Anterior cruciate ligament (ACL)-retaining total knee arthroplasty (TKA) has been associated with more physiologic motion patterns, more normal knee kinematics, and higher patient preference than ACL-sacrificing implant designs. However, it remains unclear how many osteoarthritic patients can be expected to have an intact ACL at the time of surgery in order to undergo ACL-retaining TKA. A systematic literature review was performed in November 2018 using the PubMed and EMBASE databases. Papers written in English, with more than 10 adult patients relevant to the research question were included, whereas cadaveric, revision, animal and simulation studies and conference abstracts were excluded. Data on ACL retention during intraoperative assessment or MRI scans were extracted and analysed using proportional meta-analyses. Twenty-six eligible publications (4167 knees) were included: 20 using intraoperative assessment, 4 using MRI, and 2 using both. Intraoperative assessment of the ACL during TKA showed that the ligament was present in 78% (95% confidence interval [CI]: 72–84%) and intact in 55% (95% CI: 45–65%) of the patients examined. MRI scans revealed higher percentages of ACL presence and intactness than intraoperative assessment, with 91% (95% CI: 79–96%) of the ACL being present and 68% (95% CI: 28–92%) intact. Fewer studies reported on MRI results compared to studies reporting on the intraoperative status of the ACL. In conclusion, intraoperative assessment suggests that over half of the osteoarthritic patients have an intact ACL at the time of TKA surgery, some of whom may qualify for bicruciate-retaining arthroplasty. For any figures or tables, please contact authors directly

Purpose. To update recent findings about the relationship between obesity and post-operative outcome including acetabular cup positioning, complications, readmissions and revision rates, and also inpatient rehabilitation outcome following total hip arthroplasty. Methods. A literature review was done using standard keyword search. Articles were scrutinized by the investigators to ensure relevancy to the purpose of this review. Summary of the review. As the number of all obese(body mass index(BMI) >30) are rising, the development of hip osteoarthritis and the need for total hip arthroplasty(THA) increased. Recent studies found that high BMI was the most significant risk factor contributed to acetabular cup malpositioning following THA. Obesity was found to be a predicting factor for 30-day readmission due to complications include wound infections and thromboembolism after THA. A meta-analysis had shown increased rates of aseptic loosening, dislocation and infection in obese patients thus resulted in higher revision rates compared to nonobese patients but the increase was not found to be statistically significant. Obese patients can make functional improvements during inpatient rehabilitation but at slow progress and higher cost. Conclusion. Based on the current literature, obesity may have a negative impact on the outcome of THA. It appeared that as BMI increases, obesity was related with the risk of postoperative complications, and affected outcomes after total hip arthroplasty. Therefore, this needs to be informed to every patient prior to considering total hip arthroplasty

Aim. The aim of this systematic review was to determine all cultured bacteria, antibiotic strategies, and their outcome from literature describing treatment of FRI patients between 1990 and 2018. Methods. A systematic literature search was performed on treatment and outcome of FRI. All studies in English that described surgical patient series for treatment of FRI were included, using Medline, Embase, Web of Science, Cochrane, and Google Scholar. Publications before 1990 and studies that did not describe FRI patient treatment or did not report original data (e.g., reviews or meta-analyses) were excluded. Study selection and data collection were done by two authors independently. Main collected parameters were preoperative cultures, use of local antibiotics, postoperative antibiotic protocol, cultured microorganisms, and overall outcome of treatment, i.e., eradication of infection and bony union, recurrence, amputations, revisional surgery, and number of complications. Dichotomous data were pooled using Medcalc, and weighted means were calculated for continuous data using Excel. Results. 2,171 studies were identified. Of these, 110 studies were included, describing 119 patient series, in which 4561 patients (4614 fractures) were treated. The population was predominantly male (76%), and the main location of FRI was the tibia (69%). In 78 (71%) studies, 3,234 microorganisms were cultured, of which Methicillin-sensitive Staphylococcus aureus (MSSA) was found in 1,094 (34%) patients, followed by Coagulase-negative Staphylococci (CNS), 431 (13%), Methicillin-resistant Staphylococcus aureus (MRSA), 283 (9%), and Pseudomonas aeruginosa 276 (9%). Polymicrobial infections were present in 11% of patients. Local antibiotics were used in 63 (53%) patient series, with PMMA being the most frequent carrier (73%). Calcium-based cements were used in nine series (14%). Clear postoperative antibiotic protocols were described in only 39 (35%) studies and differed widely. Bony union and infection eradication were achieved in 92% (CI 90–94) of all patients. Recurrence was seen in 9% (CI 8–11), and amputation was required in 3% (CI 3–4) of patients. The effect of local antibiotics on overall outcome of FRI treatment was unclear. Conclusions. This systematic literature review clearly shows that standardized antibiotic treatment protocols for FRI patients are lacking and that internationally accepted guidelines are required. The data also confirm that S. aureus is the most common microorganism encountered in FRI. Due to the large heterogeneity of used local antibiotics and carriers, a reliable comparison was not feasible. Indications for the use of local antibiotics are unclear, and future prospective studies seem necessary

Purpose. To update current surgical management of knee osteoarthritis. Methods. A literature review was done using standard keyword search. Articles were scrutinized by the investigators to ensure relevancy to the purpose of this review. Summary of the review. Arthroscopy, osteotomy and arthroplasty are three major techniques for knee osteoarthritis. Arthroscopy is more and more common as it is diagnostically and therapeutically useful, especially for patients with painful osteoarthritis with mechanical symptoms. Recently, arthroscopic techniques to treat subchondral bone marrow lesions associated with knee osteoarthritis have been developed. Osteotomy is a technique that preserves the natural biomechanics of the joint and reestablishes joint alignment. Its accuracy has been improved with the advancement of computer-assisted surgery. Arthroplasty includes Unicompartmental knee arthroplasty (UKA) and Total knee arthroplasty (TKA). In UKA, patient selection is a key factor for good outcomes, which can be enhanced with newer implant designs and robotic technology. TKA is the mainstay technique for end-stage osteoarthritis. Minimally invasive TKA was developed to overcome major limitations of conventional technique. Considerable number of new technologies have been introduced for patients requiring TKA, such as gender-specific knee implants, computer-assisted navigation, robotic-assisted surgery and patient-specific cutting guides. Conclusion. As advances in surgical techniques and tools continue and numerous options are available, appropriate patient selection and understanding indications to each options are critical to success

Aims

Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence.

Abstract

Introduction

The rate of technological innovation in procedural total knee arthroplasty has left little time for critical evaluation of a new technology before the adoption of even newer modalities. With more drastic financial restrictions being placed on operating room spending, orthopaedic surgeons are now required to provide excellent results on a budget.

It is integral that both clinical efficacy and cost-effectiveness of these intraoperative technologies be fully understood in order to provide patients with effectual, economically conscious care. The purpose of this qualitative analysis of literature was to evaluate clinical and economic efficacy of the three most prominent technologies currently used in TKA: computer navigation, patient-specific instrumentation, and kinetic sensors.

Purpose:

Despite advances in limb reconstruction, there are still a number of young patients who require trans-tibial amputation. Amputation osteoplasty is a technique described by Ertl to enhance rehabilitation after trans-tibial amputation. The purpose of the present study was to evaluate the results of the original Ertl procedure in skeletally immature patients, and to assess whether use of this procedure would result in a diminished incidence of bony overgrowth.

Osteoid osteoma is a benign bone-forming lesion, characterized by its small size, its clearly demarcated outline and by the usual presence of a surrounding zone of reactive bone formation. It often poses a diagnostic challenge due to its ambiguous presentation. The aetiology of osteoid osteoma is poorly understood. The previous suggestion that osteoid osteoma was not associated with trauma or infection has been challenged by more recent literature raising the possibility that it could be a reactive or healing response or a phenomenon associated with the revascularisation process. This case report describes an unusual presentation of a post-traumatic osteoid osteoma. Two years following a diaphyseal, spiral tibial fracture treated nonoperatively, the patient developed new pain at the previous fracture site. The pain was constant, relieved by non-steroidal analgesia and not associated with systemic upset. It was initially attributed to other more likely diagnoses such as osteomyelitis and neuropathic pain. Multiple investigations and interventions were undertaken prior to the definitive diagnosis being obtained by surgical excision of the lesion and histological studies five years after the injury and three years following the initiation of the discomfort. In both English and foreign language literature there are only seven case reports that document osteoid osteoma following fracture, these are predominantly in the lower limb with no predominance to operative or nonoperative management. This case report should raise the index of clinical suspicion of osteoid osteoma occurring post fracture.

Introduction. Patient-reported outcome measures (PROMs) has gained momentum in the orthopaedic literature. The GOAL-LD (Gait Outcomes Assessment List for Limb Deformity) incorporates the framework of The WHO International Classification of Functioning, Disability and Health and correlates highly with the Paediatric Outcomes Data Collection Instrument (PODCI) when applied in a limb reconstruction setting. The Royal Children's Hospital Melbourne, Australia, supported by The University of Melbourne is designing and implementing a Limb Reconstruction Registry, prospectively enrolling patients with a number of key conditions and provide a mechanism for capturing surgical data and PROMs at regular follow-up intervals. LimbDREAM (The Limb Reconstruction Registry of Experience, Aspiration and Measures) has begun recruiting participants, and this paper serves as a narrative review of our design and implementation process. Materials & Methods. After provision of a research grant, audit was conducted to examine local case mix and estimate recruitment based on conditions selected. Literature review was focussed on (i) registries in the paediatric limb reconstruction domain and (ii) use of PROMs across conditions selected. A high-level process-flow chart was constructed in order to inform governance and staffing requirements in addition to REDCap Database structure. Local as well as scalable deployment was considered. Alpha and beta testing was performed by principal and associate investigators prior to participant recruitment. Results. Audit identified 6 condition streams for inclusion: Congenital limb deficiencies, congenital pseudarthrosis of the tibia, bone dysplasias, bone tumours, amputation, and complex deformity of other etiology. Literature review identified 20 PROMs used across these conditions, with limited validation studies and significant implementation heterogeneity. REDCap database design took longer than anticipated (planned 10 months, actual 18 months) before being recruitment ready, due to the complexity of ensuring data collection logic would work across highly diverse patient journeys. Initial recruitment across all streams has been promising. Email and text message reminders have proved helpful in increasing survey return rates. Conclusions. Prospective collection of PROMs as well as surgical data via a standardized dataset will provide the basis for future condition-specific research, with the ability to support nested trials. Implementation requires forethought with regard to time frames and staffing for non-automated steps as well as data integrity review. The next phase of the LimbDREAM project will be to integrate use of the Registry into our weekly Limb Reconstruction Meeting to ensure that operative plans and data are captured close to the point of care

There is growing interest in the peri-operative management of patients with indications for hip and knee arthroplasty in the setting of modifiable risk factors such as morbid obesity, type 2 diabetes mellitus, and smoking. A recent survey of the American Association of Hip and Knee Surgeons (AAHKS) found that 95% of respondents address modifiable risk factors prior to surgery. The aim of this study was to poll Australian arthroplasty surgeons regarding their approach to patients with modifiable risk factors. The survey tool used in the AAHKS study was adapted for use in the Australian context and distributed to the membership of the Arthroplasty Society of Australia via Survey Monkey. Seventy-seven survey responses were received, representing a response rate of 64%. The majority of respondents were experienced, high volume arthroplasty surgeons. Overall, 91% of respondents restricted access to arthroplasty for patients with modifiable risk factors. Seventy-two percent of surgeons restricted access for excessive body mass index, 85% for poor diabetic control, and 46% for smoking. Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Despite differences in healthcare systems, our findings were similar to those of the AAHKS survey, although their responses were more restrictive in all domains. Differences were noted in responses concerning financial considerations for potentially underprivileged populations. The survey is currently being administered by arthroplasty societies in six other countries, allowing comparison of orthopaedic practice across different healthcare systems around the world. In conclusion, over 90% of Australian arthroplasty surgeons who responded to the survey address modifiable risk factors prior to surgery

Systematic reviews (SR) can provide physicians with effective means to further strengthen their practice and identify gaps in clinical knowledge. The focus of any SR is to identify the current state of evidence for a given treatment or condition, with the hopes of providing the best interventional methods physicians can base their practice on. In paediatric orthopaedics, high-level studies are lacking, thus potentially limiting the effectiveness of SRs in the field. There isn't one specific way to qualify research on its effectiveness, but there has been gradual enhancement in finding ways to identify a successful and reproducible study. The purpose of this study was to evaluate the quality of paediatric orthopaedic SRs, and highlight aspects of these SRs that have contributed to improved outcomes. A literature review was performed in EMBASE, MEDLINE and Cochrane databases to identify pre-existing systematic reviews that have been published in five well-known orthopaedic journals between 2007 and 2017. SRs were included if the study population was between 0 and 18 years of age. Selected articles had an AMSTAR checklist applied in order to score the studies on their quality and methodology. Articles were independently reviewed by two reviewers to determine the extent of AMSTAR guidelines fulfillment. A total of 40 SRs were identified and reviewed, 20 of which partially or completely fulfilled AMSTAR guidelines. There was no disagreement between reviewers as to which of the analyzed articles have successfully reflected the checklist. Only 20/40 SRs analyzed at least partially fulfilled AMSTAR guidelines. One of the weaknesses identified in the reviewed papers so far is the lack of justification for the chosen study designs for SRs and what strategy was used to decide on the exclusion of articles. There needs to be clear-cut criteria that mark studies to be included and excluded in a comprehensive systematic review. Further improvements are required to ensure that full details on the involvement of papers and the success rates regarding each interventional method are included in order to strengthen the quality of SRs across the paediatric orthopaedic literature

Aim. The coronavirus disease 2019 (COVID-19) pandemic presents significant challenges to healthcare systems globally. Orthopaedic surgeons are at risk of contracting COVID-19 due to their close contact with patients in both outpatient and theatre environments. The aim of this review was to perform a literature review, including articles of other coronaviruses, to formulate guidelines for orthopaedic healthcare staff. Methods. A search of Medline, EMBASE, the Cochrane Library, World Health Organization (WHO), and Centers for Disease Control and Prevention (CDC) databases was performed encompassing a variety of terms including ‘coronavirus’, ‘covid-19’, ‘orthopaedic’, ‘personal protective environment’ and ‘PPE’. Online database searches identified 354 articles. Articles were included if they studied any of the other coronaviruses or if the basic science could potentially applied to COVID-19 (i.e. use of an inactivated virus with a similar diameter to COVID-19). Two reviewers independently identified and screened articles based on the titles and abstracts. 274 were subsequently excluded, with 80 full-text articles retrieved and assessed for eligibility. Of these, 66 were excluded as they compared personal protection equipment to no personal protection equipment or referred to prevention measures in the context of bacterial infections. Results. There is a paucity of high quality evidence surrounding COVID-19. This review collates evidence from previous coronavirus outbreaks to put forward recommendations for orthopaedic surgeons during the COVID-19 pandemic. The key findings have been summarized and interpreted for application to the orthopaedic operative setting. Conclusion. For COVID-19 positive patients, minimum suggested PPE includes N95 respirator, goggles, face shield, gown, double gloves, and surgical balaclava. Space suits not advised. Be trained in the correct technique of donning and doffing PPE. Use negative pressure theatres if available. Minimize aerosolization and its effects (smoke evacuation and no pulse lavage). Minimize further unnecessary patient-staff contact (dissolvable sutures, clear dressings, split casts)

Surgical site infections (SSIs) are associated with significant consequences in orthopaedic surgery, where their presence can lead to ultimate revision of the implant. Furthermore, infections and impaired wound healing can prolong length of hospital stay following orthopaedic surgery, which can place additional financial burdens on healthcare systems. The current analysis was conducted to determine whether the use of the PICO single-use negative pressure wound therapy (sNPWT) system after orthopaedic surgery reduced the incidence of SSIs and length of hospital stay compared with using conventional dressings. A systematic literature review (SLR) was performed using the PubMed, Embase and Cochrane Library databases. English-language studies comparing PICO sNPWT to conventional dressings published from 2011 to August 2018 with ≥10 patients in each treatment arm were included. Reference lists of included studies were searched for further relevant studies. Meta-analyses were performed using a fixed effect (I. 2. < 50%) or random effects model (I. 2. ≥ 50%). The SLR identified 6,197 studies, of which 5 relevant studies (607 patients) were included. The odds of an SSI were reduced by 57% (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.21–0.86; p = 0.02) and there was consistency between studies (I. 2. = 0%). Three studies reported on length of hospital stay. The mean difference between patient groups indicated that PICO sNPWT was associated with a 1-day reduction in hospital stay (mean difference [MD]: −0.99; 95% CI: −1.32 to −0.65; p < 0.00001) and there was again consistency between studies (I. 2. = 0%). These results suggest that the use of PICO sNPWT system after closed surgical incisions can reduce the incidence of SSIs and shorten the duration of hospital stay when used in orthopaedic patient populations

Aims

The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature.

Introduction. Metal-on-Metal (MoM) bearing surfaces were historically used for young patients undergoing total hip arthroplasty, and remain commonplace in modern hip resurfacing. In theory, it has been postulated that metal ions released from such implants may cross the placental barrier and cause harm to the fetus. In light of this potential risk, recommendations against the use of MoM components in women of child-bearing age have been advocated. The purpose of this systematic review was to evaluate: 1) the Metal-on-Metal bearing types and ion levels found; 2) the concentrations of metals in maternal circulation and the umbilical cord; and 3) the presence of abnormalities in the fetus. Methods. A comprehensive literature review was conducted of studies published between January 1st, 1975 and April 1st, 2019 using specific keywords. (See Fig 1). We defined the inclusion criteria for qualifying studies for this review as follows: 1) studies that reported on the women who experienced pregnancy and who had a Metal-on-Metal hip implant; 2) studies that reported on maternal metal ions blood and umbilical cord levels; and 3) studies that reported on the occurrence of fetal complications. Data on cobalt and chromium ion levels in the maternal blood and umbilical cord blood, as well as the presence of adverse effects in the infant were collected. Age at parturition and time from MoM implant to parturition were also collected. A total of 6 studies were included in the final analysis that reported on a total of 21 females and 21 infants born. The mean age at parturition was 40 years (range, 24–41 years), and the mean time from MoM implantation to parturition was 47.2 months (range, 11–119 months). Results. Maternal blood cobalt levels were found as a weighted average of 33.94ug/L (0.972–143), while umbilical cord blood cobalt levels were found to be 22.07 ug/L(0.486–75). Cobalt levels were reduced by an average of 35% between maternal and umbilical cord blood. Maternal cord blood chromium levels were found as a weighted average of 9.25 ug/L (1–25), while umbilical cord chromium levels were found to be 1.30 ug/L(0.288–2.3). Chromium levels were reduced by an average of 86% between maternal and umbilical cord blood. No cobalt or chromium was detected in the umbilical cord blood of three patients. Out of the 21 infants born to women with MoM implants, 20 were born healthy with no adverse effects or complications. Conclusion. To date, there is a lack of consensus as to whether Metal-on-Metal hip arthroplasty implants are to be avoided in the child-bearing female population and whether it constitute a hazard to the fetus in-utero. Both chromium and cobalt ions were markedly reduced in levels when transitioning from maternal to cord blood. In particular, chromium showed a greater reduction on average than cobalt (86% vs. 35%). Based on the current evidence, there appears to be no correlation between the presence of metal ions in umbilical cord blood and complications, particularly congenital malformations in the fetus, as none of the infants experienced abnormalities uniquely attributable to the presence of metal ions. For any figures or tables, please contact the authors directly

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

Aims

The purpose of this survey study was to examine the demographic and lifestyle factors of women currently in orthopaedic surgery.

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

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. Specifically, obese patients have shown increased rates of infection, dislocation, need for revision, wound dehiscence, increased operative time and prolonged hospital stay. Additionally, obese TKA patients have been shown to have increased rates of aseptic loosening, thromboembolic events, wound complications, and cardiopulmonary events. Worsening severity of obesity seems to correlate with worsening outcomes and super obesity (BMI>50) has been identified as an independent risk factor for complications. Patients with BMI>35 have shown to be 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. How can we improve outcomes in the obese patient? Preoperative care for the obese patient involves nutritional counseling, incorporating weight loss methods, physical therapy, metabolic workup and diagnosis and management of frequent comorbid conditions (OSA, DM2, HTN, HLD, malnutrition, renal failure). Identifying and managing comorbidities is especially important given that some comorbidities such as malnutrition have been shown to be as strong or even stronger an independent risk factor for postoperative TJA complications than obesity. In some cases higher complications were seen which some authors attribute to bariatric patients remaining in a catabolic state after weight loss.  . 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 preoperative screening and management is essential in reducing complications. Although weight loss is important, 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 optimization to ensure successful treatment in obese TJA patients