Understanding the role of total knee arthroplasty for primary treatment of tibial plateau fracture: a systematic review of the literature

Abstract Background Surgical fixation of tibial plateau fracture in elderly patients with open reduction and internal fixation (ORIF) provides inferior outcomes compared with younger patients. Primary total knee arthroplasty (TKA) may be of benefit in elderly patients with a combination of osteoporotic bone and metaphyseal comminution. However, there continues to be conflicting evidence on the use of TKA for primary treatment of tibial plateau fracture. This systematic review was performed to quantify the outcomes and perioperative complication rates of TKA for primary treatment of tibial plateau fracture. Materials and methods A comprehensive search of MEDLINE, Embase, and PubMed databases from inception through March 2018 was performed in accordance with PRISMA guidelines. Two reviewers independently screened papers for inclusion and identified studies featuring perioperative complications and outcomes of primary TKA for tibial plateau fracture. Weighted means and standard deviations are presented for each outcome. Results Seven articles (105 patients) were eligible for inclusion. All-cause mortality was 4.75 ± 4.85%. The total complication rate was 15.2 ± 17.3%. Regarding outcomes, Knee Society scores were most commonly reported. The average Knee Society Knee Score was 85.6 ± 5.5, while the average Knee Society Function Score was 64.6 ± 13.7. Average range of motion at final follow-up was 107.5 ± 10.0°. Conclusions Primary TKA for select tibial plateau fractures has acceptable clinical outcomes but does not appear to be superior to ORIF. It may be appropriate to treat certain geriatric patients with TKA to allow for early mobilization and reduce the need for reoperation. Other factors may need to be considered in deciding the optimal treatment. Level of evidence Level III

Symptomatic bilateral pulmonary embolism without deep venous thrombosis in an adolescent following arthroscopic anterior cruciate ligament reconstruction: a case report and review of the literature

Abstract Background Venous thromboembolism, specifically pulmonary embolism, is a rare complication following elective pediatric orthopedic surgery. Bilateral pulmonary embolism with associated pulmonary hemorrhage/infarct without concomitant deep vein thrombosis has never been reported following routine anterior cruciate ligament reconstruction in an adolescent. Case presentation A 16-year-old white girl presented with acute onset shortness of breath and pleuritic chest pain 6 days following elective anterior cruciate ligament reconstruction. After performing a thorough work-up, she was diagnosed as having provoked bilateral pulmonary embolism with associated pulmonary hemorrhage without concomitant deep vein thrombosis. She was treated successfully with 3 months of anticoagulation therapy with daily Lovenox (enoxaparin) injections. Conclusions Symptomatic bilateral pulmonary embolism may have a good prognosis if it is diagnosed early and treated appropriately. It is important to appreciate the risk of provoked thromboembolic events in healthy adolescents undergoing arthroscopic knee surgery

Clinical results and complications following surgical management of symptomatic os acromiale: a systematic review

Abstract Background This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations. Methods A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction. Range of motion and several standardized outcome measurement tools were also included in the final analysis. Results Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improvements in postoperative outcomes (i.e., active range of motion and patient-reported outcome scores). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%. Conclusion This study reports on the largest sample of patients who underwent surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with meticulous repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good to excellent patient satisfaction. However, patients must be informed that a second procedure may be required to remove symptomatic hardware

Association between the Orthopaedic Trauma Society classification of open fractures and economic costs

Aims The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs. Methods Resource use was measured during the six months that followed open fractures of the lower limb in 748 adults recruited as part of two large clinical trials within the UK Major Trauma Research Network. Resource inputs were valued using unit costs drawn from primary and secondary sources. Economic costs (GBP sterling, 2017 to 2018 prices), estimated from both a NHS and Personal Social Services (PSS) perspective, were related to the degree of complexity of the open fracture based on the OTS classification. Results Adjusted mean total NHS and PSS costs were £13,785 following treatment of complex fractures and £3,550 following treatment of simple fractures, where the open fracture wound is closed at the end of the first wound debridement, generating a mean difference of £10,235 (95% confidence interval £8,074 to £12,396). Conclusion Following previous work correlating clinical outcomes with the OTS classification of open fractures, this study suggests that the new OTS classification also correlates with economic costs estimated from alternative study perspectives

Computational modelling of hip resurfacing arthroplasty investigating the effect of femoral version on hip biomechanics.

AimHow reduced femoral neck anteversion alters the distribution of pressure and contact area in Hip Resurfacing Arthroplasty (HRA) remains unclear. The purpose of this study was to quantitatively describe the biomechanical implication of different femoral neck version angles on HRA using a finite element analysis.Materials and methodsA total of sixty models were constructed to assess the effect of different femoral neck version angles on three different functional loads: 0°of hip flexion, 45°of hip flexion, and 90° of hip flexion. Femoral version was varied between 30° of anteversion to 30° of retroversion. All models were tested with the acetabular cup in four different positions: (1) 40°/15° (inclination/version), (2) 40°/25°, (3) 50°/15°, and (4) 50°/25°. Differences in range of motion due to presence of impingement, joint contact pressure, and joint contact area with different femoral versions and acetabular cup positions were calculated.ResultsImpingement was found to be most significant with the femur in 30° of retroversion, regardless of acetabular cup position. Anterior hip impingement occurred earlier during hip flexion as the femur was progressively retroverted. Impingement was reduced in all models by increasing acetabular cup inclination and anteversion, yet this consequentially led to higher contact pressures. At 90° of hip flexion, contact pressures and contact areas were inversely related and showed most notable change with 30° of femoral retroversion. In this model, the contact area migrated towards the anterior implant-bone interface along the femoral neck.ConclusionFemoral retroversion in HRA influences impingement and increases joint contact pressure most when the hip is loaded in flexion. Increasing acetabular inclination decreases the area of impingement but doing so causes a reciprocal increase in joint contact pressure. It may be advisable to study femoral neck version pre-operatively to better choose hip resurfacing arthroplasty candidates