Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term.

We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score.

Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores.

Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain.

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking.

We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80.

A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax.

This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax.

To determine in skeletally mature patients with a traumatic, first-time, patellar dislocation, the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes. Three online databases MEDLINE, EMBASE and PubMed were searched from database inception (1946, 1974, 1966 respectively), to August 20th, 2021, for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative kujala score as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS and Detsky scores. Overall, there were a total of 22 studies and 1705 patients included in this review. The pooled mean redislocation rate in 18 studies comprising 1409 patients in the rehabilitation group was 31% (95% CI 25%-36%, I2 = 65%). Moreover, the pooled mean redislocation rate in five studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2%-17%, I2 = 70%). The pooled mean postoperative Kujala anterior knee pain score in three studies comprising 67 patients in the reconstructive group was 91 (95% CI 84-97, I2 = 86%), compared to a score of 81 (95% CI 78-85, I2 = 78%) in 7 studies comprising 332 patients in the rehabilitation group. The reoperation rate was 9.0% in 936 patients in the rehabilitation group and 2.2% in 322 patients in the reconstruction group. Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation and a higher Kujala score, as well as noninferiority with respect to complication rates compared to nonoperative treatment. The paucity of high-level evidence warrants further investigation in this topic in the form of well-designed and high-powered RCTs to determine the optimal management option in these patients

Flail chest and multiple rib fractures are common injuries in trauma patients. Several small randomized studies have suggested significant improvements in patient outcomes with surgical fixation, compared to nonoperative management, yet emerging population-level data report some conflicting results. The objectives of this study were to compare the results of surgical fixation and nonoperative management of multiple rib fractures and flail chest injuries and to assess whether effects varied by study design limitations, including risk of confounding by indication. A comprehensive search of electronic databases (Medline, Embase, Web of Science) was performed to identify randomized controlled trials and observational studies. Random effects models were used to evaluate weighted risk ratios (RR) and mean differences (MD). Risk of confounding by indication was assessed for each study (low, medium, and high risk), and this categorization was used to stratify results for clinical outcomes. Publication bias was assessed. Thirty-nine studies, with a total of 19,357 patients met inclusion criteria. Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures was associated with decreased risk of death (overall RR 0.40, 95% confidence interval (CI) 0.28–0.56), pneumonia (overall RR 0.70, 95% CI 0.52–0.93), tracheostomy (overall RR 0.62, 95% CI 0.41–0.93), and chest wall deformity (overall RR 0.16, 95% CI 0.06–0.42). However, many of the observational studies were at risk of confounding by indication, and results varied according to risk of confounding by indication. Differences in ventilator time, intensive care unit length of stay (LOS), hospital LOS, and return to work will be assessed (results pending). Compared to nonoperative treatment, surgical fixation of flail chest and multiple rib fractures is associated with improved clinical outcomes. Discrepancies between some study results may be due to confounding by indication. Additional prospective randomized trials and high-quality observational studies are required to overcome potential threats to validity and to expand on existing evidence around optimal treatment of these injuries

The Gartland extension-type supracondylar humerus fracture is the most common elbow fracture in the paediatric population. Depending on fracture classification, treatment options range from nonoperative treatment such as taping, splinting or casting to operative treatments such as closed reduction and percutaneous pinning or open reduction. Classification variability between surgeons is a potential contributing factor to existing controversy over nonoperative versus operative treatment for Type II supracondylar fractures. The purpose of this study was to investigate levels of agreement in classification of extension-type supracondylar humerus fractures using the Gartland classification system. A retrospective chart review was conducted on patients aged 2–12 years who had sustained an extension-type supracondylar fracture and received either operative or nonoperative treatment at a tertiary children's hospital. De-identified baseline anteroposterior (AP) and lateral plain elbow radiographs were provided along with a brief summary of the modified Gartland classification system to surgeons across Canada, United States, Australia, United Kingdom and India. Each surgeon was blinded to patient treatment and asked to classify the fractures as Type I, IIA, IIB or III according to the classification system provided. A total of 21 paediatric orthopaedic surgeons completed one round of classification, of these, 15 completed a second round using the same radiographs in a reshuffled order. Kappa values using pre-determined weighted kappa coefficients were calculated to assess interobserver and intraobserver levels of agreement. In total, 60 sets of baseline elbow radiographs were provided to survey respondents. Interobserver agreement for classification based on the Gartland criteria between surgeons was a mean of 0.68, 95% CI [0.67, 0.69] (0.61–0.80 considered substantial agreement). Intraobserver agreement was a mean of 0.80 [0.75, 0.84]. (0.61–0.80 substantial agreement, 0.81–1 almost perfect agreement). Radiographic classification of extension-type supracondylar humerus fractures at baseline demonstrated substantial agreement both between and within surgeon raters. Levels of agreement are substantial enough to suggest that classification variability is not a major contributing factor to variability in treatment between surgeons for Type II supracondylar fractures. Further research is needed to compare patient outcomes between nonoperative and operative treatment for these fractures, so as to establish consensus and a standardized treatment protocol for optimal patient care across centres

There are many reasons that the surgically inclined orthopaedic surgeon should be responsible for the medical management of osteoarthritis of the knee. These include: 1) The nonoperative treatment of OA is often highly effective for all stages of the disease; 2) A nonoperative treatment program is the best preparation for a successful surgical outcome; and 3) Patients appreciate a surgeon's interest in their overall care and are likely to return if surgery is needed; 4) Medicare and many insurance companies are refusing to pay for a TJA until many months of conservative management has been administered. There are many potential causes of pain in an arthritic knee. These include intra-articular (e.g. degenerative meniscal tears, loose bodies, synovitis) and extra-articular (tendonitis, e.g. ilio-tibial band syndrome, bursitis, muscle overload syndromes and referred pain) sites. The potential sources of pain in an arthritic knee produce a wide range of symptoms that are not necessarily correlated with objective measurements (e.g. x-rays, MRI). Moreover, the natural history of an arthritic knee is unpredictable and variable. The treatment of the young, arthritic knee patient of all stages requires a systematic and consistent non-surgical approach. This approach includes the use of: 1) analgesics/anti-inflammatory agents; 2) activity modification; 3) alternative therapies; 4) exercise; 5) injections/lavage. The response to each form of non-surgical treatment is unpredictable at each stage (Kellgren 1–4) of OA. The placebo effect of each from of treatment, including the physician-patient interaction, is 50–60% in patients with mild-moderate OA. The components of a nonoperative treatment program include: 1) Education-emphasising the importance of the patient taking charge of his/her care; 2) Appropriate activity/life style modifications-emphasising the importance of remaining active while avoiding activities that aggravate symptoms (e.g. running to biking); 3) medications-oral, topical, intra-articular; 4) Physical therapy. There are extensive data to support each of these interventions. The AAOS has issued guidelines highlighted the literature based effectiveness of conservative interventions

Purpose. A recent multicentre randomized control trial (RCT) failed to demonstrate superior quality of life at one year following open reduction and internal fixation (ORIF) compared to nonoperative treatment for unstable isolated fibular fractures. We sought to determine the cost-effectiveness of ORIF compared to non-operative management of unstable fibular fractures. Method. A decision tree was used to model the results of a multicentre trial comparing ORIF versus nonoperative treatment for isolated fibular fractures. A single payer, governmental perspective was used for the analysis. Utilities (a measure of preference for a health state) were obtained from the subjects Short-Form-6D scores and used to calculated Quality Adjusted Life Years (QALYs). Probabilities for each strategy were taken from the one-year trial endpoint. Costs were obtained from the Ontario Case Costing Initiative. Sensitivity analysis was performed for all model variables to determine when ORIF is a cost-effective treatment (incremental cost per QALY gained < $75,000). Results. Nonoperative management was the preferred treatment during the one-year time-horizon. The nonoperative treatment strategy had an average cost of $2,099 $885 for an average gain of 0.717 0.064 QALYs. ORIF had an average cost of $6,455 $3,589 for an average gain of 0.734 0.051 QALYs. The incremental cost effectiveness ratio for the ORIF treatment was $256,235 per QALY. ORIF becomes the preferred treatment at extreme values for its costs (< $1,450) and its effectiveness (QALY > 0.81). Conclusion. From a single-payer, governmental perspective open reduction and internal fixation does not appear to be cost-effective; however, if operative fixation decreases the lifetime incidence of post-traumatic ankle arthrosis or a broader societal perspective with a higher willingness to pay threshold is adopted, then the economic attractiveness of ORIF would improve

Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

Prevention: Many periprosthetic femur fractures may be prevented by: good patient follow-up; timely reoperation of lytic lesions if radiographs suggest fracture risk; prophylactic use of longer stemmed implants or strut grafts to bypass cortical defects at revision surgery. Treatment: Periprosthetic fractures can be treated using an algorithmic approach based on the Vancouver classification system. Fractures of greater or lesser trochanter (Type A): nonoperative treatment if displacement acceptable and if not associated with lysis; operative treatment if displacement unacceptable or associated with progressive lysis. Fractures of distal femur well distal to implant (Type C): treat as any other femur fracture, usually operatively; fixation options: plate/retrograde nails. Fractures around the implant or at its tip (Type B): these fractures almost always require surgery. Nonoperative treatment is associated with high rate of malunion, nonunion, poor results. Treatment is according to fixation status of implant and bone quality. Well-fixed stem (Type B1): ORIF with cable plate and/or strut grafts; or with locking plate and minimally invasive biologic technique. Loose stem (Type B2 and Type B3): revise implant to long stem; usually use uncemented distally-fixed implant; occasionally long cemented stem (avoid cement extrusion). In most cases we favor use of a modular fluted tapered stem which provides axial and rotational stability by fixation distal to the fracture. Principles: obtain fracture stability, implant stability, and optimise conditions for bone healing (use bone grafts, don't strip periosteum)

Background. Operative treatment of complex proximal humerus fractures remains controversial. The transition to value-based health care demands a better understanding of the costs associated with surgery. The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and non-operative treatment and compare the costs associated with the initial-day and subsequent 89-days of care. Methods. A query of the Humana insurance claims database was performed through the PearlDiver Supercomputer (Warsaw, IN) from 2010 to 2014 using the diagnosis codes for proximal humerus fractures together with current procedural terminology codes (CPT) for hemiarthroplasties (HA), open reduction internal fixation (ORIF), reverse shoulder arthroplasty (RSA) and nonoperative treatment (NO). Reimbursement from the insurance claims database was used as a marker for costs. The same day, subsequent 89-day, and ninety day costs were analyzed trough the use of descriptive and comparative statistical analysis. Results. RSA was the most costly procedure for the same-day and 90-day costs (p<0.001) (Figure 1). Mean initial-day reimbursement costs were significantly different amongst treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), ORIF ($6,745) and lastly, NO ($1,932). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA and ORIF (p=0.112) (Figure 1 and 2); however, NO treatment incurred significantly lower costs (p=0.008) (Figure 3). Conclusion. The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial-day costs. RSA was associated with the highest cost, followed by HA and ORIF. NO management incurred the lowest costs

Supracondylar femur fractures are an uncommon but serious complication following TKA. The optimal treatment method often depends on the specific fracture pattern and various patient-related factors, and can be controversial in many cases. Nonoperative treatment can be considered in low-demand patients with minimally displaced fractures, whereas fractures associated with loose components typically require revision surgery. Displaced fractures with well-fixed implants can be treated successfully using one of several different strategies. Internal fixation after open or closed reduction can be achieved using either an intramedullary device or plate-and-screw constructs. Good results have been reported using intramedullary nails, although their use is limited to certain fracture patterns and implants designs. Modern periarticular locking plates featuring polyaxial locking screws can be inserted laterally in a submuscular fashion and offer the ability to achieve rigid fixation in the short distal fragment. These plates offer a robust treatment option for most fracture patterns. Alternatively, reliable healing and good functional results can also be achieved by revision of the femoral component using stemmed implants to bypass the fracture site. This strategy typically does not require distal femoral replacement or conversion to a hinge, and can provide consistently good results. Regardless of the treatment method chosen, careful attention should be given at the time of surgery avoid malalignment, malrotation, and distraction at the fracture site which can compromise the ultimate clinical outcome. Intra-operative femoral fractures are a rare complication that usually occurs during exposure, bone preparation, or trialing. If recognised intra-operatively and treated appropriately, reliable healing can occur

Introduction:. Unicompartmental knee arthroplasty (UKA) is a well established method for treatment of single compartment arthritis. However, a subset of patients still present with continued pain after their procedure in the setting of a normal radiographic examination. We propose the use of magnetic resonance imaging (MRI) as a useful modality in determining the etiology of symptoms in symptomatic unicompartmental knee arthroplasties. Materials & Methods:. An IRB-approved retrospective analysis of 300 consecutive unicompartmental knee arthroplasties between 2008–2010 found 28 cases symptomatic for continued pain. Magnetic resonance imaging was performed with a 1.5 T Surface Coil unit after clinical and radiographic assessment. MRI evaluation included assessment for osteoarthritis, synovitis, osteolysis, and loosening. Validated questionnaires including PAQ, WOMAC and UCLA Activity Score were used for clinical assessment. Results:. The average age at surgery was 56.1 ± 10.9 years (34–79). Imaging results indicated progressive arthritis in 28 patients (100%), synovitis in 17 patients (61%), osteolysis in 9 patients (32.0%), and loosening in 3 patients (11%). Based on these results and other clinical findings, a revision or conversion to a TKR was advised for 10 patients and 18 were recommended for nonoperative therapies. One patient received treatment at a separate hospital, and another was lost to follow-up. At post-operative follow-up of 1.4 ± 0.9 years, 7 of the 10 patients (70%) in the operative group experienced improvement in pain and function. The mean PAQ, UCLA and WOMAC index scores for these patients were 8.0 ± 1.4 (7–9), 5.5 ± 6.4 (1–10), and 2.0 ± 2.8 (0–4), respectively. In the nonoperative group, 11 of the 18 patients (61%) experienced improvement in pain and function. Among these patients, the mean PAQ, UCLA and WOMAC index scores were 7.6 ± 3.7 (0–10), 5.9 ± 3.2 (1–10) and 8.9 ± 12.0 (0–28), respectively. Conclusion:. The use of MRI as an imaging modality for symptomatic arthroplasty patients is becoming more commonly used. This study shows how MRI with sound clinical judgment can influence treatment decisions and supports the use of high quality MRI as a diagnostic tool for the symptomatic unicompartmental knee arthroplasty

Fracture of the acetabulum can result in damage to the articular surface that ranges from minimal to catastrophic. Hip arthroplasty may be required for more severe injuries due to marked articular surface damage, post traumatic degenerative changes, persistent malunion or nonunion, or occasionally avascular necrosis and destruction of the femoral head. These problems may be seen following both closed and open fracture treatment, but prior open reduction and internal fixation often makes subsequent THA more difficult due to soft tissue scarring and retained hardware. In select acute acetabular fracture cases with severe initial comminution of the joint, open reduction and fixation can be technically impossible or so clearly destined to early failure that initial fracture treatment with combined limited fixation and simultaneous THA is the best option, especially in osteoporotic elderly fracture patients. Problems which may be encountered during any THA in a patient with a prior acetabular fracture include: difficult exposure due to soft tissue defects and scarring, presence of heterotopic ossification, and nerve palsy from the original fracture or subsequent osteosynthesis. Retained hardware can present significant challenges and frequently is left in place or removed in part or completely, when intraarticular in location or blocking preparation of the acetabular cavity and placement of the cup. Additional potential problems include residual deformity and malunion, persistent pelvic dissociation or nonunion of fracture fragments, cavitary or segmental bone loss from displaced or resorbed bone fragments, and occasionally occult deep infection. Preoperative assessment and planning should include careful consideration of the most appropriate surgical approach, which may be impacted by the need for hardware removal. Screening laboratory studies and aspiration of the hip may prove helpful in excluding associated deep infection. Intraoperative sciatic nerve monitoring may be of assistance in patients with partial residual nerve deficits or where extensive posterior exposure and mobilization of the sciatic nerve is needed for hardware removal or excision of heterotopic ossification. Metal cutting tools to allow partial removal of long plates and adjunctive equipment for removal of broken or stripped screws should be routinely available during these cases. Careful preoperative planning regarding implant and reconstructive options can also ensure availability of proper components and equipment. Often implants and techniques developed for revision surgery for management of major bone deficiencies are needed. Reported results suggest that surgery is frequently prolonged, can be associated with greater blood loss and may result in increased risk of post-arthroplasty heterotopic ossification when compared to routine primary procedures. Bone stock and fracture union may be better in patients with prior internal fixation than in those with nonoperative treatment of major displaced acetabular fractures. Available long-term results document more durable results with lower rates of aseptic loosening with uncemented acetabular fixation compared to cemented acetabular components. These patients are at higher risk of revision and failure than patients undergoing THA for simple osteoarthritis, though initial short-term results are comparable to conventional hip arthroplasty patients, as long as early wound healing problems and deep infection can be avoided, which is a greater risk for acute THA for initial fracture care. The application of newer implant designs, highly porous ingrowth materials, and methods for management of acetabular bone deficiency developed for revision THA have helped improve results in this challenging subset of primary THA patients

Aim. Periprosthetic fractures are usually observed in patients aged over 65 years. The incidence of postoperative periprosthetic femur and tibia fractures is rising with increasing number of hip and knee joint replacements and the increasing life expectancy. The aetiology of periprosthetic fractures is multifactorial. Minimal trauma is causal for the fracture in most cases. Other risk factors are: generalized osteoporosis, loosening of the prosthesis and revision arthroplasty. Our aim is restoration of the patient's pre-fracture functional status. Method. Between 2004 and 2009 in the Asklepios Orthopedic Clinic Hohwald 118 patients (82 women, 36 men) were operated because of periprosthetic fractures. Mean patient age at surgery was 71 years (range 60-87). The right treatment depends on the location of the fracture and the stability of the implant. Very important is also the quality of bone and the patient's general state of health. Results. A successful surgical treatment requires a careful preoperative planning. The type of the fracture with or without prostheses instability and with or without bone defect all have influence on the type of patients surgery. Two patients died within one year. There were 2 cases of infection and cases of 5 late healing. Fixation with different plates was used for 67 fractures, at intact and undamaged endoprosthesis was used usually osteosynthesis with “Less Invasive Stabilisation System” plate (LISS, NCB). It combines high primary stability with the biological advantages of a slide-insertion plate osteosynthesis. Retrograde nailing was possible in 5 patients and 8 further with screws and cerclage wiring. In 38 cases we changed the endoprosthesis partially or completely. We reconstructed prosthetic damage or periprosthetic fractures with bone defect using modular prostheses. This system allows a large number of additional components and their combination with cone blocks for reconstruction of severe bone defects. Conclusion. Periprosthetic fractures have such a range of clinical presentations that they need to be managed on individual basis. The best functional results for stable implants gived internal fixation with a plate. Alternative osteosynthetic techniques and additive minimal osteosynthesis can work better in special cases. Modular prostheses for bone replacement are a method of choice for fractures with extensive bone loss. Nonoperative treatment should only be performed in exceptional cases. Periprosthetic fractures are serious complications because of the mortality and the difficulty in achieving functional recovery after treatment. Our primary aim is remobilization as early as possible-that is the best prevention of secondary complications

Total knee arthroplasty (TKA) has produced excellent results, but many surgeons are hesitant to perform TKA in younger patients with isolated patellofemoral arthritis. In properly selected patients, patellofemoral arthroplasty (PFA) is an effective procedure with good long-term results. Contemporary PFA prostheses have eliminated many of the patellar maltracking problems associated with older designs, and short-term results, as described here, are encouraging. Long-term outcome and prospective trials comparing TKA to PFA are needed. Incidence. Isolated patellofemoral arthritis occurs in as many as 11% of men and 24% of women older than age 55 years with symptomatic osteoarthritis (OA) of the knee; Isolated patellofemoral arthritis found in 9.2% of patients older than age 40 years; 7% to 19% of patients experience residual anterior knee pain when TKA is done for isolated patellofemoral arthritis. Imaging. Weight bearing AP radiographs as supine radiographs can underestimate the extent of tibiofemoral arthritis; Midflexion posteroanterior radiographs to rule out posterior condylar wear; Lateral radiographs to identify the presence or absence of patella alta or baja; Axial radiographs identify the presence of trochlear dysplasia, patellar tilt or subluxation, and extent of patellofemoral arthritis; Magnetic resonance imaging and arthroscopic photographs should be reviewed if available. Indications. Osteoarthritis limited to the patellofemoral joint; Symptoms affecting daily activity referable to patellofemoral joint degeneration unresponsive to lengthy nonoperative treatment; Posttraumatic osteoarthritis; Extensive Grade-III chondrosis; Failed extensor unloading surgical procedure; Patellofemoral malalignment/dysplasia-induced degeneration. Contraindications. No attempt at nonoperative care or to rule out other sources of pain; Arthritis of greater than Grade 1 involving tibiofemoral articulation; Systemic inflammatory arthropathy; Osteoarthritis/chondrosis of the patellofemoral joint of Grade 3 or less; Patella baja; Uncorrected patellofemoral instability or malalignment; Uncorrected tibiofemoral mechanical malalignment; Active infection; Evidence of chronic regional pain syndrome or evidence of psychogenic pain; Fixed loss of knee range of motion, minimum 10–110 degrees ROM. Results. Majority of failures related to patellar instability from uncorrected patellar malalignment, soft-tissue imbalance, or component malposition; With improved implant designs tibiofemoral arthritis has become the primary source of failure; Failure from component subsidence or loosening occurring in <1% of knees. Our Series. Retrospective review 34 patients, 40 knees average 30 month follow-up using Natural Knee II Patello-femoral Joint System (Zimmer, Warsaw, IN); Average age 61, ranging from 34–84 years of age; Average subset KOOS scores were 93 for pain, 94 for symptoms, 94 for ADL's, 70 for sports and recreation, 82 for quality of life; Average pre-operative Tegner score 2.6, increasing to 4.7 post-operatively; 38/40 survival over 30 months with the two failures undergoing revision for traumatic injuries; No revisions to TKA; At most recent follow-up no progression of OA to involve tibiofemoral compartments; No evidence of component loosening

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.