Introduction. Survival after contemporary solid organ transplant (SOT) is increasing, and demand for total hip arthroplasty (THA) among SOT recipients is rising accordingly. The purpose of this study is to compare the perioperative outcomes and short-term implant- and patient-survivorship of contemporary THA following the most common types of SOT. Methods. Among SOT recipients, 119 primary THAs (92 patients, 39% female) were performed at a single institution from 2000–2020 and were retrospectively reviewed at a mean follow-up of 3.6yrs. Revisions, conversion to THA and multiple organs transplanted were excluded. The most common SOT was renal (39%), followed by lung (34%), liver (18%) and heart (8%). Demographics, peri-operative outcomes, 90-day re-admissions, re-operations and mortality were compared between SOT groups using chi-squared, Fisher's exact, Wilcoxon tests and Cox proportional hazard ratios. Results. Renal (median: 52yrs, 25–75%ile: 45.1–58.1) and heart transplant patients (55.4, 53.8–68.8) presented for THA at younger ages than liver (62.8, 50.0–67.6) and lung patients (63.1, 55.4–69.0; p<0.001). However, renal patients had the longest duration between SOT and THA (8.2yrs, 2.8–13.7; p=0.002), followed by liver (5.0, 1.2–11.4), heart (4.2, 2.4–9.6) and lung (2.6, 1.3–5.5). LOS was 3.0 days (p=0.31), 16% were discharged to a facility (p=0.87), and 9.4% required transfusion (p=0.43). Eighteen patients required re-admission within 90days (15%; p=0.44), and four underwent revision at 1-yr (3.4%; p=0.42). Mortality was 4.3% at 1yr (95% CI: 1.6–10.9) and 23.1% at 3yrs (95% CI: 15.0–32.9). When adjusted for age, ASA class, and duration from SOT to THA, lung transplant had higher mortality relative to kidney (RR 4.28, 95% CI: 1.79–11.26; p<0.001) and liver (RR 5.84, 95% CI: 1.95–25.29; p<0.001). Conclusion. SOT patients are a medically complex group with substantial requirements for facility placement, transfusions and re-admissions after THA. Short-term implant survivorship is acceptable, but THA in SOT patients is not without mortality risk, especially among lung transplant recipients

Three-dimensional (3D) printing has become more frequently used in surgical specialties in recent years. Orthopaedic surgery is particularly well-suited to 3D printing applications, and thus has seen a variety of uses for this technology. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production. As with any new technology, it is important to assess the clinical impact, if any, of three-dimensional printing. The purpose of this review was to answer the following questions: . What are the current clinical uses of 3D printing in orthopaedic surgery?. Does the use of 3D printing have an effect on peri-operative outcomes?. Four electronic databases (Embase, MEDLINE, PubMed, Web of Science) were searched for Articles discussing clinical applications of 3D printing in orthopaedics up to November 13, 2018. Titles, abstracts, and full texts were screened in duplicate and data was abstracted. Descriptive analysis was performed for all studies. A meta-analysis was performed among eligible studies to compare estimated blood loss (EBL), operative time, and fluoroscopy use between 3D printing cases and controls. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria for non-randomized studies and the Cochrane Risk of Bias Tool for randomized controlled trials (RCTs). This review was prospectively registered on PROSPERO (Registration ID: CRD42018099144). One-hundred and eight studies were included, published between 2012 and 2018. A total of 2328 patients were included in these studies, and 1558 patients were treated using 3D printing technology. The mean age of patients, where reported, was 47 years old (range 3 to 90). Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3D printing (N = 63), followed by final implants (N = 32) and PSI (N = 22). Titanium was the most commonly used 3D printing material (16 studies, 27.1%). A wide range of costs were reported for 3D printing applications, ranging from “less than $10” to $20,000. The mean MINORS score for non-randomized studies was 8.3/16 for non-comparative studies (N = 78), and 17.7/24 for non-randomized comparative studies (N = 19). Among RCTs, the most commonly identified sources of bias were for performance and detection biases. Three-dimensional printing resulted in a statistically significant decrease in mean operative time (−15.6 mins, p < .00001), mean EBL (−35.9 mL, p<.00001), and mean fluoroscopy shots (−3.5 shots, p < .00001) in 3D printing patients compared to controls. The uses of 3D printing in orthopaedic surgery are growing rapidly, with its use being most common in trauma and oncology. Pre-operative planning is the most common use of 3D printing in orthopaedics. The use of 3D printing significantly reduces EBL, operative time, and fluoroscopy use compared to controls. Future research is needed to confirm and clarify the magnitude of these effects

Objective

Compare the safety and effectiveness of different anesthetic technique used in the simultaneous bilateral total knee arthroplasty (BTKA).

Aims. Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. Methods. A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. Results. From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. Conclusion. For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160–6

Aims

Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored.

We have previously reported the short-term radiological results of a randomised controlled trial comparing kinematically aligned total knee replacement (TKR) and mechanically aligned TKR, along with early pain and function scores. In this study we report the two-year clinical results from this trial. A total of 88 patients (88 knees) were randomly allocated to undergo either kinematically aligned TKR using patient-specific guides, or mechanically aligned TKR using conventional instruments. They were analysed on an intention-to-treat basis. The patients and the clinical evaluator were blinded to the method of alignment.

At a minimum of two years, all outcomes were better for the kinematically aligned group, as determined by the mean Oxford knee score (40 (15 to 48) versus 33 (13 to 48); p = 0.005), the mean Western Ontario McMaster Universities Arthritis index (WOMAC) (15 (0 to 63) versus 26 (0 to 73); p = 0.005), mean combined Knee Society score (160 (93 to 200) versus 137 (64 to 200); p= 0.005) and mean flexion of 121° (100 to 150) versus 113° (80 to 130) (p = 0.002). The odds ratio of having a pain-free knee at two years with the kinematically aligned technique (Oxford and WOMAC pain scores) was 3.2 (p = 0.020) and 4.9 (p = 0.001), respectively, compared with the mechanically aligned technique. Patients in the kinematically aligned group walked a mean of 50 feet further in hospital prior to discharge compared with the mechanically aligned group (p = 0.044).

In this study, the use of a kinematic alignment technique performed with patient-specific guides provided better pain relief and restored better function and range of movement than the mechanical alignment technique performed with conventional instruments.

Cite this article: Bone Joint J 2014;96-B:907–13.

The June 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.

Total hip replacement (THR) has been shown to be a cost-effective procedure. However, it is not risk-free. Certain conditions, such as diabetes mellitus, are thought to increase the risk of complications. In this study we have evaluated the prevalence of diabetes mellitus in patients undergoing THR and the associated risk of adverse operative outcomes. A meta-analysis and systematic review were conducted according to the guidelines of the meta-analysis of observational studies in epidemiology. Inclusion criteria were observational studies reporting the prevalence of diabetes in the study population, accompanied by reports of at least one of the following outcomes: venous thromboembolic events; acute coronary events; infections of the urinary tract, lower respiratory tract or surgical site; or requirement for revision arthroplasty. Altman and Bland’s methods were used to calculate differences in relative risks. The prevalence of diabetes mellitus was found to be 5.0% among patients undergoing THR, and was associated with an increased risk of established surgical site infection (odds ratio (OR) 2.04 (95% confidence interval (CI) 1.52 to 2.76)), urinary infection (OR 1.43 (95% CI 1.33 to 1.55)) and lower respiratory tract infections (OR 1.95 (95% CI 1.61 to 2.26)). Diabetes mellitus is a relatively common comorbidity encountered in THR. Diabetic patients have a higher rate of developing both surgical site and non-surgical site infections following THR.

Cite this article: Bone Joint J 2013;95-B:1474–9.

To examine the relationship between obesity (BMI> 30) and the incidence of peri-operative complications, outcome of surgery and return to work in patients undergoing elective less invasive posterior lumbar inter-body fusion of the lumbar spine for low back pain and leg pain (“LI-PLIF”). 15 patients with BMI> 30 who underwent (“LI-PLIF”) were identified by reviewing the clinical notes and the pre-operative admission sheet from April 2005- to March 2007. All had suffered chronic low back pain for a minimum of 2 years that had proven unresponsive to conservative treatment. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). Minimum follow-up was for 12 months. Blood loss was dependent on BMI, number of levels, and surgical time. Post operative complication was more in the morbidly obese group than the in the obese. 10 patients (66.6%) returned to their normal pre-operative employment within the 12 months of the index procedure. There was a significant improvement in the ODI and in the VAS for back pain. Length of hospital stay was a mean of 3.3 days. Although surgery is technically more demanding our experience with less invasive posterior inter-body fusion has shown less incidence of post operative complication, less intra-operative blood loss and short in-patient hospital stay. We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain. Ethics approval: None: Audit Interest Statement None

Increasing numbers of posterior lumbar fusions are being performed. The purpose of this study was to identify trends in demographics, mortality and major complications in patients undergoing primary posterior lumbar fusion. We accessed data collected for the Nationwide Inpatient Sample for each year between 1998 and 2008 and analysed trends in the number of lumbar fusions, mean patient age, comorbidity burden, length of hospital stay, discharge status, major peri-operative complications and mortality. An estimated 1 288 496 primary posterior lumbar fusion operations were performed between 1998 and 2008 in the United States. The total number of procedures, mean patient age and comorbidity burden increased over time. Hospital length of stay decreased, although the in-hospital mortality (adjusted and unadjusted for changes in length of hospital stay) remained stable. However, a significant increase was observed in peri-operative septic, pulmonary and cardiac complications. Although in-hospital mortality rates did not change over time in the setting of increases in mean patient age and comorbidity burden, some major peri-operative complications increased. These trends highlight the need for appropriate peri-operative services to optimise outcomes in an increasingly morbid and older population of patients undergoing lumbar fusion.

This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the 3D group (p < 0.05). The percentage comparisons of cortical bone area showed that cortical bone in the superior distal segment is thicker than in the inferior segment, it is also thicker in the anterior mid-section than in the posterior (p < 0.05). If fixation of midshaft fractures of the clavicle with a plate is indicated, a 3D reconstruction plate is better than one placed superiorly, because it is consistent with the stress distribution and shape of the clavicle