Introduction. The usefulness of minimal invasive hip replacement is frequently discussed but there is a lack of data on the effect of the surgical approach on early results. We wanted to study the effect of the surgical approach on the peri- and early postoperative outcome. Material/Methods. In a prospective case control study 315 elective hip replacements were performed between January 2008 and March 2010. Until March 2009 a lateral transgluteal approach (STD) was used, then the approach was changed to a minimal invasive anterior approach (MIS). All operations were performed in the same routine setting not affected by the approach. Duration of operation, complications and bloodloss were assessed. 1 week postoperatively, independent mobility, stairs, central analgetics were analysed and length of stay was recorded. At 6 and 12 weeks, pain and patients satisfaction (VAS) and the Harris Hip Score were assessed. Pre- and postoperative radiographs were compared for component position and orientation (EBRA). Results. 6 patients (hips) refused participation, 4 were excluded for other reasons. 174 (57%) hips belonged to STD and 131 (43%) to MIS. There were no demographic differences between both groups. Operation time was longer for MIS (109 vs. 123 min, p=.001). At 1 week, MIS patients were more mobile (rising up from bed, p=.009; stairs, p=.015) and time of hospitalisation became shorter (p=.001). At 6 weeks, MIS patients had less pain at motion (p=.013), less limb (p=.001), a higher HHS (p=.007) and were more satisfied (p=.046). The differences remained unchanged after 12 weeks. There was no difference in implant positioning between the groups. Inclination was higher in group MIS [39° (SD 6°) vs. 38° (SD 7°), p=.030], anteversion was lower [21° (SD 8°) vs. 24° (SD 8°), p=.010]. Conclusion. The introduction of the MIS anterior approach was safe. Early rehabilitation was facilitated and clinical results were better. Radiographical results were not impaired by the new approach. We see no disadvantage of the MIS anterior approach. Adaptions in the clinical setup might further facilitate rehabilitation

We aim to determine the differences in lower limb joint kinematics during the golf swing of patients who had undergone Total Knee Arthroplasty (TKA) and a control group of native knee golfers.

A case-control study was undertaken with ten golfers who had undergone TKA (cruciate retaining single radius implant) and five age and matched golfers with native knees. Each golfer performed five swings with a driver whilst being recorded at 200Hz by a ten-camera motion capture system. Knee and hip three-dimensional joint angles (JA) and joint angular velocities (JAV) were calculated and statistically compared between the groups at six swing events.

The only significant differences in knee joint kinematics between TKA and control groups was a lower external rotation JA in the left knee during the backswing (p=0.010). There was no significant difference in knee JAV between the groups. Both hips demonstrated significantly (p=0.023 for left and p=0.037 for right) lower flexion in the TKA group during the takeaway swing event, and there was lower internal rotation in the backswing and greater external rotation in the downswing of the right hip. There was also slower left hip extension JAV in the downswing.

Normal knee kinematics were observed during the golf swing following TKA, with the exception of reduced external rotation in the left knee during the back swing and the right during the down swing. The differences demonstrated in the hip motion indicate that they may make compensatory movements to adjust to the reduced external rotation demonstrated in the knee.

There is a lack of information about the association between patellofemoral osteoarthritis (PFOA) and both adolescent Anterior Knee Pain (AKP) and previous patellar dislocations.

This case-control study involved 222 participants from our knee arthroplasty database answering a questionnaire. 111 patients suffering PFOA were 1:1 matched with a unicompartmental tibiofemoral arthritis control group. Multivariate correlation and binary logistic regression analysis was performed, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. This analysis helps us assess the effect of both variables whilst adjusting for major confounders, such as previous surgery and patient-reported instability.

An individual is 7.5 times more likely to develop PFOA if they have suffered adolescent AKP (OR 7.5, 95% CIs 1.51–36.94). Additionally, experiencing a patellar dislocation increases the likelihood of development of PFOA, with an adjusted odds ratio of 3.2 (95% CIs 1.25–8.18). A 44-year difference in median age of first dislocation was also observed between the groups.

This should bring into question the traditional belief that adolescent anterior knee pain is a benign pathology. Patellar dislocation is also a significant risk factor. These patients merit investigation, we encourage clinical acknowledgement of the potential consequences when encountering patients suffering from anterior knee pain or patellar dislocation.

Aims

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

Aims. The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery. Patients and Methods. A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential ‘safe window’ exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk. Results. A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the ‘safe window’, the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004). Conclusion. A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385–1391

There is a lack of evidence surrounding selective patella resurfacing, but patella cartilage loss at time of total knee arthroplasty (TKA) is often used as an indication in those who perform it. This study compares the outcomes of TKA without patella resurfacing in patients with and without patella cartilage loss (PFOA). Prospective case control study of 209 consecutive patients undergoing cruciate retaining single radius TKA without patella resurfacing for KL≥3 osteoarthritis. The presence and location of full thickness patella cartilage loss was documented intra-operatively at TKA, identifying n=108 cases with PFOA (mean age 70±9.7, mean BMI 31±6.2, 72 (67%) female) Vs n=101 controls without PFOA (age 68±9.2, BMI31±5.6, 52 (51%) female). Primary outcome measure was improvement in the Oxford Knee Score (OKS) at one year. There were more females in the PFOA group (67% Vs 51%, p=0.037), but no other preoperative differences. There was no difference in preoperative OKS between patients with patella cartilage loss (20.6±7.9) and those without (21.0±7.2, p=0.720). There was no difference in OKS improvement following TKA without patella resurfacing between those with full thickness patella cartilage loss (14.2±9.8) and those without (15.4±9.5, p=0.365). Facet involvement (number and location) did not affect OKSs. No differences were found in the individual OKS questions between groups (p>0.05). There was no difference in one-year OKS or improvements therein between patients with and without full thickness patella cartilage loss treated with single radius cruciate retaining TKA without patella resurfacing, questioning its use an indication for selective patella resurfacing

Aims. Currently, periprosthetic fractures are excluded from the American Society for Bone and Mineral Research (ASBMR) definition of atypical femoral fracture (AFFs). This study aims to report on a series of periprosthetic femoral fractures (PFFs) that otherwise meet the criteria for AFFs. Secondary aims were to identify predictors of periprosthetic atypical femoral fractures (PAFFs) and quantify the complications of treatment. Patients and Methods. This was a retrospective case control study of consecutive patients with periprosthetic femoral fractures between 2007 and 2017. Two observers identified 16 PAFF cases (mean age 73.9 years (44 to 88), 14 female patients) and 17 typical periprosthetic fractures in patients on bisphosphonate therapy as controls (mean age 80.7 years (60 to 86, 13 female patients). Univariate and multivariate analysis was performed to identify predictors of PAFF. Management and complications were recorded. Results. Interobserver agreement for the PAFF classification was excellent (kappa = 0.944; p < 0.001). On univariate analysis compared with controls, patients with PAFFs had higher mean body mass indices (28.6 kg/m. 2. (. sd. 8.9) vs 21.5 kg/m. 2. (. sd. 3.3); p = 0.009), longer durations of bisphosphonate therapy (median 5.5 years (IQR 3.2 to 10.6) vs 2.4 years (IQR 1.0 to 6.4); p = 0.04), and were less likely to be on alendronate (50% vs 94%; p = 0.02) with an indication of secondary osteoporosis (19% vs 0%; p = 0.049). Duration of bisphosphonate therapy was an independent predictor of PAFF on multivariate analysis (R. 2. = 0.733; p = 0.05). Following primary fracture management, complication rates were higher in PAFFs (9/16, 56%) than controls (5/17, 29%; p = 0.178) with a relative risk of any complication following PAFF of 1.71 (95% confidence interval (CI) 0.77 to 3.8) and of reoperation 2.56 (95% CI 1.3 to 5.2). Conclusion. AFFs do occur in association with prostheses. Longer duration of bisphosphonate therapy is an independent predictor of PAFF. Complication rates are higher following PAFFs compared with typical PFFs, particularly of reoperation and infection. Cite this article: Bone Joint J 2019;101-B:1285–1291

Aims

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Aims

The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

Implementation of the World Health Organisation checklists have reduced errors, however, the impact of pre-operative briefings on adverse events has not been assessed. A prospective case control study assessing the association between pre-operative briefings and minor, potentially major and major adverse events was performed in two phases. Phase one involved prospective data collection for trauma and orthopaedic lists over 2 weeks. Changes were implemented and following this, the study was repeated (phase two). 41 lists were audited during phase one and 47 lists in phase two. Adequate pre-operative briefings were performed in 10/41 lists (24%) in phase one. There was a significant association between the occurrences of intra-operative adverse events (n=37) when a briefing was not performed (p=<0.01), and when a briefing was performed incompletely (p=0.01). In phase two, after staff re-education and policy change, briefings were found to be adequate in 38/47 lists (81%) with the occurrence of only three minor adverse events. Team familiarity also improved significantly (p=0.02). Inadequate pre-operative briefings are associated with increased minor adverse events and are detrimental to team familiarity. On the basis of our findings we recommend that all surgical units perform pre-operative briefings

Introduction. Low total Mini-Mental State Examination (MMSE) score might significantly increase risk of hip fractures. This study was to investigate the effects of MMSE subdomains on the risk of hip fractures with a sex and age matched case control study. Materials & Methods. A total of 217 patients with first low-trauma hip fractures were matched with 215 hospitalised controls. Seven MMSE subdomains were analysed using conditional logistic regression with adjustment of five important clinical confounders: education level, ADL, physical activities, body mass index and bone mineral density. ROC curve analyses were further used to investigate the predictability of the independent subdomains. Results. In univariate analyses, low score of all MMSE subdomains significantly increased the risk of hip fracture. However, only time orientation and visual construction domain remained significant in multivariate analyses. In the ROC curve analyses, the AUC of these two independent subdomains along with five clinical confounders was significantly larger (p=0.008) than that of clinical confounders alone. The AUC of summed scores of these two subdomains were significantly higher than that of total MMSE score (p=0.009). Conclusions. Time orientation and visual construction subdomains were significant independent risk factors for hip fractures and could be effectively used to screen the patients with high fracture risk in the hospital. Preventive intervention can be given to these patients

Aims

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

Introduction. Although tension band wiring fixation of patellar fracture has been the most widely used technique, the metal implants related complications including implant loosening, postoperative pain are very common and additional surgeries are often necessary. Hypothesis. A totally metal free technique of transosseous suturing method could outperform the traditional fixation technique. Materials & Methods. A total of 25 patients (mean age of 59.60 years) with displaced patellar fracture treated by transosseous suturing technique were compared with a 1:1 matched historical control group who underwent modified tension band wiring fixation of patellar fracture. Union time, union rate, operation time, number of procedures, mean hospitalization days and the complications were compared between cases and controls. Results. Union time (8.43 ±2.92 weeks versus 8.64 ±2.82 weeks) and operation time (69.00 ±19.31 versus 64.89 ±14.27 minutes) were not different between two groups. Mean hospitalization days (4.04 ±1.40 versus 5.76 ±1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower among transosseous suturing group (P< 0.001). Conclusions. Transosseous suturing technique is safe and effective in the transverse or comminuted fractures of patella. The complication rate is significantly lower than that of conventional tension band wiring technique

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure. At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively). We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

We evaluated the cost and consequences of proximal femoral fractures requiring further surgery because of complications. The data were collected prospectively in a standard manner from all patients with a proximal femoral fracture presenting to the trauma unit at the John Radcliffe Hospital over a five-year period. The total cost of treatment for each patient was calculated by separating it into its various components. The risk factors for the complications that arose, the location of their discharge and the mortality rates for these patients were compared to those of a matched control group. There were 2360 proximal femoral fractures in 2257 patients, of which 144 (6.1%) required further surgery. The mean cost of treatment in patients with complications was £18 709 (£2606.30 to £60.827.10), compared with £8610 (£918.54 to £45 601.30) for uncomplicated cases (p < 0.01), with a mean length of stay of 62.8 (44.5 to 79.3) and 32.7 (23.8 to 35.0) days, respectively. The probability of mortality after one month in these cases was significantly higher than in the control group, with a mean survival of 209 days, compared with 496 days for the controls. Patients with complications were statistically less likely to return to their own home (p < 0.01).

Greater awareness and understanding are required to minimise the complications of proximal femoral fractures and consequently their cost.