Aim. Repeat revision surgery of total hip or knee replacement may lead to massive bone loss of the femur. If these defects exceed a critical amount a stable fixation of a proximal or distal femur replacement may not be possible. In these extraordinary cases a total femur replacement (TFR) may be used as an option for limb salvage. In this retrospective study we examined complications, revision free survival (RFS), amputation free survival (AFS) and risk factors for decreased RFS and AFS following a TRF in cases of revision arthroplasty with a special focus on periprosthetic joint infection (PJI). Method. We included all implantations of a TFR in revision surgery from 2006–2018. Patients with a primary implantation of a TFR for oncological indications were not included. Complications were classified using the Henderson Classification. Primary endpoints were revision of the TFR or disarticulation of the hip. The minimum follow up was 24 month. RFS and AFS were analyzed using Kaplan-Meier method, patients´ medical history was analyzed for possible risk factors for decreased RFS and AFS. Results. After applying the inclusion criteria 58 cases of a TFR in revision surgery were included with a median follow-up of 48.5 month. The median age at surgery was 68 years and the median amount of prior surgeries was 3. A soft tissue failure (Henderson Type I) appeared in 16 cases (28%) of which 13 (22%) needed revision surgery. A PJI of the TFR (Henderson Type IV) appeared in 32 cases (55%) resulting in 18 (31%) removals of the TFR and implantation of a total femur spacer. Disarticulation of the hip following a therapy resistant PJI was performed in 17 cases (29%). The overall 2-year RFS was 36% (95% confidence interval(CI) 24–48%). Patients with a Body mass Index (BMI) >30kg/m² had a decreased RFS after 24 month (>30kg/m² 11% (95%CI 0–25%) vs. <30kg/m² 50% (95%CI 34–66%)p<0.01). The overall AFS after 5 years was 68% (95%CI 54–83%). A PJI of the TFR and a BMI >30kg/m² was significantly correlated with a lower 5-year AFS (PJI 46% (95%CI 27–66%) vs no PJI 100%p<0.001) (BMI >30kg/m² 30% (95% KI 3–57%) vs. <30km/m² 85% (95% KI 73–98%)p<0.01). Conclusions. A TFR in revision arthroplasty is a valuable option for limb salvage but complications in need of further revision surgery are common. Patients with a BMI >30kg/m² should be informed regarding the increased risk for revision surgery and loss of extremity before operation

Arthrofibrosis is a less common complication following anterior cruciate ligament (ACL) reconstruction and there are concerns that undergoing early surgery may be associated with arthrofibrosis. The aim of this study was to identify the patient and surgical risk factors for arthrofibrosis following primary ACL reconstruction. Primary ACL reconstructions prospectively recorded in the New Zealand ACL Registry between April 2014 and December 2019 were analyzed. The Accident Compensation Corporation (ACC) database was used to identify patients who underwent a subsequent reoperation with review of operation notes to identify those who had a reoperation for “arthrofibrosis” or “stiffness”. Univariate Chi-Square test and multivariate Cox regression analysis was performed. Hazard ratios (HR) with 95% confidence intervals (CI) were computed to identify the risk factors for arthrofibrosis. 9617 primary ACL reconstructions were analyzed, of which 215 patients underwent a subsequent reoperation for arthrofibrosis (2.2%). A higher risk of arthrofibrosis was observed in female patients (adjusted HR = 1.67, 95% CI 1.22 – 2.27, p = 0.001), patients with a history of previous knee surgery (adjusted HR = 1.97, 95% CI 1.11 – 3.50, p = 0.021) and when a transtibial femoral tunnel drilling technique was used (adjusted HR = 1.55, 95% CI 1.06 – 2.28, p = 0.024). Patients who underwent early ACL reconstruction within 6 weeks of their injury did not have a higher risk of arthrofibrosis when compared to patients who underwent surgery more than 6 weeks after their injury (3.5% versus 2.1%, adjusted HR = 1.56, 95% CI 0.97 – 2.50, p = 0.07). Age, graft type and concomitant meniscal injury did not influence the rate of arthrofibrosis. Female sex, a history of previous knee surgery and a transtibial femoral tunnel drilling technique are risk factors for arthrofibrosis following primary ACL reconstruction

Aim. To investigate the incidence and time-trend in reoperation due to deep Surgical Site Infection (SSI) following hip fracture surgery. Method. This was a population-based, nationwide, cohort study. We included 74,771 from the Danish Multidisciplinary Hip Fractures Register (1) consisting of patients 65 years of age or older, who underwent surgery between January 1. st. 2005 and December 31. st. 2016 for all types of hip fracture. Cross-linkage with the Danish National Patient Register and The Danish Civil Registration system was made. Demographic data extracted included vital status, civil status, gender, age, Body Mass Index (BMI), fracture classification (AO/OTA 31A-C) and surgical procedures binary registered as joint replacement or internal fixation, Charlson comorbidity index (CCI) and secondary diseases not included in CCI. Outcome was reoperations due to deep SSI in accordance with the definition from Centre for Disease Control (2). We computed cumulative incidence rates and risk ratios (RR) by calendar year periods and by different risk factors, considering death as competing risk and adjusting for age, gender, CCI, fracture type and surgery type. Results. Within 365 days of primary surgery 2.1% of all hip fractures had undergone reoperation due to deep SSI. During the period 2005–2016, the incidence of reoperation due to SSI decreased from 2.7% to 1.7%, We could not identify differences in reoperation due to SSI within one year regarding gender, BMI or CCI. Patients aged above 85 had about 50% lower risk of being reoperated compared with the youngest age group; 65–74 years (RR: 0.5; 95% CI: 0.4:0.6). The RR for reoperation due to deep SSI was lower for patients with pertrochanteric or subtrochanteric fractures (AO/OTA: 31A1-3) versus femoral neck fractures (AO/OTA: 31B1-3), RR was 0.7 (95%CI: 0.7:0.8). However, RR for surgery type (joint replacement vs internal fixation) at 365 days was significantly lower for joint replacement, RR: 0.6 (95% CI: 0.6:0.7). Conclusions. This study shows reoperation risk due to SSI for all types of hip fractures of 2.1%. There was a 45% decrease in reoperation over time from 2005 to 2016. However, the risk of revision is still high, and further action in avoidance of SSI should be taken

Aim. Prosthetic joint infections (PJI) and fracture related infections (FRI) are the most challenging complications in orthopaedic surgery. An interdisciplinary approach is mandatory not only to correctly diagnose and treat major musculoskeletal infections but also to address the comorbidities and impairments these patients are not rarely suffering from. Since, little data exists on cardiac complications following PJI and FRI revision surgery, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality. Method. We prospectively included consecutive patients at high cardiovascular risk (defined as expected postoperative hospital stay of >24 hours PLUS age >45 years with pre-existing coronary, peripheral or cerebrovascular artery disease OR age >65 years) undergoing major orthopaedic surgery between 2014 and 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T (hs-cTnT). All-cause mortality was assessed at 30 days and one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery (for PJI/FRI) and patients receiving aseptic major bone and joint surgery. Results. In total 911 consecutive patients, with an overall PMI rate of 15.4% (n=140) were included. The PMI incidence in patients undergoing septic revision surgery was significantly higher compared to aseptic orthopaedic surgeries (29.2% vs 14.3%, p=0.001), also after multivariable adjustment (odds ratio 2.1, p=0.02). Mortality was higher at one year (16.9% vs. 8.3%, p=0.037) and numerically at 30 days (6.2% vs. 2.4%, p=0.085) in patients undergoing septic revision surgery. Virulence of the disease-causing pathogen showed no significant relationship with PMI incidence or mortality. Conclusions. Patients undergoing revision surgery for PJI or FRI were at a distinct higher risk of PMI and death compared to matched non-septic patients. In major bone and joint infections screening for PMI and treatment in specialized multidisciplinary units should be considered

Aim. Periprosthetic joint infection (PJI) is a devastating complication in revision total hip arthroplasty (THA). As preoperative diagnosis can be difficult, some patients who undergo planned aseptic revision surgery might have positive intraoperative cultures and later be classified as infected. In this retrospective study we analyzed the influence of intraoperative positive cultures and possible underlying risk factors in patients undergoing planned aseptic THA revision. Method. We retrospectively analyzed 276 cases of aseptic THA revision surgery between 2010 and 2017 who had a minimum follow-up period of 24 months. All patients underwent preoperative serum and synovial diagnostics according to the Center of Disease Control (CDC) (2010) or Musculoskeletal Infection Society (MSIS) Criteria (2011–2017) for PJI and were classified as aseptic prior to surgery. In all cases intraoperative tissue samples were taken and reviewed. Primary endpoint was defined as any complication leading to revision surgery. Secondary endpoint was explantation due to PJI or death. Revision free survival (RFS) and infection free survival (IFS) for intraoperative negative and positive cultures was calculated via Kaplan Meyer Method. Patients’ medical history was analyzed for possible risk factors for positive cultures. Results. In 96 (34.78%) cases positive cultures were found. 67 (24.28%) had a single positive culture and 29 (10.51%) had ≥ two positive cultures. Coagulase negative staphylococci were found in 57.69% of the positive cultures. While the revision free survivorship was not different in patients with single positive cultures compared to patients with negative cultures (72.86 (95%CI 60.08–85.64) vs 83.01 months (95%CI 75.42–90.60) p=0.201), patients with ≥ two positive cultures had a reduced mean RFS (38.46 (95%CI 20.16–50.76) vs. 83.01 months (95%CI 75.42–90.60) p<0.02). 22 (7.97%) patients underwent explantation of the THA due to PJI. The IFS was reduced if ≥ two cultures were positive compared to culture negative patients (56.48 (95%CI 46.20–66.75) vs 110.78 months (95%CI 106.78–114.77) p=0.001). Risk for explantation due to PJI increased if ≥ two cultures were positive (Odds Ratio (OR) 3.19 (95%CI 1.36–7.52). A BMI ≥ 30 was associated with the risk of ≥ two positive cultures (OR 2.85 (95%CI 1.40–5.78). Conclusions. Occurrence of two or more positive cultures in aseptic revision THA has devastating influence on the revision free survival and infection free survival. As the risk for ≥ two positive cultures increase almost 3-fold in patients with a BMI ≥ 30, extended preoperative diagnostics in obese patients should be considered to detect possible low grade PJI before revision surgery

Recent advances in arthroplasty for the hip and the knee have motivated modern foot and ankle research to perfect the implant and technique for the optimal total ankle replacement. Unlike in the hip where different approaches can be done with similar implants, the approach of a total ankle is intimately associated to the prosthetic design. The anterior and lateral approaches have pros and cons regarding their respective soft tissue complications, osteotomy necessity, orientation of the bone cut and gutter visualization. While both have been studied independently, very few reports have compared both in the same setting. This study retrospectively looked at the difference in reoperations rate after each ankle arthroplasty within two years estimating that both had similar rate of return to the operating room. A retrospective study was conducted from a single center between 2014 and 2017 including a total of 115 total ankles performed by one of four fellowship-trained foot and ankle surgeon. Re-operations were reported in the charts as an operative report. The index approach used was determined by the surgeon's practice preference. Patients were included when they had a primary TAR in the timeframe noted and had a complete dataset up to at least the two-year data. This cohort comprised 67 anterior and 48 lateral with balanced demographic for age (95%CI 63–67 yo) and gender (47% F). The lateral group had more complex cases with higher COFAS type arthritis. Comparing the two groups, a total of 40 reoperations (7 anterior, 33 lateral) occurred in 27 patients (5A, 22L). One patient had up to four related reoperations. The only revision was in the anterior group. The only soft tissue reconstruction was an STSG in the lateral group. Nine reoperations were irrigation debridement related to an infective process (3 A, 6L). The majority (19/33) of reoperations in the lateral group were gutter debridement (8) or lateral hardware removal (11). Operative time was not statistically different. The odds ratio of having a reoperation with a laterally based TAR was 6.19 compared to the anterior group. This retrospective study outlines the intermediate results at two years of lateral and anterior total ankle replacements. This is a first study of this kind in the literature. This study did show that there were more reoperations after a laterally-based TAR than an anterior TAR, recognizing the significant case complexity imbalance between groups. This speaks to the relative increase resource utilization of laterally based TAR patients. Both implant designs carry different reoperation rates favoring the anterior group however larger prospective datasets will be needed with patient-reported outcome

Aims. Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. Materials and Methods. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome. Results. 180 revisions in 163 patients were identified at a median follow-up of 5.48 (2–11.7) years. There were 152 (84.4%) in the symptomatic subgroup and 28 (15.6%) in the asymptomatic group. Overall median OHS improved from 29 to 37 with revision (P<0.001). Symptomatic patients experienced greater functional benefit (DOHS 6.5 vs. 1.4, p=0.012) compared to asymptomatic patients, though they continued to report inferior outcomes (OHS 36.5 vs 43, p=0.004). The functional outcome of asymptomatic patients was unaffected by revision surgery (pre-revision OHS 41, post-revision OHS 43, p=0.4). Linear regression analysis confirmed use of a cobalt-chrome (CoCr)-containing bearing surface (MoM or metal-on- polyethylene) at revision and increasing BMI were predictive of poor functional outcome (R. 2. 0.032, p=0.0224 and R. 2. 0.039, p=0.015 respectively). Pre- and post-revision serum metal ions and pre-revision MRI findings were not predictive of outcome. The overall complication rate was 36% (n=65) with a re-revision rate of 6.7%. The most common complication was ongoing adverse reaction to metal debris (ARMD, defined as positive post-revision MRI) in 21.1%. The incidence of ongoing ARMD was not significantly different between those with CoCr reimplanted and those without (p=0.12). Conclusions. To our knowledge, our study represents the largest single-centre consecutive series of revision THRs from MoM bearings in the literature. Symptomatic patients experience the greatest functional benefit from revision surgery but do not regain the same level of function as patients who were asymptomatic prior to revision. The re-implantation of CoCr as a primary bearing surface and increasing BMI was associated with poorer functional outcome

This study aims to determine the incidence of surgical site infection leading to reoperation for sepsis following minor hand procedures performed outside the main operating room using field sterility in the South African setting. The investigators retrospectively reviewed the records of 485 patients who had WALANT-assisted minor hand surgery outside a main operating theatre, a field sterility setting between March 2019 and April 2023. The primary outcome was the presence or absence of deep surgical site infection that required reoperation within four weeks. Cases included where elective WALANT minor hand procedures, a minimum age of 18 with complete clinical records. The patients were mostly female (54.8%), with a mean age of 56.35 years. The majority of cases were trigger finger and carpal tunnel release. An overall 485 cases were reviewed, the deep surgical site infection rate resulting in reoperation within 4 weeks post-operatively was 1.24% ((95% Confidence Interval (CI) 0.0034 to 0.0237); p = 0.009). Minor hand procedures performed under field sterility using WALANT have a low surgical site infection rate. The current study's infection rates are comparable to international surgical site infection rates for similar surgeries performed in main operating rooms using standard sterilisation procedures. Field sterility is a safe and acceptable clinical practice that may improve work efficiency in public sector

Aim. In two-stage replacements for septic loosening, some studies have suggested that associate bacterial colonization of spacers had a worse result in relation to the control of the infection and a higher rate of complications after the implantation of the definitive prosthesis. The aim of our study was to determine the reoperation rate of patients undergoing two-stage revision surgery according to the results of spacer sonication. Method. A retrospective observational study was conducted in which 56 hip or knee spacers implanted at our center from 2010 to 2017 were analysed. Patients were grouped into three categories:. Patients with positive spacer sonication fluid culture, with or without positive cultures from the rest of the samples. Patients with negative spacer sonication culture and negative second-stage intraoperative cultures. Patients with negative spacer sonication culture but positive cultures of the rest of intraoperative samples. Results. Of the 56 patients analysed, 11 were included in group A, 32 in group B and 13 in group C. The reoperation rate was 36%, 34% and 54% respectively. Reoperation rate due to infection was 9%, 25% and 46% respectively. In only two cases (both in group C), the reoperation was caused by infection by a previously isolated microorganism. Spacers were colonized in all cases by low virulence microorganisms (coagulase negative staphylococci, P. acnes or Candida). Within group A, six patients also had other positive cultures. Conclusions. In our study, bacterial colonization of the spacer is not associated with a higher rate of reoperations in the short-medium term. The group of patients with positive cultures in the second stage surgery was the one with the highest rate of reoperations

C-reactive protein (CRP) level is used at our tertiary paediatric hospital in the diagnosis, management, and discharge evaluation of paediatric septic arthritis patients. The purpose of this study was to evaluate the efficacy of a discharge criterion of CRP less than 2 mg/dL for patients with septic arthritis in preventing reoperation and readmission. We also aimed to identify other risk factors of treatment failure. Patients diagnosed with septic arthritis between January 1, 2007 and December 31, 2017 were reviewed retrospectively. The diagnosis of septic arthritis was made based on clinical presentation, laboratory results and the finding of purulent material on joint aspiration or the isolation of a bacterial pathogen from joint fluid or tissue. Bivariate tests of associations between patient or infection factors and readmission and reoperation were performed. Quantitative variables were analyzed using Mann-Whitney tests and categorical variables were analyzed using Chi-square tests. One hundred eighty-three children were included in the study. Seven (3.8%) were readmitted after hospital discharge for further management, including additional advanced imaging, and IV antibiotics. Six (85.7%) of the readmitted patients underwent reoperation. Mean CRP values on presentation were similar between the two groups: 8.26 mg/dL (± 7.87) in the single-admission group and 7.94 mg/dL (± 11.26) in the readmission group (p = 0.430). Mean CRP on discharge for single-admission patients was 1.71 mg/dL (± 1.07), while it was 1.96 mg/dL (± 1.19) for the readmission group (p = 0.664), with a range of < 0 .8 to 6.5 mg/dL and a median of 1.5 mg/dL for the two groups combined. A total of 48 children (25.9%) had CRP values greater than the recommended 2 mg/dL at discharge, though only three of these patients (6.2%) were later readmitted. The only common variable in the readmitted children was either a negative culture result at time of discharge or atypical causative bacteria. CRP values are useful in monitoring treatment efficacy but not as reliable as a discharge criterion to prevent readmission or reoperation in children with septic arthritis. We recommend determining discharge readiness on the basis of clinical improvement and downtrending CRP values. There was a higher risk of readmission in children with an atypical causative bacteria and when culture results were negative at discharge. Close monitoring of these patients after discharge is suggested to identify signs of persistent infection

Introduction. PSI technology have proved helpful in difficult primary Total Knee Replacement. However applying it to revision was impossible due to multiple factor. To Start with the landmark We usually destroy it. There is an extensive damage at the bone at the epiphysis, the implant prevent an accurate visualization and debridement usually change the surface of the bone as well which make applying the psi dyed impossible, we are proposing a new way of using psi in revision where we don't depend on the all masses adjusted in primary. However we depend on the metaphysical area of the bone. Material & method. We have reviewed 56 MRI & CT scans for cases posted for revision and showed clearly that in spite of the extensive bony destruction and metal presence the MRI / CT scan we were able to visualize well the metaphysical area in the intramedullary canal in both tibial and femoral we have established a special external guide that depends on the outside surface of the metaphysis of the femur. We have tried this model on six plastic bone and showed that this external guide can give the accurate details that the surgeon is looking for in a revision surgery. Result & discussion. We have performed revision surgery on six bony model utilizing the new external guide that depend on the metaphysical bone mark. In all cases we were able to have a good lock for the external guide enabling us to precisely indicate the flexion extension joint line as well as the femoral rotation accurately. The guide established to us were the trial component should be seated and the surgery after that was quite easy filling the gap with necessary block and augment based on the accurate joint line. Furthermore, performing the surgery this way enabled us to offreem in order to correct the deformity that may result from the fixed angle of the stem in both femoral and tibial component. Our suggested way of performing the revision surgery is to use the metaphysical guide to indicate the entry point for reaming. this will allow the surgeon to offream after which the external guide also block the phantom or trial component indicating both flexion and extension joint line and rotation. After that the surgeon build up to the joint line. Conclusion. Depending on a new landmark outside metaphysical and suggesting a new type of guide will make psi possible regardless of the amount of bony destruction in the epiphyseal area. Furthermore performing the surgery this way will decrease the error that is based on the judgment of the surgeon for his joint line and rotation and point of entry. We believe that further work and development is needed to make it durable for commercial

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and the development of subsequent deep infection has not been established in the literature. Traditionally, irrigation of an open fracture has been recommended within six-hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multi-centre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound irrigation (within six hours of injury versus beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open extremity fractures requiring surgical treatment. To adjust for the influence of patient and injury characteristics on the timing of irrigation, a propensity score was developed from the data set. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% Confidence Intervals (CIs), and p-values. All analyses were conducted using STATA 14 (StataCorp LP, College Station, TX, USA). Two thousand, two hundred eighty-six of 2,447 patients randomized to the trial from 41 orthopaedic trauma centers across five countries had complete data regarding time to irrigation. Prior to matching, the patients managed with early irrigation had a higher proportion requiring reoperation for infection or healing complications (17% versus 12.8%, p=0.02), however this does not account for selection bias of more severe injuries preferentially being treated earlier. After the propensity score-matching algorithm was applied, there were 373 matched pairs of patients available for comparison. In the matched cohort, reoperation rates did not differ between early and late groups (16.1% vs 16.6%, p=0.84). When accounting for propensity matching in a logistic regression analysis, early irrigation was not associated with reoperation (OR 0.93, 95% CI 0.62 to 1.40, p=0.73). When accounting for other variables, late irrigation does not independently increase risk of reoperation

A significant portion of ankle arthroplasty and ankle arthrodesis procedures performed in British Columbia are funded by the public medical services plan (MSP). However, some patients are treated privately through self-pay or by the workers compensation board (WCB), with the latter two groups being more likely to receive treatment sooner. The potential effect of payer on patient-reported outcomes and reoperation rates has not been previously explored. A retrospective chart review was performed using data from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. N=443 patients (393 MSP, 26 self-pay, 24 WCB), treated with total ankle replacement or ankle arthrodesis by three subspecialty-trained surgeons in Vancouver from 1999–2003, were analyzed. Outcomes were compared, by payer, preoperatively and at long-term follow-up (6.3 years, range 2–14 years). Function was assessed using the Ankle Osteoarthritis Scale (AOS) Total score (primary outcome) and the AOS Pain and Difficulty subscores. Expectation and satisfaction with symptoms was assessed using the Musculoskeletal Outcomes Data Evaluation and Management Scale, and physical and emotional quality of life was assessed using the Short Form-36 (SF-36) Health Survey in terms of the mental component summary (MCS) and physical component summary (PCS). Swelling and reoperation rates were also compared. AOS Total score was not significantly different between payers. WCB patients had significantly worse preoperative AOS Difficulty scores (73, 95%CI 65–80) compared to MSP (65, CI 63–67) and self-pay patients (56, CI 49–63)(p < 0 .008). Their SF-36 MCS scores were also significantly worse pre- and postoperatively (WCB: 43, CI 38–49, 45, CI 40–50, MSP: 51, CI 50–52, 51, CI 50–52, self-pay: 51, CI 46–56, 54, CI 49–58)(p < 0 .03). AOS Pain scores and SF-36 PCS scores were not different. Pre- and postoperatively, MSP patients reported more satisfaction with symptoms (1.31, CI 1.24–1.38, 3.21, CI 3.07–3.35), compared to WCB (1.13, CI 0.84–1.41, 2.83, CI 2.26–3.41) and self-pay patients (1.19, CI 0.91–1.47, 2.88, CI 2.33–3.44). Preoperatively, WCB patients had the lowest expectations (76, CI 69–84), the worst AOS Total (64, CI 57–71) and SF-36 scores (MCS 43, CI 38–49, PCS 28, CI, 25–32), and the most swelling (3.5, CI 3.1–4). Conversely, self-pay patients had the highest preoperative expectations (88, CI 81–95), the best AOS Total (53, CI 46–60) and SF-36 scores (MCS 51, CI 46–56, PCS: 34, CI 30–37) and the least swelling (3, CI 2.6–3.4). Postoperatively, WCB and self-pay patients had lower expectations met (35, CI 23–47 and 40, CI 28–51) and worse AOS Total scores (36, CI 27–45 and 35, 26–43), compared to MSP patients (Expectations: 29, CI 26–32, AOS Total: 31, CI 29–33). Reoperation rates were similar among groups. WCB patients had significantly more difficulty with symptoms prior to surgery and worse SF-36 MCS scores pre- and postoperatively. The preoperative expectations of WCB patients were lowest, while those of self-pay patients were highest. Both groups had lower expectations met postoperatively

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients, whereas, arthroplasty is preferred for displaced fracture patterns. Given technological advancements in implant design and excellent long-term outcomes, arthroplasty may provide improved outcomes for the treatment of non-displaced femoral neck fractures. The aim of our study was to conduct a systematic review of the orthopaedic literature (1) to investigate the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients and (2) to compare the outcomes of patients treated with internal fixation to arthroplasty in this patient population. Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included only if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation or arthroplasty or (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient reported outcomes, length of hospital stay, infection, and transfusions. An a priori decision was made to classify studies into comparative or non-comparative groups. Comparative studies directly compared arthroplasty to internal fixation in the specific study population while the non-comparative studies included separate cohorts of patients treated with arthroplasty or internal fixation. A fixed-effects model was used to quantitatively pool study outcomes. Twenty-five non-comparative studies were identified with a total of 22,020 patients, all of which were treated with internal fixation. The pooled incidence of reoperation after internal fixation was 14.4% (95% CI: 10.8 – 18.8). The incidence of mortality within one-year of injury was 14.4% (95% CI: 6.7 – 28.3), based on the reporting in 14 studies. Three comparative studies were identified with a total of 360 patients (128 treated with arthroplasty and 232 treated with internal fixation). All three studies reported reoperation rates. The overall risk of reoperation was 3.1% in the arthroplasty group compared to 9.5% in the internal fixation group (relative risk: 0.30, 95% CI: 0.10 – 0.84, p= 0.02). Only two studies reported mortality. The relative risk of mortality in patients treated with arthroplasty compared to internal fixation was 2.54 (95% CI: 1.38 – 4.70, p= 0.003). Internal fixation of minimally displaced femoral neck fractures in the elderly is associated with a risk of reoperation and mortality that exceeds 14%. Treatment with arthroplasty may reduce the risk of reoperation by 70%. However, this benefit maybe tempered by a potential increased risk of mortality associated with arthroplasty in this patient population

Introduction

Osseointegration has emerged as a promising alternative to rehabilitating with a traditional socket mounted prosthesis. Advantages have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and better gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent transcutaneous opening often referred to as the stoma. Several systematic reviews have indicated that the occurrence of minor infections can be quite common, serious complications are reported to be rare. In addition to commonly anticipated complications including fractures, surgical debridements or revisions, we have identified several significant events in which a patient may require to be readmitted and go through additional surgery. The objective of this study is to examine the rate of occurrence and reports on the best management practices of serious complications across a multi-centre review of more than 1000 osseointegration surgeries.

Our aim was to highlight that there is a sub-group of patients with disabling symptoms after leg lengthening at primary hip replacement who benefit from revision surgery. Most patients with an over lengthened limb after total hip arthroplasty are either asymptomatic or find it an inconvenience which can often be treated with a shoe raise. A minority, however, find this severely debilitating, patients describing that the leg “feels long”, with pain felt around the hip, difficulty sitting and limited function. It is this sub-group of patients that we feel benefit from revision surgery to equalise leg lengths. We report on 8 cases (6 female; 2 male) that underwent revision surgery for leg lengthening over a 7 year period . The mean leg length difference was 14.3mm (range 10-20mm). Five patients had revision of the stem only and the remaining 3 both cup and stem. Time to revision varied from 8 months to 3 years. We outline our method of radiological measurement of leg length after total hip arthroplasty, using the centre of hip rotation as the reference point. Individual cases are discussed with radiographs highlighting the typical clinical features and this radiological technique. All patients reported an immediate improvement in their symptoms following revision surgery and have remained pleased with the outcome at their latest follow up. Leg lengthening as a result of total hip arthroplasty is well recognised but its treatment remains controversial. There is a sub-group of patients who are particularly sensitive to over lengthening, often of short stature. We reiterate that this revision surgery is beneficial to the patient with a lengthened leg ONLY if they have significant symptoms and limitation of function. Our small series emphasises the need to recognise this group of patients who can achieve a successful outcome after revision surgery

Introduction

Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address.

Introduction

Advantages of osseointegration have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent transcutaneous opening often referred to as the stoma.

Background. The aim of this study was to evaluate causes and results of revision surgery in unstable total knee arthroplasties. Methods. We retrospectively reviewed 24 knees that underwent a revision arthroplasty for unstable total knee arthroplasty. The average follow-up period was 33.8 months. We classified the instability and analyzed the treatment according to its cases. Stress radiographs, postoperative component position and joint level were measured. Clinical outcomes were assessed using the score and range of motion of the Hospital for Special Surgery (HSS). Results. Causes of instability included coronal instability with posteromedial polyethylene wear and lateral laxity in 13 knees(Fig. 1) and coronal instability with posteromedial polyethylene wear in 6 knees(Fig. 2), coronal and sagittal instability in 3 knees including post breakage in 1 knee(Fig. 3), global instability in 1 knee(Fig. 4) and flexion instability in 1 knee. Mean preoperative/postoperative varus and valgus angles were 5.8°/3.2° (p = 0.713) and 22.5°/5.6° (p = 0.032). Mean postoperative α, β, γ, δ angle were 5.34°, 89.65°, 2.74°, 6.77°. Mean changes of joint levels were from 14.1 mm to 13.6 mm from fibular head (p = 0.82). The mean HSS score improved from 53.4 to 89.2 (p = 0.04). The average range of motion was changed from 123° to 122° (p = 0.82). Conclusions. Revision total knee arthroplasty with or without a more constrained prosthesis will be a definite solution for an unstable total knee arthroplasty. The solution according to the causes is very important and seems to have a chance of avoidance of unnecessary over-constrained implant selection in revision surgery for total knee instability

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery