Introduction

The current study reports on the impact of immediate mobilization of patients treated by tissue-preserving, computer-assisted total hip arthroplasty on length of stay, disposition, and complications.

To systematically review the literature regarding post-surgical treatment regimens on ankle fractures, specifically whether there is a benefit to early weightbearing or early mobilization (6 weeks form surgery). The PubMed, MEDLINE and Embase databases were searched from inception to May 24, 2020. All randomized controlled trials that analyzed the effects of early weightbearing and mobilization following an ankle surgery were included. The primary outcome measure was the Olerud Molander Ankle Score (OMAS). Secondary outcomes included return to work (RTW) and complications. Logistic regression models with random intercepts were used to pool complication data by protocol clustered by study. Twelve RCT's were included, with a total of 1177 patients (41.8 ± 8.4 years). In total, 413 patients underwent early weightbearing and early mobilization (35%), 338 patients underwent early weightbearing and delayed mobilization (29%), 287 patients underwent delayed weightbearing and early mobilization (24%), and 139 patients underwent delayed weightbearing and delayed mobilization (12%). In total, 81 patients had a complication (7%), including 53 wound complications (5%), 11 deep vein thromboses (1%), and 2 failures/nonunions (0%). Early ankle mobilization resulted in statistically significant increases in OMAS scores compared to delayed mobilization (3 studies [222 patients], 12.65; 95% CI, 7.07-18.22; P < 0.00001, I2 = 49%). No significant differences were found between early and delayed weightbearing at a minimum of one-year follow-up (3 studies [377 patients], 1.91; 95% CI, −0.73-4.55, P = 0.16, I2 = 0%). Patients treated with early weightbearing and early mobilization were at higher odds of facing any complication (OR 3.6, 95%CI 1.05-12.1, p=0.041) or wound complications (OR 4.9, 95%CI 1.3-18.8, p=0.022) compared to those with delayed weightbearing and delayed mobilization. Early mobilization following surgical treatment for an ankle fracture resulted in improved ankle function scores compared to delayed mobilization regimens. There were no significant differences between early and delayed weightbearing with respect to patient reported outcomes. Patients who were treated with early mobilization and early weightbearing had an increased odds of postoperative complications

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

Introduction. Pain control following total knee arthroplasty (TKA) heavily influences timing of mobilization and rehabilitation postoperatively as well as length of hospital stay. Recently, periarticular injection of liposomal bupivacaine (EXPAREL®; Pacira Pharmaceuticals, Inc., San Diego, California) has demonstrated pain relief comparable to femoral nerve block for postoperative analgesia in TKA with earlier mobilization and shortened hospital stay. In order to better explore the use of EXPAREL® in TKA, we standardized the postoperative analgesia to intraoperative periarticular injection of multimodal pain management, which is a recommended postoperative method of pain control in TKA. We studied the effectiveness of periarticular EXPAREL® in TKA postoperative pain control, including impact on early mobilization and length of hospital stay, compared to another local analgesic (Ropivacaine) when both are used as part of a multimodal pain management approach. Methods. We performed a double blind, randomized, controlled, prospective, IRB-approved study that enrolled 96 participants who underwent a unilateral TKA by one surgeon between May 2014 and March 2015. The two randomized groups were as follows: group 1 (control group) was given the standard intra-articular “pain cocktail” injection, consisting of ropivacaine, ketorolac, morphine, and epinephrine mixed with saline into a 100cc preparation and group 2 (study group) was given a similar intra-articular injection consisting of bupivacaine, ketorolac, morphine, and epinephrine mixed with saline into an 80cc preparation as well as an injection of EXPAREL®, 20cc of 1.3% EXPAREL®, to total 100cc. All patients included in the study were determined to be opioid naïve as described by the Food and Drug Administration criteria. Patients were treated with the same postoperative pain management protocol as well as the same post-operative physical therapy program. The consumption of oral and intravenous narcotics at specific time points as well as total use was recorded during hospital stay. We recorded Visual Analog Pain scores, hours to ambulate 100 feet and length of hospital stay (hours). Both the investigator and the patient were blinded as to which group the patient was randomized, making this a double blind study. Results. On a per hour basis, the mean use of narcotics of the two groups differed by only 0.1mg. For total narcotic use during hospital stay, the weighted sum used by patients in the EXPAREL® group, 97.7mg of hydrocodone ±42.84 mg, exceeded the weighted sum, 89.6 mg of hydrocodone ± 58.57 mg, used by patients in the control group. The difference between the two groups was not significant. The means for length of stay differed by only 26 minutes and the difference was not significant. Similarly insignificant, the means for the time to ambulate 100 feet differed by 53 minutes, with the EXPAREL® group actually taking the longer time. The two groups did not differ for Visual Analog Score for pain on day 1 or day 2 post-operatively. Conclusion. When comparing the use of EXPAREL® to another multimodal pain management approach using ropivacaine, there is no difference in post-operative opioid consumption, Visual Analong Scores for pain, amount of time to ambulate or length of hospital stay

Introduction. Air travel and total joint arthroplasty are both established risk factors for development of venous thromboembolism (VTE); accordingly patients are typically counseled against flying in the early postoperative period. The basis for this recommendation may be unfounded, as the risk of VTE associated with flying in the early postoperative period has not been investigated. Methods. This is a case-control study of 1465 consecutive unilateral total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed by a single surgeon over an 18-month period. A multimodal regimen was used for VTE prophylaxis, consisting of early mobilization, mechanical prophylaxis, and chemoprophylaxis according to a risk-stratification model; 96% of patients received aspirin as the sole chemoprophylactic agent. The study population consisted of 220 patients (15.0%) who flew at a mean of 2.9 days after surgery. Patients who elected to fly were encouraged to wear anti-embolic stockings, perform frequent ankle-pump exercises, and move around at least every hour. Mean flight duration was 2.7 hours (range, 1.1 to 13.7 hours). This study population was compared to a control population of 1245 patients (85.0%) who did not fly during this time. Baseline characteristics were similar between the groups, with the exception that the group who flew tended to be older (65.5 vs. 59.5 years, p < 0.001) with a lower body-mass index (28.4 vs. 31.1 kg/m. 2. , p < 0.001). Results. Differences in the rates of DVT, PE, or overall VTE were not statistically significant between the groups. Symptomatic deep vein thrombosis (DVT) occurred in 2 patients (0.91%) in the study group compared with 5 patients (0.40%) in the control group. Symptomatic pulmonary embolism (PE) occurred in 1 patient in the study group (0.45%) compared with 10 patients in the study group (0.80%). Mean flight time among the three patients who developed symptomatic VTE was 2.3 hours (range, 1.4 to 3.7 hours). Conclusion. Using a multimodal approach to prophylaxis with an emphasis on early mobilization, the rate of symptomatic VTE was very low among patients who flew during the early postoperative period following THA and TKA, and was not increased over the control population who did not fly. Although there may be some degree of self-selection bias among patients who choose to fly after surgery, allowing them to do so appears to a safe practice

Early mobilization within the first 12 hours (day zero) of total joint arthroplasty (TJA) has been shown to reduce length of stay (LoS) without risking clinical outcomes, patient safety or satisfaction. The purpose of this study was to investigate associations between the degree of mobilization on day zero (i.e., standing at the bedside versus walking in the hallway) and LoS in TJA patients. In addition, we investigated predictors of LoS and day zero mobilization. A retrospective cohort study was undertaken of the health records of patients in a community hospital setting who had an elective unilateral primary TJA between June 2015 and May 2017 and had mobilized on day zero. The total sample was 283 patients (184 TKA and 99 THA) across four mobilization categories: Sat on beside (n = 76), Stood by bed/marched in place (n = 83), Walked in the room (n = 79), and Walked in hall (n = 45). Analysis of variance found no significant group differences in age, ASA score, Charlson Comorbidity Index score, anesthesia, surgeon, procedure type, pain medication, and patient reported symptoms recorded by physiotherapists. Significantly more women were in the Sat group and significantly more men were in the Hall group (p < .001). Patient reported symptoms of nausea and drowsiness were significantly greater for the Sat group (p < .001). LoS was also significantly different across the groups. Post hoc Tukey comparisons found the Walked Hall group had significantly shorter LoS (M = 2.7 days) than the Sat group (M = 3.9, p < .001), Stood group (M = 3.4, p = .011), and the Walked Room group (M = 3.5, p = .004). A hierarchical regression was performed to determine predictors of LoS. Block 1 consisted of demographic, medical status, and patient reported symptoms as variables. Mobilization was entered in Block 2. The first model was significant (p < .001) and explained 24% of variance in LoS. The final model was also significant (p < .001), accounting for a total of 26% of the variance in LoS. Thus, block 2 (i.e., mobilization) accounted for a small but significant 2% incremental variance (p = .008) beyond the block 1 variables in the prediction of LoS. With mobilization added, only male gender (p = .002), lower BMI (p = .026), and lower ASA scores (p = .006) remained significant predictors of shorter LoS, and the predictive ability of several of the block 1 variables were reduced to non-significant levels. A simultaneous regression model was then used to predict degree of mobilization. The model accounted for 24% of the variance in mobilization (p < .001). Variables significantly associated with a greater degree of mobilization included: younger age, male gender, lower BMI, and fewer symptoms, namely nausea, numbness, lightheadedness, and drowsiness. This study found length of stay was shorter when patients mobilized farther on the day of surgery. Some factors predictive of mobilization may be modifiable. Focusing on symptom management could increase opportunities for farther mobilization on the day of surgery, and thus decrease length of stay

INTRODUCTION. The primary goal of THA or TKA is to relieve pain and restore mobility. The success is determined by the longevity of prostheses and early return to routine activities, such as driving. With enhanced recovery regimens, patients are being discharged within 24–48hrs post-op.. The aim of this study was to determine when our patients returned to driving after anterior hip replacements and patient specific knee replacements. METHODOLOGY. This study included 207 soft tissue sparing anterior bikini THA and 146 patient specific instrumented (PSI) TKAs between Feb 2017 and March 2018. All patients included drove before surgery. Non-drivers were excluded. A detailed questionnaire was sent to all patients 3 to 6 weeks after surgery to record their driving status. 50 patients were randomly selected to assess flexion at the hip, knee, and ankle joints whilst seated in the driver's seat of their vehicle. RESULTS. There were 213 females and 124 males (mean age of 69 years) and average BMI of 18.24. There were 207 THAs (99 left, 106 right and 1 bilateral one stage) and 146 TKAs (L=70 & R=76). 76% of patients returned to driving within the first 3 weeks after surgery of which 32 patients (21 THAs (14%) and 11 TKAs (10%)) resumed driving within the first post-op week, 110 patients (69 THAs (39%)and 49 TKAs (35%)) drove in the second week and 73 (38 THAs (23%)and 38 TKAs(28%)) returned to driving in the third week. The rest of the 82 patients reports that they could have driven earlier but chose not to, since they had alternatives that they preferred. The earliest a patient resumed driving post-surgery was on the 2. nd. day(Post THA and TKA). 96.4% stated that they were confident when they first resumed driving. There were 40 patients out of the total 337 that did not return to driving post-surgery. 3 (2 hips and 1 knee) due to medical comorbidities and the rest 37 (14 THAs and 6TKAs) reported they had their children/spouses to drive them but were confident that they could have driven themselves if required. There was statistically no direct correlation between resumption of driving and the side of surgery. There were 282 patients driving automatic cars, 23 driving manual cars and the remaining did not comment. Out of the manual car drivers, 8 were operated on the left side (5 hips and 3 knees), but still all confidently returned to driving within 6 weeks earliest returning within the 1st week. Post measurement of angles of flexion at hip, knee and ankle while accelerating and braking among 50 patients we found that ankle movements significantly affect driving more so than hip and knee. CONCLUSION. We found that after soft tissue sparing anterior bikini THA and PSI TKA, patients were driving as early as within a week with the majority feeling confident and less apprehensive about recommencing driving, potentially due to enhanced recovery measures which were taken, including the minimally invasive surgical technique, local analgesia infiltration and early mobilization post procedure

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation; avoid IR of the femoral and ER of the tibial components; maintain correct joint line position; achieve symmetrical soft tissue balance. Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues. When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall procedure). Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation, avoid IR of the femoral and ER of the tibial components, maintain correct joint line position, achieve symmetrical soft tissue balance. Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues. When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall procedure). Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function

Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management, VTE prophylaxis and early mobilization and early intake. The primary outcome was transfusion requirement, other parameters such as blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay were also compared. Multivariate logistic regression analysis and meta-analysis were also performed to identify the risk factors of transfusion and confirm the results of current study. Results. Transfusion of at least 1U of erythrocyte blood cell occurred in 25 patients (8.65%) in treatment group and in 77 (24.06%, OR=0.299, p<0.001) in control group. The mean level of Hb on POD 1 (111.70±18.40 g/L) and POD 3 (108.16±17.25 g/L) in TXA group were higher than control group (107.29±18.70 g/L, p= 0.008; 104.22±15.16 g/L, p= 0.005 respectively). More patients get off bed to ambulate within 24 hours after surgery in TXA group (37.02% Vs 26.25%, p= 0.004). And the length of hospital stay was shorter (11.82±4.39 Vs 15.96±7.30, p= 0.003). No statistical significance were detected regarding VTE and other adverse events. Logistic regression analysis showed that the relative odds reduction after adjustment for these covariates was 67% (OR= 0.327, 95%CIs= 0.197 to 0.544) in favor of tranexamic acid. Other risk factors included preoperative hemoglobin level, operation time, VTE prophylaxis. Pooling the data showed that tranexamic acid led to a significant reduction in transfusion (OR= 0.33, 95%CIs= 0.25 to 0.43) without sacrificing safety (OR= 0.70, 95%CIs= 0.25 to 1.97). Conclusion. Tranexamic acid was effective and safe to reduce blood loss and transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Treatment of osteoarthritis of the knee remains a challenging problem since the evolution of the disease may be different in each compartment of the knee, as well as the state of the ligaments. Total knee arthroplasty may provide a reliable long-lasting option but do not preserve the bone stock. In another hand, compartmental arthroplasty is a bone and ligament sparing solution to manage limited osteoarthritis of the knee affecting the medial, lateral or the patello-femoral compartment.1, 2, 3. Patient's selection and surgical indication are based on the physical examination and on the radiological analysis including full-length x-rays and stress x-rays. Clinical experience has shown the need for high flexion in patients who have both high flexibility and a desire to perform deep flexion. Additionally the shape differences related to anatomy or the patient expectations after the surgery may also affect the surgeon decision. 4. The limited incision into the extensor mechanism allows a quicker recovery which represents a functional improvement for the patient additionally to the cosmetic result. A dedicated physiotherapy starting on the following day allowing weight bearing exercises protected by crutches and focusing on early mobilization and range of motion combined to a multimodal pain management approach is critical despite the type of individualized solution chosen for the patient knee. 5. Since bony landmarks may be different form a patient to another one as well as anatomical shapes, several tools have been developed in order to provide the surgeons an assisted tool during the surgery adapted to each knee, this include navigation, patient specific instrumentation and robotic surgery

Functional restoration of patella kinematics is an essential component of TKA, whether the patella is replaced or not. This goal is accomplished by a multifactorial approach: establish proper component position and alignment, especially rotation; avoid IR of the femoral and ER of the tibial components; maintain correct joint line position; achieve symmetrical soft tissue balance. Most modern TKA designs have an anatomic trochlear groove shape to enable midline tracking. Patella implants are better designed as well with three equilateral lugs for fixation and either dome or anatomic shape. The apex of the patella component should be aligned with the apex of the patella raphe which is more medial than lateral. This method leaves an island of exposed lateral patella facet which is managed with the “lateral slat technique” to be described. It is essentially an intraosseous lateral release. The early mobilization of modern TKA patients demands watertight closure to prevent soft tissue attenuation and late tracking issues. When confronted with a patient with a laterally dislocated patella, implementation of the “lateral slat technique” should be done at the approach to obtain midline tracking. Such patients require a median parapatellar (MPP) approach and may need distal-lateral vastus medialis advancement (Insall Procedure). Adherence to the principles iterated herein will produce a happy patient with good patello-femoral kinematics and function

Background:. Role of intra-articular Tranexamic acid in total knee replacement arthroplasty. Materials and methods. Prospective evaluation was done to see the effect of intra-articular Tranexamic acid on blood loss in 60 patients (120 knees) undergoing total knee arthroplasty. All the patients were operated by one surgeon with same technique by using same implants. Patients were randomly injected 1500 mg/20 ml of Tranexamic acid on one side of the knee only. Nothing was injected on the contra lateral knee. Evaluation was done for swelling and the amount of blood loss in the drain. Results:. Average blood loss in the drain on Tranexamic side was 140 ml and the opposite side was 390 ml. Swelling was more observed on the non Tranexamic side. Average time for drain removal on Tranexamic side was 36 hours while it was 48 hours on non Tranexamic side. Early mobilization and weight bearing was less painful in Tranexamic side. No patient had systemic complications of Tranexamic acid. Conclusion:. Intra-articular injection of Tranexamic acid reduces blood loss, swelling around the knee without systemic side effects and allows early weight bearing and mobilization of the joint

Acetabular fractures, particularly in the geriatric population are on the rise. A recent study indicated a 2.4-fold increase in the incidence of acetabular fractures, with the fastest rising age group, those older than the age of 55. Controversy exists as to the role and indications for total hip arthroplasty (THA), particularly in the acute setting. Three common scenarios require further evaluation and will be addressed. 1.) What is the role of THA in the acute setting for young patients (< 55 years old)? 2.) What is the role and indications for THA in the older patient population (>55 years) and what are surgical tips to address these complex issues? 3.) What are the outcomes of THA in patients with prior acetabular fractures converted to THA?. Acetabular fractures in young patients are often the result of high energy trauma and are a life changing event. In general, preservation of the native hip joint and avoidance of arthroplasty as the first line treatment should be recommended. A recent long-term outcome study of 810 acetabular fractures treated with Open Reduction and Internal Fixation (ORIF) demonstrated 79% survivorship at 20 years with need for conversion to THA as the endpoint. Risk factors for failure were older age, degree of initial fracture displacement, incongruence of the acetabular roof and femoral head cartilage lesions. In selected younger patients, certain fracture types with concomitant injuries to articular surfaces may best be treated by acute THA. In the elderly patient population, acetabular fractures are more likely the result of low energy trauma but often times result in more displacement, comminution and damage to the articular surface. Osteoporosis and generalised poor bone quality make adequate reduction and fixation a challenge in these acute injuries. As such, the role of acute arthroplasty is becoming more widespread. Consideration should be given to delayed arthroplasty in certain patients to allow time for fracture healing followed by THA. However, early mobilization and weight bearing is important in the elderly population and consideration should be given to acute THA. The challenge remains gaining appropriate acetabular fixation in the fractured, osteoporotic bone. Early results showed high complication rates with acetabular fixation. However, newer fixation surfaces and advances in ORIF techniques have led to improved results. In addition, the need for complex acetabular reconstruction with the use of cages or cup cage constructs may be required in this setting. Appropriate 3-D imaging is essential to evaluate the extent of involvement of the anterior and posterior columns as well as the acetabular walls. Mears et al. reported on 57 patients who underwent THA for acute acetabular fracture and reported results at a mean of 8.1 years. 79% of patient reported good or excellent results and no acetabular cups were revised for loosening. One of the more common scenarios is the patient that presents with a prior ORIF of an acetabular fracture that has developed post-traumatic arthritis or avascular necrosis of the hip and requires conversion to THA. Challenges in this patient population include dealing with prior hardware that may interfere with THA component fixation, severe stiffness of the joint making exposure difficult and prior heterotopic ossification that may put neurovascular structures at risk. Previous studies have demonstrated lower long-term survivorship of the acetabular component (71% at 20 years) compared to primary THA for osteoarthritis. New acetabular fixation surfaces should mitigate the risk of aseptic loosening in this challenging patient population

The purpose of this study was to review the long term functional results of patients undergoing treatment for high energy tibial plateau fractures. Between January 1994 and June 2013 our unit managed 105 high energy tibial plateau fractures (Schatzker IV-VI) with an Ilizarov frame. All cases were treated via ligamentotaxis and percutaneous fine wire fixation or with a limited open reduction of the joint surface. A retrospective analysis of all patients that have undergone Ilizarov fixation of a tibial plateau fracture was performed with radiological and clinical functional outcome measurements. We analysed 105 patients with a mean follow up of 93.5 months (range 5–200). The patient group had an average age of 49 years (range 15–87) with 62 patients being male. Fracture pattern was analysed with Schatzker's classification showing 18 type IV, 10 type V and 77 type VI tibial plateau fractures. All fractures had an average time to union of 145 days. Patients had and average range of movement of 117 degrees. Patients undergoing Ilizarov treatment for high energy tibial plateau fractures achieve successful results long term. Definitive treatment should be decided with respect to fracture pattern and the soft tissue envelope. The management aim should be to achieve anatomical reduction and stable fixation to enable early mobilization. Our study confirms the good functional outcomes and low morbidity that can be achieved in high energy fractures treated with Ilizarov fixation

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years. Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Introduction. Early rehabilitation of hip and knee replacement patients has been advocated with the recent minimally invasive approaches to lower limb replacement allowing earlier mobilization and earlier discharge. Rehabilitation has been progressively shortened from the time of Charnley in such a way that patients are now expected to stay in hospital for only a couple of days before going home. New rehabilitation protocols recommend mobilization on day 0, the day of surgery, with earlier discharge possible. Methods. All primary hip and knee replacement patients were enrolled in a rapid rehabilitation protocol. All patients had standard incisions performed: a posterior approach for THR and a standard Insall para-patellar approach for TKR. The protocol included pre-emptive analgesia, post-op oral analgesia with high dose NSAIDs, pregabolin, neuro-axial anaesthesia, avoidance of opiates and colloid fluid replacement prior to mobilization. Morning patients were mobilized the day of surgery and afternoon patient the following morning. Duration of hospitalisation was compared to patients treated the previous year where the only difference in protocol was femoral blocks for TKR, no colloid replacement prior to mobilization, and routine day 1 mobilization. Results. 125 patients were enrolled (78 TKR and 47 THR). All patients could be mobilized according to this protocol, irrespective of age. The day of discharge was on average 4,2 days post-op. (Range 3 – 6 days). This was compared to the previous year of joint replacements where the average discharge day was 6,3 days (range 4 – 8 days). Conclusion. This protocol has seen an average 2,1 day earlier discharge from hospital with the same end point at discharge. This has shown us that safe day 0 mobilization of patients is possible, with dramatically improved patient morale, which resulted in much earlier discharge from hospital. These results can thus be achieved not only by minimal invasive surgery but also with standard arthroplasty approaches. NO DISCLOSURES