. Included studies were of moderate- to high-quality evidence with low risk of bias. There was no significant difference between the two groups in regard to postoperative pain, Knee Society Score, or postoperative range of motion. Postoperative blood loss was significantly lower in synovium-retaining TKA group (MD = 99.41 mL; 95% confidence interval, 45.08-153.75). Based on these results, there is currently no evidence to support the use of synovectomy in TKA for primary OA, as it provides no clinical benefit and increases postoperative blood loss.