Below-elbow or above-elbow cast for conservative treatment of extra-articular distal radius fractures with dorsal displacement: A prospective randomized trial

Background: Distal radial fractures are common traumatic injuries, but their management remains controversial also in case of conservative treatment regarding the type of immobilisation. Hence, we conducted a two-arm, parallel-group, prospective randomised trial to compare the capacity of long casts (above-elbow) and short casts (below-elbow) to maintain the reduction of extra-articular distal radius fractures with dorsal displacement (AO/OTA classification: 2R3A2.2). Methods: Seventy-four eligible patients with AO/OTA 2R3A2.2 fractures treated with closed reduction and cast immobilisation were randomised to the long cast group (n°= 37) or to the short cast group (n°= 37). Baseline radiological parameters, radial inclination (RI), radial height (RH), ulnar variance (UV) and palmar tilt (PT) were taken, and compared with clinical (DASH, Mayo Wrist and Mayo Elbow) and radiological scores taken at 7-10 days, 4 weeks and 12 weeks. Furthermore, to evaluate correlations between radiological parameters and functional outcomes, patients were divided into two groups according to whether or not their radiological parameters at Follow-ups 2 and 3 were acceptable, i.e. within the range 11-12 mm for RH, 16°-28° for RI, - 4-+ 2 mm for UV and 0°-22° for PT. Results: Patient demographic and baseline radiological parameters were similar between groups. At follow-up, there were no statistically significant differences between the two types of cast in terms of RI, RH, UV or PT, or Mayo wrist or DASH scores. Short cast group patients displayed better Mayo elbow score at follow-up 2 (4 weeks), but this difference was no longer statistically significant at follow-up 3 (12 weeks). No statistically significant differences in clinical outcomes were found between patients who presented acceptable radiographic parameters at follow-up and those who did not. Conclusion: As there were no significant differences between short casts and long casts in terms of fracture reduction maintenance or clinical outcomes, short casts are an effective method of post-reduction immobilisation in AO/OTA 2R3A2.2 fracture of the radius. Radiological parameters outside the range conventionally considered acceptable do not preclude a satisfactory clinical outcome. Trial registration: ClinicalTrials.gov PRS, NCT04062110. Registred 20 August 2019

The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus?

Early arthroplasty designs were associated with a high level of anterior knee pain as they failed to cater for the patello-femoral joint. Patellar resurfacing was heralded as the saviour safeguarding patient satisfaction and success but opinion on its necessity has since deeply divided the scientific community and has become synonymous to topics of religion or politics. Opponents of resurfacing contend that the native patella provides better patellar tracking, improved clinical function, and avoids implant-related complications, whilst proponents argue that patients have less pain, are overall more satisfied, and avert the need for secondary resurfacing. The question remains whether complications associated with patellar resurfacing including those arising from future component revision outweigh the somewhat increased incidence of anterior knee pain recorded in unresurfaced patients. The current scientific literature, which is often affected by methodological limitations and observer bias, remains confusing as it provides evidence in support of both sides of the argument, whilst blinded satisfaction studies comparing resurfaced and non-resurfaced knees generally reveal equivalent results. Even national arthroplasty register data show wide variations in the proportion of patellar resurfacing between countries that cannot be explained by cultural differences alone. Advocates who always resurface or never resurface indiscriminately expose the patella to a random choice. Selective resurfacing offers a compromise by providing a decision algorithm based on a propensity for improved clinical success, whilst avoiding potential complications associated with unnecessary resurfacing. Evidence regarding the validity of selection criteria, however, is missing, and the decision when to resurface is often based on intuitive reasoning. Our lack of understanding why, irrespective of pre-operative symptoms and patellar resurfacing, some patients may suffer pain following TKA and others may not have so far stifled our efforts to make the strategy of selective resurfacing succeed. We should hence devote our efforts in defining predictive criteria and indicators that will enable us to reliably identify those individuals who might benefit from a resurfacing procedure. Level of evidence V

A six-year retrospective analysis of cut-out risk predictors in cephalomedullary nailing for pertrochanteric fractures: Can the tip-apex distance (TAD) still be considered the best parameter?

Intramedullary fixation is considered the most stable treatment for pertrochanteric fractures of the proximal femur and cut-out is one of the most frequent mechanical complications. In order to determine the role of clinical variables and radiological parameters in predicting the risk of this complication, we analysed the data pertaining to a group of patients recruited over the course of six years.A total of 571 patients were included in this study, which analysed the incidence of cut-out in relation to several clinical variables: age; gender; the AO Foundation and Orthopaedic Trauma Association classification system (AO/OTA); type of nail; cervical-diaphyseal angle; surgical wait times; anti-osteoporotic medication; complete post-operative weight bearing; and radiological parameters (namely the lag-screw position with respect to the femoral head, the Cleveland system, the tip-apex distance (TAD), and the calcar-referenced tip-apex distance (CalTAD)).The incidence of cut-out across the sample was 5.6%, with a higher incidence in female patients. A significantly higher risk of this complication was correlated with lag-screw tip positioning in the upper part of the femoral head in the anteroposterior radiological view, posterior in the latero-lateral radiological view, and in the Cleveland peripheral zones. The tip-apex distance and the calcar-referenced tip-apex distance were found to be highly significant predictors of the risk of cut-out at cut-offs of 30.7 mm and 37.3 mm, respectively, but the former appeared more reliable than the latter in predicting the occurrence of this complication.The tip-apex distance remains the most accurate predictor of cut-out, which is significantly greater above a cut-off of 30.7 mm

Radiographic assessment and clinical outcome after total hip arthroplasty with a Nanos® short stem prosthesis in 147 patients

Background. New generation short stem implants have some unquestionable advantages, which make them particularly attractive. However, in order to achieve good clinical results every implant must respect the normal joint anatomy and biomechanics. Objectives. To evaluate if these implants can fulfill the normal biomechanical parameters, such as femoral offset and leg length, and to assess the clinical outcome. Methods. The main radiographic parameters (horizontal and vertical rotation centre, femoral offset, leg length) have been evaluated in 147 patients who had a short stem implanted between July 2010 and July 2012 at the Private Hospital The Avenue in Melbourne, Australia. Patients have been clinically assessed with the Harris Hip Score and the WOMAC score preoperatively and at 3 months and at 1 year follow-up. Results. Restoration of the four main radiographic parameters was achieved within 5 mm of the contralateral side in most of our patients. Clinical results are excellent, as with the standard stems. Conclusions. With the Nanos® stem we can expect only minor and probably meaningless differences concerning the biomechanical parameters and the leg length; clinical results are comparable to the standard stems. Therefore, we believe the Nanos® stem to be a very useful implant for the total hip arthroplasty

MINIMALLY INVASIVE TECHNIQUES IN THE MANAGEMENT OF AMYELIC THORACOLUMBAR FRACTURES

A number of techniques have been described in the management of thoracolumbar spinal fractures, reporting a lack of consensus on their treatment. Internal fixation of unstable thoracolumbar spine fractures requires correction of the missing anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae. Above and two vertebrae below the fracture. Each approach requires extensive exposure of the spine, with prolonged operative times and profuse intraoperative blood loss. Part of the controversy is focused on the option of either surgery or conservative management for certain fracture types. For the past few years, minimally invasive techniques have been developed to limit surgery-related iatrogenic injury. The objective of this study was to report the results of percutaneous management of these lesions and the technical progress made based on our experience. We retrospectively reviewed the data of 21 patient with 31 thoracolumbar burst fractures without neurologic deficits admitted to our institution between 2010 and 2012. The surgical technique used systematically included balloon kyphoplasty and osteosynthesis via the posterior percutaneous approach. The two techniques have been used alone or in combination between them. The assembly was short, with screws in the vertebral pedicles above and below to the fracture and, when possible, even in the fractured vertebra. The primary outcome considered was the incidence of reoperation and loss of correction of kyphosis within the period of follow-up. We also evaluated the long-term functional status and pain. Isolated kyphoplasty for some stable fractures (like AO/Magerl A1.1, A1.2, A3.1), has the aim to obtain reduction of the fracture deformity by inflation of balloons in the vertebral body, followed by reinforcement with injection of cement into the cavity created, limiting at the same time the risk of intraoperative leakage. The possibility of using new materials, based on calcium phosphate, for the vertebral body augmentation extends its indication also to young patients. Kyphoplasty and percutaneous osteosynthesis systems may be used in combination for the treatment of unstable fractures (AO/Magerl: A3.1, A3.2, A3.3). The objective was to obtain maximal correction by ligamentotaxis and then to perform kyphoplasty secondarily to making raising of the vertebral plateau and to consolidate the vertebral body by reducing the pressure necessary in the balloons and thus reduce the risk of cement leakage. If direct support of the anterior column is not necessary (AO/Magerl: A2, A3, B), short-segment pedicle instrumentation is an attractive solution for fast stabilization of vertebral fractures, instrumenting only one vertebra above and one vertebra below the fracture and when possible, even the fractured vertebra. Percutaneous surgery by sparing the paravertebral muscles, should limit bleeding, reduce infection rates and postoperative pain, which would reduce the length of hospitalisation, make rehabilitation easier and faster and could limit the destabilisation of adjacent levels over the long term. The radiographical results at 1 year are equal to anterior stabilization and are better than other posterior-only techniques. Percutaneous augmented instrumentation is a non-fusion technique, therefore, after the fracture has healed, the instrumentation can be removed and motion restored to the instrumented levels. The results of this study support the growing interest in minimally invasive techniques in the management of spinal injuries with no neurological deficit. Rigorous patient selection is necessary and the learning curve must be taken into account. Prospective randomized studies with a larger number of patients and a longer follow-up will be essential in better defining the indications for these various techniques and to confirm the stability of the correction over time

Early outcomes of patella resurfacing in total knee arthroplasty

Background Patella resurfacing in total knee arthroplasty is a contentious issue. The literature suggests that resurfacing of the patella is based on surgeon preference, and little is known about the role and timing of resurfacing and how this affects outcomes. Methods We analyzed 134,799 total knee arthroplasties using data from the Australian Orthopaedic Association National Joint Replacement Registry. Hazards ratios (HRs) were used to compare rates of early revision between patella resurfacing at the primary procedure (the resurfacing group, R) and primary arthroplasty without resurfacing (no-resurfacing group, NR). We also analyzed the outcomes of NR that were revised for isolated patella addition. Results At 5 years, the R group showed a lower revision rate than the NR group: cumulative per cent revision (CPR) 3.1% and 4.0%, respectively (HR = 0.75, p < 0.001). Revisions for patellofemoral pain were more common in the NR group (17%) than in the R group (1%), and “patella only” revisions were more common in the NR group (29%) than in the R group (6%). Non-resurfaced knees revised for isolated patella addition had a higher revision rate than patella resurfacing at the primary procedure, with a 4-year CPR of 15% and 2.8%, respectively (HR = 4.1, p < 0.001). Interpretation Rates of early revision of primary total knees were higher when the patella was not resurfaced, and suggest that surgeons may be inclined to resurface later if there is patellofemoral pain. However, 15% of non-resurfaced knees revised for patella addition are re-revised by 4 years. Our results suggest an early beneficial outcome for patella resurfacing at primary arthroplasty based on revision rates up to 5 years

Post-operative blood loss in total knee arthroplasty: knee flexion versus pharmacological techniques.

To compare the blood loss and the blood transfusion between a control group and a group of patients following either a local administration of tranexamic acid or a mechanical post-operative knee flexion, a controlled randomized study was performed.JOURNAL ARTICLEinfo:eu-repo/semantics/publishe