The senior author has treated a series of patients with subtrochanteric and diaphyseal femoral stress fractures associated with long-term alendronate or other bisphosphonate usage. Several patients completely fractured their femurs prior to referral. Most patients had consulted other physicians and were referred for presumed neoplasms. All patients had been diagnosed with osteoporosis and had been treated with bisphosphonates. Their plane radiographs revealed abnormalities that are pathognomonic of bisphosphonate-associated stress fractures. However, due to the subtle nature of these new unfamiliar abnormalities, most were unrecognized as such by clinicians (including experienced ISTA member hip surgeons) and radiologists. This series is presented to illustrate this pattern of impending fracture.

The authors have reviewed and will present a series (n=17) of femoral stress fractures in bisphosphonate-treated patients to illustrate the clinical and radiographic pattern of these stress fractures, and review their treatment.

The most common lesion is a subtrochanteric lateral cortical thickening that in actuality is a horizontal plane “dreaded black line” of a stress fracture with surrounding proximal and distal cortical thickening of the endosteal and periosteal bone. The stress fracture line is obscured unless a near-perfect radiographic projection is obtained. The lesion is best seen with CT scans. MRI scans reveal the stress fracture lines with surrounding edema (Fig 1), which may be misinterpreted as a tumor. Without treatment, a low-impact completed fracture will likely occur.

Many bisphosphonate-associated impending subtrochanteric femoral stress fractures are misdiagnosed as trochanteric bursitis, leading to subsequent displaced subtrochanteric fractures [Fig. 2 - Note subtle impending fracture lesion on right, completed fracture on left]. The clinical and subtle radiographic findings must be recognized by orthopaedic surgeons, particularly hip surgeons, to prevent these complete fractures. These fractures are preventable with internal fixation. Long-term administration of bisphosphonates can have adverse effects, and alternatives to long-term continuous dosing must be investigated to determine optimal administration regimens.

The coronavirus 2019 (COVID-19) global pandemic has had a significant impact on trauma and orthopaedic (T&O) departments worldwide. To manage the peak of the epidemic, orthopaedic staff were redeployed to frontline medical care; these roles included managing minor injury units, forming a “proning” team, and assisting in the intensive care unit (ICU). In addition, outpatient clinics were restructured to facilitate virtual consultations, elective procedures were cancelled, and inpatient hospital admissions minimized to reduce nosocomial COVID-19 infections. Urgent operations for fractures, infection and tumours went ahead but required strict planning to ensure patient safety. Orthopaedic training has also been significantly impacted during this period. This article discusses the impact of COVID-19 on T&O in the UK and highlights key lessons learned that may help to proactively prepare for the next global pandemic. Cite this article: Bone Joint Open 2020;1-7:420–423

Despite the widespread success of total hip arthroplasty (THA), postoperative pain management remains a concern. Opioids have classically been administered for pain relief after THA, but their side effect profile, in addition to the cognizance of the growing opioid epidemic, has incited a shift toward alternative pain modalities. Although the nonsteroidal anti-inflammatory drug (NSAID) diclofenac is a promising addition, its impact on immediate THA outcomes has not previously been investigated. Thus, in the present study, we evaluate the effects of adjunctive diclofenac on: 1) postoperative pain intensity, 2) opioid consumption, 3) discharge destination, 4) length of stay, and 5) patient satisfaction in primary THA patients. A retrospective review was performed to identify all patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients were stratified into a study group (n=25), who were treated with postoperative diclofenac in addition to the standard pain control regimen, and a control group (n=88), who did not receive adjunctive diclofenac. Repeated-measures analysis of variance (ANOVA)/analysis of covariance (ANCOVA) and chi-square/logistic regression analysis were used for continuous and categorical variables, respectively. Patients receiving adjunctive diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02, p=0.049). In addition, patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the diclofenac group. Finally, patients who received diclofenac had lower opioid consumption on postoperative days one and two (−67.2 and −129 mg, respectively, p=0.001 for both). The rapid growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. The present study demonstrates that THA patients receiving adjunctive diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. This will, in turn, decrease complications and total hospital costs, leading to a more cost-effective pain control regimen. In order to further investigate the optimal regimen, future studies comprising larger cohort, as well as a comparison of diclofenac to other NSAIDs, are warranted

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

Osteoarthritis (OA) is one of the most common causes of knee pain in the aging population and presents with higher odds with increased BMI. Total knee arthroplasty (TKA) has become the standard of care for the treatment of OA. Over “719,000 TKA's were performed in 2010 in the USA alone, with dramatic economic burden- costing 16,000 USD per TKA” (CDC 2012). Over the past two decades, this cost was compounded by the unknown increasing rate of primary TKA and cannot be explained by the expanding population or worldwide obesity epidemic. These facts raise two key questions: are patients' quality of life expectations higher and driving the TKA rate up, or have surgeons changed their indications and started to operate on less disabled people? Our study aimed to determine the average functional profile for patients undergoing TKA using patient reported Outcome Measure (SF-36), to document if preoperative SF-36 scores have changed over the past two decades, and lastly to asses if patient pre-operative SF-36 scores are lower in in the USA vs the rest of the world. A literature search of Medline, Embase and Cochrane databases was performed extracting data from publishing year 1966 to 2016 with a search date of Dec 12, 2016. Two independent reviewers revised the abstracts and excluded articles with: no TKA, revision TKA, no pre-op SF-36, no SF-36 reported, incomplete scores to calculate SF-36, duplicates, review article, meta-analysis, letter to the editor, conference proceeding or abstract, disagreements were resolved with a third reviewer. All languages were included to maximize the catchment of data. All remaining articles were independently read and excluded if they did not provide data required for our study. Included articles were analyzed for data including: for year of patient enrollment, location (USA vs. non-USA), pre-operative SF-36 mental (MCS) and physical (PCS) component summary, level of evidence. Recorded data was compared post completion to assess inter-observer accuracy as per PRISMA guidelines for meta-analysis. After applying all the exclusion criteria on 923 selected abstracts, a total of 136 articles of which 30 were randomized control trials, were completely reviewed and included in our study. A total of 56,713 patients' physical component scores were analyzed and revealed an overall pre-operative SF-36 physical component score 31.93. When stratifying the data, it was revealed that patients operated in the USA had an average score of 32.3 whereas Non-US countries were 31.7, with no statistical significance. No statistical difference between SF36 scores was seen over time amongst studies of all nations. Based on the results of this study, we have shown that orthopaedic surgeons are performing TKA universally at the same pre-operative scores, independent of country of origin or year of surgery. The indications thus have remained consistent for two decades regardless of the advances in technology. Functional profiles of patients appear similar among US and Non-US countries. Further, we infer that based on pre-operative SF-36 PCS scores, the optimal time to undergo a TKA is when PCS is 31.9 +/−3

Fracture neck of femur (NOF) in elderly is a serious debilitating injury and has been presenting in increasing proportions. Some of these patients are unfortunate to come back with a contralateral injury. We attempted at looking into the incidence of these episodes in a cohort attending our trust and compared various parameters. We retrospectively assessed our hospital theatre data for fracture NOF in patients over 60 years in the last 3 years. We reviewed their demographics, mode of injury, time to contralateral injury, incidence of any other insufficiency fracture, operative procedure and any complications. There were 1435 patients who underwent surgery for fracture NOF over the 3 years. Forty-three of these had bilateral fractures. Females had 3 times more incidence as compared to males; average age at first injury was 84 years and at contralateral side was 85 years. Time between the two injuries ranged from 20 to 855 days (Median 242 days). Almost equal incidence of intra / extracapsular fractures was noted. Contralateral fracture pattern (Intra vs Extracapsular) for the was similar in 34 patients. Twelve patients had an associated insufficiency fracture. Fracture NOF in elderly is a rising epidemic. Only 3% of these patients suffer a contralateral fracture NOF which usually occurs within a year. The fracture pattern is frequently similar to the first fracture in and hence similar implants have been used. Only 21% patients were on bone protection medications. It is rather difficult to identify this small group and hence prevent a second contralateral incident

Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003. We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone

Background. Opiate abuse is a rapidly growing epidemic in the US, and orthopaedic surgeons are among the highest prescribers. While surgeons have relied heavily on opiates after total hip replacement (THR), our goal was to determine whether a multimodal pain regimen could improve pain control and reduce or even obligate the need for opiates. Methods. In a cluster-randomised, crossover trial, we assigned 235 patients undergoing THR to receive either a multimodal pain regimen with a minimal opiate supply (Group A- 10 tablets only), a conventional multimodal regimen (Group B- 60 tablets), or a traditional opiate regimen without multimodal therapy (Group C- 60 tablets). Clusters were determined by surgeon, with each cluster alternating between regimens in 4-week intervals. The multimodal pain regimen comprised standing-dose acetaminophen, meloxicam, and gabapentin. Primary outcomes were VAS pain and daily opiate use for the first 30 days postoperatively. Secondary outcomes included daily assessments of satisfaction, sleep quality, and opiate-related symptoms, hip function at 1-month, and 90-day adverse events. Results. Daily pain was significantly lower in both multimodal groups, Group A (Coeff −0.81, p=0.003) and Group B (Coeff −0.61, p=0.021). While daily opiate utilization and duration of use was also lower for both Group A (Coeff −0.77, p=0.001) and Group B (Coeff −0.30, p=0.04) compared with Group C, Group A also had significantly lower daily opiate use than Group B (Coeff −0.46, p=0.002), and few prescription refills were required in any group. Opiate-related symptoms, in particular fatigue, were significantly lower in Group A compared to Group C (p=0.005), but Group B and C did not differ (p=0.13). Additionally, both multimodal regimens improved satisfaction and sleep, and there was no difference in hip function or adverse events. Conclusions. While a multimodal pain regimen after THR improved pain control and decreased opiate utilization, patients also receiving a minimal opiate supply had a much greater reduction in opiate use and, consequently, fewer opiate-related adverse effects. It's time to rethink traditional approaches to pain management after elective surgery

The US obesity epidemic has transcended into the arthroplasty patient population and surgeons must assess whether obesity is a risk factor for poor outcomes in total joint arthroplasty (TJA) and determine how it should be managed in order to insure good clinical outcomes. In the United States, 34.9% of adults are currently obese (BMI > 30). In a recent study, 54.5% of patients reporting to arthroplasty clinics in the US were obese. We performed a recent literature review to determine how obesity impacts outcomes in total hip and knee arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient. We know that obesity and its associated comorbid conditions do have worse outcomes and increased complications in TJA patients. We also know that complications proportionately increase with increasing severity of obesity. The super-obese population is at the greatest risk of complication following TJA and pre-operative screening and management is essential in reducing complications. Although weight loss is important, our bariatric data has shown that it does not solve the problem of obesity in itself and the patient's metabolic state is likely a more important issue. Implant selection is important and strong consideration should be given to avoiding direct anterior approach in the THA obese patient. Understanding of obesity specific complications and treatment options is crucial for patient counseling and optimisation to ensure successful treatment in obese TJA patients

As the American population ages and a trend toward performing total hip arthroplasty (THA) in younger patients continues, the number of Americans undergoing THA is projected to increase over time. The advent of the bundled payment system combined with the current medical utilization climate has placed considerable pressure on surgeons to produce excellent results with early functional recovery and short hospital stays. The US obesity epidemic has transcended into the arthroplasty patient population and surgeons must assess whether obesity is a risk factor for poor outcomes in THA and determine how it should be managed. We performed a recent literature review to determine how obesity impacts outcomes in total hip arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient. Our goal is to answer 3 questions: does obesity increase the complication rate in THA, if obesity matters how obese is too obese, and what must be done to improve outcomes in the obese patient?. Ultimately, obesity has been shown to correlate with increased post-operative complications in THA. The arthroplasty surgeon must optimise the obese patient prior to surgery by identifying associated comorbidities and consider malnutrition screening with counseling. Notice should be taken of the degree of obesity as patients with BMI > 40 have demonstrated much higher complication rates. Strong consideration should be given to avoiding direct anterior approach in the obese patient. Healthy weight loss must be encouraged with appropriate patient counseling and treatment in order to achieve success with THA in obese patients.  

In 1983 we underscored the importance of understanding the cause or mechanism of failure following total knee arthroplasty. In this article we reported that revision total knee replacement was generally unsuccessful unless the surgeon new the mechanism of failure. In the ensuing years we have collectively made improvements in instrumentation, component design and material properties such that the mechanisms of failure are now different and less common than in the earlier years. Early failure following total knee arthroplasty is generally related to technical issues. There are a myriad of such issues but many of them relate to component positioning and soft tissue balance. Post-operative wound complications are concerning as they cause an increased incidence of deep infection. Hematoma from over anticoagulation is a particular problem that leads to stiffness and increased risk for infection. Most knee systems now have multiple sizing options and instrument systems that can improve reproducibility of component implantation. Midterm failure is often due to flexion instability which has been reported in cruciate substitution and cruciate retention knees. The instability can be global, mid flexion, flexion or a combination of all 3. Issues with extension and mid flexion instability but no flexion instability are generally those with tight extensor mechanisms. Pain and stiffness are frequently due to component malalignment. One common problem is abnormal internal rotation of the tibial component. Late failure in our institution is generally seen due to wear and loosening from earlier designs with inferior polyethylene. Late hematogenous infection occurs in people with immunocompromise, severe diabetes and diagnoses that alter the patient's ability to mount an immune response. The newest epidemic in total knee failure has been that of periprosthetic fracture. As these patients are becoming older and with worse proprioception, they are at greater risk. Generalised osteopenia and increased activity also increase the risk of fracture. Total knee arthroplasty represents a remarkable improvement in the care of the patient with knee arthritis. It is only by focusing upon and decreasing the causes of failure that we will advance use of this procedure in patient care

The United States is in the midst of an opioid epidemic, with the World Health Organization reporting that American's consume 99% of the world's supply of hydrocodone and 83% of the world's oxycodone. Additionally, pre-operative opioid use has been associated with worse clinical outcomes and higher rates of complications following TKA. This is especially important in the TKA population given that approximately 15% of patients are either dissatisfied or very dissatisfied at least one year after their TKA procedure. Given the concerning rise is opioid use the American Academy of Orthopaedic Surgeons (AAOS) has recently released an information statement with practice recommendations for combating this excessive and inappropriate opiate use. However, little is known regarding peri-operative opioid use for TKA patients. Therefore, the purpose of this study was to: 1) identify rates of opioid use prior to primary TKA, 2) evaluate post-operative trends in opioid use throughout the year following TKA and 3) identify risk factors for prolonged opioid use following TKA. Overall, 31% of TKA patients are prescribed opioids within 3-months prior to TKA; this percentage has increased over 9% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following TKA, however, other intrinsic patient characteristics were also predictive of prolonged opioid use. These characteristics remained predictive after controlling for opioid user status. The increasing rates of opioid prescribing prior to TKA are concerning, especially given literature concluding opioids have minimal effect on pain or function in patients with osteoarthritis and pre-operative opioid use is associated with poor outcomes and more complications following TKA. This data provides an important baseline for opioid use trends following TKA that can be used for future comparison and identifies risk factors for prolonged use that will be helpful to prescribers as the AAOS works to decreased opioid use, misuse and abuse within the United States. Our data on THA and unicompartmental arthroplasty is similar with an increase in pre-THA use of 9% with 38% receiving narcotics within 3 months of surgery and continued use in opioid users (9 times non-opioid users at 12 months)

Aim. North America is facing a rising epidemic involving strains of methicillin-resistant Staphylococcus aureus (MRSA) that, instead of being found almost exclusively in hospitals, are community-associated (CA-MRSA). These strains are aggressive, associated with musculoskeletal manifestations including osteomyelitis (OM), and septic arthritis (SA). We aimed to establish novel management algorithms for acute OM and SA in children. We investigated S.aureus susceptibilities to current first-line antimicrobials to determine their local efficacy. Method. The project was conducted at Nemours General Children Hospital in Florida, USA, following approval by the internal review board. A literature review was conducted. An audit of S.aureus antimicrobial sensitivities was completed over three years and compared against national standards. Susceptibilities of clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX) and vancomycin were studied using local resistance ranges. Results. Two algorithms for acute OM and SA management were created adopting a multidisciplinary team approach from admission to discharge whilst differentiating higher risk patients within fast-track pathways. We analysed 532 microbiology results for antibiotic susceptibilities from 2012 to 2014. Overall, 51% of S.aureus infections were MRSA versus 49% methicillin-susceptible S.aureus (MSSA). Surprisingly, clindamycin resistance rates rose compared to 2005 (MRSA 7% in 2005 vs 39% currently, MSSA 20% vs 31% and total S.aureus resistance rate of 8% vs 35%, respectively). MRSA and MSSA isolates were near 100% sensitive to Vancomycin and TMP/SMX. No appropriate national standards existed. Conclusions. Multidisciplinary based algorithms were created for acute OM and SA treatment in children. Possible therapeutic roles for ultrasound guided aspiration and corticosteroids were highlighted in SA. Our audit revealed equal incidence of MSSA to MRSA, supporting national figures on falling MRSA. Interestingly, increased resistance of MSSA and MRSA was found towards recommended first line clindamycin, raising concern over its efficacy

The United States is in the midst of an opioid epidemic, with the World Health Organization reporting that American's consume 99% of the world's supply of hydrocodone and 83% of the world's oxycodone. Additionally, pre-operative opioid use has been associated with worse clinical outcomes and higher rates of complications following total knee arthroplasty (TKA). This is especially important in the TKA population given that approximately 15% of patients are either dissatisfied or very dissatisfied at least one year after their TKA procedure. Given the concerning rise in opioid use the American Academy of Orthopaedic Surgeons (AAOS) has recently released an information statement with practice recommendations for combating this excessive and inappropriate opiate use. However, little is known regarding peri-operative opioid use for TKA patients. Therefore, the purpose of this study was to: 1) identify rates of opioid use prior to primary TKA, 2) evaluate post-operative trends in opioid use throughout the year following TKA and 3) identify risk factors for prolonged opioid use following TKA. Overall, 31% of TKA patients are prescribed opioids within 3-months prior to TKA; this percentage has increased over 9% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following TKA, however, other intrinsic patient characteristics were also predictive of prolonged opioid use. These characteristics remained predictive after controlling for opioid user status. The increasing rates of opioid prescribing prior to TKA are concerning, especially given literature concluding opioids have minimal effect on pain or function in patients with osteoarthritis and pre-operative opioid use is associated with poor outcomes and more complications following TKA. This data provides an important baseline for opioid use trends following TKA that can be used for future comparison and identifies risk factors for prolonged use that will be helpful to prescribers as the AAOS works to decreased opioid use, misuse and abuse within the United States

Obesity is clearly a worldwide epidemic with significant social, health care and economic implications. A clear association between obesity and the need for both hip and knee replacement surgery has been demonstrated. Specifically the presence of class 3 obesity (BMI > 40) increases the incidence of THA by 8.5 times and the incidence of TKA by 32.7 times, compared with patients of normal weight. Issues related to TJA in the morbidly obese include:. Outcomes - There is a growing body of evidence to support the premise that patients undergoing either THA or TKA who are morbidly obese derive significant benefit from the surgical intervention. Specifically patient and disease specific outcome measures (WOMAC, SF-12, KSCRS, HSS) demonstrate equal change between pre-operative and post-operative scores in those patients of normal weight compared to the morbidly obese cohort. Complications - It would appear that the rate of deep infection is increased in the morbidly obese, and that the greater the BMI, the greater the risk of infection. This is important to understand and appreciate pre-operatively as the surgeon discusses the risk/benefit ratio of the operative intervention. There is little debate that performing total joint arthroplasty in the morbidly obese is technically challenging and that the potential for increased peri-operative morbidity, particularly in the form of infection is present. That being said, the realised benefit to the patient of the surgical intervention is significant, and denying surgery on the basis of obesity alone is not justified

Obesity is clearly a worldwide epidemic with significant social, healthcare and economic implications. A clear association between obesity and the need for both hip and knee replacement surgery has been demonstrated. Specifically the presence of class 3 obesity (BMI > 40) increases the incidence of THA by 8.5 times, and the incidence of TKA by 32.7 times, compared with patients of normal weight. Issues related to TJA in the morbidly obese include: Outcomes - There is a growing body of evidence to support the premise that patients undergoing either THA or TKA who are morbidly obese derive significant benefit from the surgical intervention. Specifically patient and disease specific outcome measures (WOMAC, SF-12, KSCRS, HSS) demonstrate equal change between preoperative and postoperative scores in those patients of normal weight compared to the morbidly obese cohort; Complications - It would appear that the rate of deep infection is increased in the morbidly obese, and that the greater the BMI, the greater the risk of infection. This is important to understand and appreciate preoperatively as the surgeon discusses the risk/benefit ratio of the operative intervention. There is little debate that performing total joint arthroplasty in the morbidly obese is technically challenging and that the potential for increased perioperative morbidity, particularly in the form of infection is present. That being said, the realised benefit to the patient of the surgical intervention is significant, and denying surgery on the basis of obesity alone is not justified

In the USA, 34.9% of adults are currently obese (BMI > 30). Growth in total knee arthroplasty (TKA) is outpacing growth in total hip arthroplasty (THA) largely due to a differential utilization of TKA in overweight patients in the USA. In a recent study, 54.5% of patients reporting to arthroplasty clinics in the USA were obese. From 2006–2010, 61.2% of primary unilateral TKA patients in the USA ACS-NSQIP database were obese. Arthroplasty surgeons are directly affected by the obesity epidemic and need to understand how to safely offer a range of peri-operative care for these patients in order to insure good clinical outcomes. Pre-operative care for the obese patient involves nutritional counseling, weight loss methods, consideration for bariatric surgery, physical therapy, metabolic workup, and diagnosis and management of frequent comorbid conditions (OSA, DM2, HTN, HLD). Obese patients must also be counseled on their increased risk of complications following TKA. In the operating room, several steps can be taken to insure success when performing TKA on obese patients. We recommend performing TKA without the use of a tourniquet in order to prevent fat necrosis and increased pain. The incision is made in 90 degrees of knee flexion, atypically midline proximally and curved distally to the midpoint between the tubercle and the medial edge of the tibia. Care is used to minimise the creation of dead space, and the approach to the knee is an extensile medial parapatellar incision. Closure is in multiple layers. The use of negative pressure dressing following surgery can minimise the early wound drainage that is frequently seen after TKA in obese patients. Post-operative care of the obese patient following TKA involves several unique considerations. Chronic pain and obesity are frequent comorbid conditions and post-operative pain control regimens need to be tailored. Although the physical therapy regimen does not differ in obese patients, obese patients are more likely to be discharged to a rehabilitation facility. Obese patients have a higher rate of all complications compared to healthy weight. All infection and deep infection increased in obese patients in large meta-analysis. Patients with BMI > 35 are 6.7 times more likely to develop infection after TKA. Patients with BMI > 40 have a 3.35 times higher rate of revision for deep infection than those with BMI < 35. The odds ratio for major complications increases dramatically beyond BMI > 45. Although there are a few studies that have demonstrated worse clinical outcome in obese patients following TKA, most studies show no difference in clinical outcomes at short- or long-term follow-up. The arthroplasty surgeon must optimise the obese patient prior to surgery, use intra-operative techniques to maximise success, and anticipate potential problems in the post-operative course in order to achieve success with TKA in obese patients

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

Aims

Tuberculosis (TB) is one of the biggest communicable causes of mortality worldwide. While incidence in the UK has continued to fall since 2011, Bradford retains one of the highest TB rates in the UK. This study aims to examine the local disease burden of musculoskeletal (MSK) TB, by analyzing common presenting factors within the famously diverse population of Bradford.

Periprosthetic fractures in total hip arthroplasty lead to considerable morbidity in terms of loss of component fixation, loss of bone and subsequent functional deficits. We face an epidemic of periprosthetic fractures as the number of cementless implants inserted continues to rise and as the number of revisions continues to increase. The management of periprosthetic fractures requires careful preoperative imaging, planning and templating, the availability of the necessary expertise and equipment, and knowledge of the potential pitfalls so that these can be avoided both intra-operatively and in follow-up. There is a danger that these cases fall between the expertise of the trauma surgeon and that of the revision arthroplasty surgeon. The past decade has afforded us clear treatment algorithms based on fracture location, component fixation and the available bone stock. We still nevertheless face the enduring challenge of an elderly population with a high level of comorbidity who struggle to rehabilitate after such injuries. Perioperative optimisation is critical as we have seen prolonged hospital stays, high rates of systemic complications and a significant short term mortality in this cohort. We have also been presented with new difficult fracture patterns around anatomic cementless stems and in relation to tapered cemented and cementless stems. In many cases, fixation techniques are biomechanically and biologically doomed to fail and intramedullary stability, achieved through complex revision is required. The treatment of unstable peri-prosthetic femur fractures can be technically challenging due to the weak non-supportive bone stock. We have seen an increase in the frequency of Type B3 fractures that require complex reconstruction with modular tapers, interlocking implants and proximal femoral replacements. Our reconstructive practice has evolved; the aims of femoral reconstruction include rotational and axial stability of the stem, near normal hip biomechanics and preserving as much femoral bone as possible. The advent of modular prostheses that gain distal fixation but have proximal options has extended the scope of this type of fixation. We now favor modular tapered stems that afford us the opportunity to reconstruct such femora whilst attempting to preserve the proximal bone. In effect, distal cone or taper fixation provides the initial stability required for the procedure to be successful but the proximal modular implant subsequently load shares to decrease stress shielding, distribute stress more evenly through the femur and minimise the risk of stem fracture. Such systems provide the intraoperative versatility that these cases require. The use of interlocking stems with coated ingrowth surfaces offers a relatively appealing solution for some complex fractures and avoids the complications that would be associated with unstable fixation or resection of the proximal femur. Periprosthetic acetabular fractures are also increasingly recognised. This is in part due to the popularity of press fit components, which increase fracture risk both at the time of insertion and later due to medial wall stress shielding and pelvic osteolysis, and partly due to the increasing frequency of severe defects encountered at the time of revision surgery. These can present a very difficult reconstructive challenge and may require porous metal, cup-cage or custom reconstruction. Periprosthetic fractures continue to cause problems worldwide. The sequelae of periprosthetic fractures include the financial cost of fixation or revision surgery, the associated morbidity and mortality in an elderly frail population, the difficulty with mobilisation if the patient cannot fully weight bear and a poor functional outcome in a proportion of cases. The battle over which patients or fractures require fixation and which require revision surgery continues