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Aims “Get It Right First Time” (GIRFT) and NHS England’s Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a ‘paradox’. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. Methods This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70. Results Overall revision rate was 1.3% (13/1,004). A greater number of revisions were undertaken in those aged over 65 years, but numbers were small and did not reach significance. The majority of revisions were implant-independent. Single component analysis revealed a 99.9% and 99.6% survival for the uncemented cup and femoral component, respectively. Mean patient-reported outcome measures (PROMs) improvement for all ages outperformed the national PROMs and a significantly greater proportion of those aged over 65/69 years reached and maintained a meaningful improvement in their OHS earlier than their younger counterparts (p < 0.05/0.01 respectively). Conclusion This study confirms that this uncemented THA system can be used safely and effectively in patient groups aged over 65 years and those over 69 years, with low complication and revision rates. Cite this article: Bone Jt Open 2021;2(5):293–300.

This study prospectively reports survivorship and radiographic and clinical outcomes following primary elective total hip arthroplasty (THA) using a novel single hemispherical, porous-coated acetabular cup with five different bearing combinations and a minimum of five year follow-up. Continuing post-market release monitoring of this cup, we prospectively enrolled 108 patients (121 THA) between 2009 and 2015. We followed this cohort by examining survivorship, in addition to clinical and radiological outcomes for metal-on-metal (MoM) compared with non-MoM bearing combinations (ceramic-on-ceramic, oxinium-on-polyethylene, ceramic-on-metal, and metal-on-polyethylene). All 108 (121 hips) patients were followed up. Average age at time of surgery was 45.1 years (range 19 to 71 years) of which 42.1% were males. A total of seven (5.8%) cups were revised, all of which were MoM. No osteolysis was observed in any of the patients at the latest visit with a mean follow-up of 9.1 ± 1.7 years (range 4.4–10.7 years). With MoM excluded, survivorship of the cup at five years is 97.8%. Survivorship for MoM implants was 90.0%. Validated hip scores showed significant improvements for all bearing types and no significant difference between groups at latest follow-up (p = 0.614). There was no cup migration with any bearing surface. This cup showed excellent survivorship at five year follow-up, except for patients receiving a MoM articulation. While there were concerns over the early survivorship of this cup, our cohort and joint registry data confirm excellent outcomes.

It is unusual, if not unique, for three major research papers concerned with the management of the fractured neck of femur (FNOF) to be published in a short period of time, each describing large prospective randomized clinical trials. These studies were conducted in up to 17 countries worldwide, involving up to 80 surgical centers and include large numbers of patients (up to 2,900) with FNOF. Each article investigated common clinical dilemmas; the first paper comparing total hip arthroplasty versus hemiarthroplasty for FNOF, the second as to whether ‘fast track’ care offers improved clinical outcomes and the third, compares sliding hip with multiple cancellous hip screws. Each paper has been deemed of sufficient quality and importance to warrant publication in The Lancet or the New England Journal of Medicine. Although ‘premier’ journals, they only occationally contain orthopaedic studies and thus may not be routinely read by the busy orthopaedic/surgical clinician of any grade. It is therefore our intention with this present article to accurately summarize and combine the results of all three papers, presenting, in our opinion, the most important clinically relevant facts. Cite this article: Bone Joint Open 2020;1-6:198–202.

Purpose: To retrospectively review the safety and efficacy of genicular artery embolization procedures performed at our institution in patients presenting with recurrent knee hemarthrosis following total knee arthroplasty (TKA). Materials and Methods: A total of 13 consecutive patients (average age: 68; range 51-84, 62% female) were identified who underwent 14 genicular artery embolization procedures after presenting with recurrent hemarthrosis after TKA. Patient charts were retrospectively reviewed for demographic information, pre-embolization investigations, and details of embolization procedure including complications, technical success, and clinical success. Each patient had failed initial conservative therapy and all patients had a diagnostic aspiration performed by the referring physician prior to the procedure. The average time between TKA and embolization in our cohort was 21 months. Results: All procedures performed were technically successful, defined as elimination of periprosthetic hypervascular blush. An average of 3.6 genicular vessels were embolized in each patient; 355 to 500 µm polyvinyl alcohol (PVA) particles were used in each case. There were no cases of transient cutaneous ischemia, skin erythema, or skin necrosis. Clinical success was obtained in 85.7% of cases, defined by elimination of the presenting clinical symptoms (knee pain and swelling) during continued follow-up by the referring clinician. Conclusion: Particle embolization is a safe and effective treatment for recurrent hemarthrosis after arthroplasty and our experience suggests that utilizing particle sizes of greater than 300 µm appears to be important in order to avoid cutaneous ischemic complications.

© 2020 Elsevier Inc. Background: This study reports the long-term outcomes of a metaphyseal fit-and-fill cementless femoral component in total hip arthroplasty (THA) with a follow-up of 15-19 years. Methods: We conducted a retrospective review of 376 consecutive THAs (345 patients), using a triple tapered stem performed between 2000 and 2003 with a view to assessing survivorship and radiological and functional outcomes. Images were assessed for initial alignment, terminal osteolysis, or subsidence, while clinical outcomes were assessed using the St Michael's Hip Score. Results: Forty-five (11.9%) hips were lost to follow-up, 20 (5.31%) had died before our 15-year cutoff follow-up, and 4 (1.06%) had declined follow-up early on, leaving 307 hips (81.64%, 276 patients) available for both clinical and radiological follow-up at a minimum of 15 years (range 15-19). The mean age at the time of operation was 49.6 years (range 19-71) and the cohort included 131 (42.67%) male and 145 (47.23%) female patients. Seven stems (2.28%) were revised: 4 due to periprosthetic fractures, 2 for periprosthetic joint infection, and 1 for adverse reaction to metal debris at the trunnion. The St Michael's Hip Score improved from 14.2 (range 9-23) preoperatively to 22.3 (range 13 to 25) at the last documented follow-up (P = .000). Kaplan-Meier survivorship with stem revision for any reason as the end point was 97.70%. Worst-case scenario Kaplan-Meier survivorship, where all lost to follow-up are considered as failures, was 85.3%. No stem was revised for aseptic loosening. Conclusion: This triple tapered stem in THA shows excellent survivorship beyond a minimum of 15 years.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

AimsWe present the ten-year data of a cohort of patients, aged between 18 and 65 years (mean age 52.7 years; 19 to 64), who underwent total hip arthroplasty. Patients were randomised to be treated with a cobalt-chrome (CoCr) femoral head with an ultra-high molecular weight polyethylene (UHMWPE), highly cross-linked polyethylene (XLPE) or ceramic-on-ceramic (CoC) bearing surface.Patients and MethodsA total of 102 hips (91 patients) were randomised into the three groups. At ten years, 97 hips were available for radiological and functional follow-up. Two hips (two patients) had been revised (one with deep infection and one for periprosthetic fracture) and three were lost to follow-up. Radiological analysis was performed using a validated digital assessment programme to give linear, directional and volumetric wear of the two polyethylene groups.ResultsThere was a significantly reduced rate of steady-state linear wear with XLPE (0.07 mm/yr) compared with UHMWPE (0.37 mm/yr) (p = 0.001). Volumetric wear was also significantly reduced in the XLPE group (29.29 mm3/yr) compared with the UHMWPE group (100.75mm3/yr) (p = 0.0001). There were six patients with UHMWPE who had non-progressive osteolysis and none in the XLPE group. All three bearing groups had significant improvements in 12-item short form health survey scores, Western Ontario and McMaster Universities Osteoarthritis Index score and Harris Hip Score. However, the improvement in HSS was significantly less in the UHMWPE group (p = 0.0188) than in the other two groups. At ten years, the rates of volumetric and linear wear in the XLPE group remain low and predominantly below the estimated threshold for osteolysis (1 mm/yr). The rate of linear wear in the XLPE group was three times less than in the UHMWPE group at five-year follow-up and five times less at ten years. The rate of volumetric wear was also three times less in the XLPE group at ten years.ConclusionWhile CoC also performs well, XLPE at ten years remains a safe and excellent bearing option in young patients, with low rates of wear and no evidence of osteolysis. Cite this article: Bone Joint J 2017;99-B:1590–5.

ObjectiveTo evaluate the management and costs of osteoarthritis of the knee (OAK), a progressive joint disease due to bone and cartilage degeneration, with significant personal and societal impact.MethodsWe prospectively analyzed the clinical outcomes and quantifiable cumulative direct costs of patients with OAK referred to our multidisciplinary OA program over a two year time period. One hundred thirty-one subjects were assessed. All demonstrated radiographic criteria for moderate to severe OAK. Western Ontario McMaster Osteoarthritis Index (WOMAC), Minimal Clinically Important Improvement (MCII), and change in BMI were recorded and analyzed. Total medical and surgical direct costs for all subjects during the two year time period were determined.ResultsFive patients underwent total joint replacement during the two years of study. Among the group as a whole, a significant overall improvement in WOMAC scores was noted at the two year time point follow-up. After dividing the group into tertiles by baseline WOMAC scores, 46% achieved MCII. Significant weight loss was noted for individuals with baseline BMI of > 30. As all patients were considered “de facto” surgical candidates at referral, an average net savings of $9551.10 of direct costs per patient, or a potential total of $1,203,438.60 for the entire group, could be inferred as a result of medical as opposed to surgical management.ConclusionThese findings support the benefits of multidisciplinary medical management for patients with significant OAK. This approach is clinically beneficial and may provide significant cost savings. Such models of care can substantially improve the long-term outcome of this highly prevalent condition and reduce societal and financial burdens.

© 2018 AABB BACKGROUND: Tranexamic acid (TXA) therapy is effective in reducing postoperative red blood cell (RBC) transfusion in total joint arthroplasty (TJA), yet uncertainty persists regarding comparative efficacy and safety among specific patient subgroups. We assessed the impact of a universal TXA protocol on RBC transfusion, postoperative hemoglobin (Hb), and adverse outcomes to determine whether TXA is safe and effective in TJA, both overall and in clinically relevant subgroups. STUDY DESIGN AND METHODS: A retrospective observational study was performed on patients undergoing TJA at our institution spanning 1 year before and after the implementation of a universal protocol to administer intravenous (IV) TXA. The primary outcome was percentage of patients transfused, and secondary outcomes were perioperative Hb and occurrence of adverse events (death, myocardial infarction, stroke, seizure, pulmonary embolism, deep vein thrombosis, and acute kidney injury). Outcomes were compared in pre- and post-protocol groups with χ 2 analysis. Logistic regression compared risk of transfusion in pre- and post-protocol subgroups of patients with differing risk for transfusion (anemia, body mass index [BMI], and sex). RESULTS: No differences were found in baseline patient characteristics across pre- and post-protocol groups (n = 1084 and 912, respectively). TXA use increased from 32.3% to 92.2% while transfusion rates decreased from 10.3% to 4.8% (p < 0.001). Postoperative Day 3 Hb increased from 95.8 to 101.4 g/L (p < 0.001). Logistic regression demonstrated reduced transfusion in post-protocol subgroups regardless of sex, anemia, or BMI (p < 0.001). No increase in adverse events was observed (p = 0.8451). CONCLUSIONS: Universal TXA was associated with a reduction of RBC transfusion, overall and in clinically relevant subgroups, strengthening the rationale for universal therapy.

Background There is no consensus regarding the effect of the type of deformities (valgus or varus) on the functional outcome of total knee arthroplasty (TKA). We aimed to compare the TKA outcome in varus and valgus patients to find whether different angulations of the knee could affect the functional outcome of the TKA. Methods In total, 55 valgus and 53 varus osteoarthritic knees with matched age, gender, BMI, tibiofemoral angle, comorbidities, type of prosthesis, and follow-up duration were included in the study. The mean follow-up of patients was 4.5 ± 1.7 years. The knee society score (KSS) was calculated for each knee at the latest follow-up. In addition, the western Ontario and McMaster Universities arthritis index (WOMAC) was assessed for each patient several times during the study in order to monitor the course of treatment. Results The total KSS was significantly higher in varus knees than in valgus knees, with the values of 82.80 ± 10.16 versus 78.61 ± 10.7, respectively (P = 0.023). Varus patients had a significantly better preoperative WOMAC index than valgus patients (with a score of 51.2 ± 4.05 vs. 42.21 ± 4.12) (P = 0.012). At the final follow-up, varus patients still had superior WOMAC although this difference was not statistically significant (P = 0.722). Interestingly, the WOMAC change in the first and final evaluations was significantly different in the two study groups, with 22.06 in varus and 30.14 in valgus patients (P < 0.001). Conclusions According to our results, the type of deformity could affect the long-term TKA outcome. In this regard, valgus patients would benefit more than varus patients from this surgery.

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.In Canada, hospitals admit 30 000 older adults with hip fracture annually.1 These patients face an increased risk of death, with up to 5% of women and 10% of men dying within 30 days.2,3 It is generally accepted that early operative intervention improves survival by reducing patients’ exposure to immobilization and inflammation.4 In 2005, the federal, provincial and territorial governments established a benchmark of 48 hours from admission for 90% of hip fracture surgeries to prevent potentially harmful delays.5 However, delays to hip fracture surgery remain common.6 Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.7,8There has been considerable debate about the point at which delaying hip fracture surgery for nonmedical reasons worsens mortality.9–25 This uncertainty leads to prioritization without benefit to the patient or underuse of expeditious surgery that could prevent deaths. Some have argued that understanding the effects of policy change should guide reorganization of operating room resources26 and prioritization in the presence of competing demand.7,27–29 In this paper, we offer 2 new estimates: the effect of possible changes in surgical timing policy in the same population of patients, and the proportion of in-hospital deaths attributable to surgical delays.

Background It has been suggested that total knee replacement is being performed in people with less-severe osteoarthritis. We aimed to determine whether there were differences in the presurgery profile, symptoms and disability of 2 cohorts who underwent total knee replacement over a 10-year period. Methods Patients aged 18-85 years undergoing primary total knee replacement for osteoarthritis at 1 of 4 sites in Toronto and Strathroy, Ontario, were recruited in a cohort study during 2006-2008 (cohort 1) and 2012-2015 (cohort 2). Patients undergoing unicompartmental or revision arthroplasty were excluded. Demographic and health (body mass index [BMI], comorbidity) variables and osteoarthritis severity, as assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the disability component of the Late-Life Function and Disability Instrument (LLFDI-D), were collected before surgery. We calculated proportions, means and standard deviations with 95% confidence intervals (CIs) for all data. We constructed density plots by tertile score for the WOMAC pain and physical function subscales and the LLFDI-D limitation scale. Results There were 494 patients in cohort 1 and 251 patients in cohort 2. There were no differences in age, sex, education, living status, BMI, comorbidity, pain severity or disability between the cohorts based on overlapping 95% CIs and the density plots. More patients in cohort 1 than in cohort 2 were single (176 [35.6%], 95% CI 32.5%-41.1% v. 63 [25.1%], 95% CI 20.3%-31.0%). Patients in cohort 2 reported less limitation in higher-demand activities than did those in cohort 1 (mean score on LLFDI-D 62.3 [95% CI 60.7-63.9] v. 59.2 [95% CI 58.2-60.2]). Interpretation The patient profile and reported osteoarthritis severity were similar in 2 cohorts that had total knee replacement over a 10-year period. This suggests that increasing total knee replacement volumes over this period likely were not driven by these factors.

The purpose of this review article was to investigate the incidence and predisposing factors for periprosthetic proximal femoral fractures (PFF) following total hip arthroplasty.We performed a comprehensive search of the medical literature in MEDLINE and EMBASE databases to review articles related to PFF, their incidence and risk factors.The incidence of PPF after primary THA was, in general, lower than after revision THA both for intra- and postoperative PFF. The rate of intraoperative PFF ranged from 0.1% to 27.8% and of postoperative PFF from 0.07% to 18%. Predisposing factors for intraoperative PFF are osteoporosis, rheumatoid arthritis, femoral preparation and surgical technique used to insert the rasp or femoral component, the use of press-fit cementless stems, and revision THA. In case of postoperative PFF, the following seem to be significant risk factors: advanced age, female gender, post-traumatic osteoarthritis, osteoporosis and rheumatoid arthritis, proximal femoral deformities, previous surgery of the affected hip, implant type (especially cementless stems and press-fit implantation), technical errors such as cortical perforation, cortical stress risers, low-energy trauma, osteolysis, loosening and revision THA.

As outlined in our January 16, 2013, editorial , “The Case Report Redefined with JBJS Case Connector ,” one important role of JBJS Case Connector is to alert the orthopaedic community about a potentially problematic device or therapy. When two or more such cases with similar mechanisms appear, we will identify the procedure or implant as a “watchable” intervention. While this system is not statistically conclusive and may or may not be supported by other published case reports or registry data, the intention is to sharpen the focus of clinicians on the potential for similar problems and thereby enhance clinical outcomes and patient safety. The “Watch” designation may also encourage others to report related difficulties and enlist the orthopaedic community to either demonstrate that these are isolated, unrelated cases or sharpen the focus further on rigorously evaluating the intervention. Where appropriate, we may identify brand, model, or implant-lot specifics. In total hip arthroplasty (THA), a fractured ceramic head is a catastrophic but thankfully very rare event. Most case reports of ceramic head fractures involve ceramic-on-ceramic articulations, but this “Watch” describes three cases of femoral head fractures involving ceramic-on-polyethylene bearings. Moreover, the fractures occurred in association with little or no postsurgical trauma. Ceramic hip components are often chosen for younger patients in an effort to minimize long-term wear. On the downside, unlike metal, ceramic components can fracture. Ceramic femoral head fractures arise from four main factors: trauma; material or manufacturing defects; non-compatible, damaged, or contaminated femoral stem/head taper connections; or other suboptimal surgical techniques. The ceramics industry has a more-than-forty-year track record of continuous improvement in hip-component manufacturing. CeramTec, the main U.S. player in this arena, first introduced ceramic hip components in 1974; those first-generation femoral heads had a fracture rate of 0.026%. By 2003, when CeramTec introduced its fourth-generation BIOLOX …

PurposeFailure to account for medically necessary delays may lead to an underestimation of early surgery benefits. This study investigated the feasibility of using administrative data to identify the National Institute for Health and Care Excellence (NICE) 124 guideline list of conditions that appropriately delay hip fracture surgery.MethodsWe assembled a list of diagnosis and procedure codes to reflect the NICE 124 conditions. The list was reviewed and updated by an advanced clinical coder. The list was refined by five clinical experts. We then screened Canadian Institute for Health Information discharge abstracts for 153 918 patients surgically treated for a non-pathological first hip fracture between 1 January 2004 and 31 December 2012 for diagnosis codes present on admission and procedure codes that antedated hip fracture surgery. We classified abstracts as having medical reasons for delaying surgery based on the presence of these codes.ResultsIn total, 10 237 (6.7%; 95% CI 6.5% to 6.8%) patients had diagnostic and procedure codes indicating medical reasons for delay. The most common reasons for medical delay were exacerbation of a chronic chest condition (35.9%) and acute chest infection (23.2%). The proportion of patients with reasons for medical delays increased with time from admission to surgery: 3.9% (95% CI 3.6% to 4.1%) for same day surgery; 4.7% (95% CI 4.5% to 4.8%) for surgery 1 day after admission; 7.1% (95% CI 6.9% to 7.4%) for surgery 2 days after admission; and 15.5% (95% CI 15.1% to 16.0%) for surgery more than 2 days after admission. The trend was seen for admissions on weekday working hours, weekday after hours and on weekends.ConclusionAdministrative data can be considered to identify conditions that appropriately delay hip fracture surgery. Accounting for medically necessary delays can improve estimates of the effectiveness of early surgery.

© 2017 Elsevier Ltd Introduction: The incidence of periprosthetic femoral fractures around total hip arthroplasties is increasing. Fractures around a stable implant stem (Vancouver type B1) are among the most common of these fractures. Various fixation strategies for Vancouver type B1 periprosthetic fractures have been reported in the literature; however, little high-level evidence exists. This study was designed to determine the current management strategies and opinions among orthopaedic surgeons treating Vancouver type B1 periprosthetic femoral fractures, and to evaluate the need for a large prospective randomized controlled trial for the management of these injuries. Methods: Orthopaedic surgeon members of the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the Hip Society were invited to participate in a 51-item web-based survey surrounding the management of periprosthetic femoral fractures around total hip replacements, as well as the perceived need for future research in this area. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training. Results: For Vancouver type B1 fractures, open reduction and internal fixation (ORIF) with locked plating was favoured slightly over ORIF with cable plating ± cortical strut allograft (51.1% versus 45.5%). When compared to cable plating with cortical strut allograft, respondents believed that isolated locked plating resulted in lower nonunion and reoperation rates, but similar infection and malunion rates. Subgroup analyses revealed that practice type, surgeon age, case volume, and fellowship training influenced surgeons’ management of periprosthetic femoral fractures and beliefs regarding complications. There is high demand for a large prospective randomized controlled trial for Vancouver type B1 fracture fixation. Conclusions: Consensus surrounding the management of Vancouver type B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries.

© 2015, The Association of Bone and Joint Surgeons®. Background: Despite modern fracture management techniques allowing for near anatomic reduction of acetabular fractures, there continues to be a risk of posttraumatic arthritis and need for total hip arthroplasty (THA). Few well-controlled studies have compared THA after acetabular fractures with THAs performed for other indications in terms of survivorship or complications, and none, to our knowledge, present 10-year survivorship data in this setting. Questions/purposes: (1) How does the 10-year survival of THA compare between those patients who underwent THA after an acetabular fracture and those who underwent THA for primary arthritis or avascular necrosis (AVN)? (2) Is there an increased risk of serious complications like infection, dislocation, and aseptic loosening as well as heterotopic ossification associated with a THA performed after a previous acetabular fracture? Methods: This retrospective case-control study compared findings of patients who underwent THA after acetabular fracture versus a matched cohort of patients who had received a primary THA for primary osteoarthritis or AVN. Between 1987 and 2011, we performed 95 THAs after acetabular fracture; of those, 74 (78%) met inclusion criteria and had documented followup beyond 2 years in our institutional registry. We selected 74 matched patients based on an algorithm that matched patients based on preoperative diagnosis, date of operation, age, gender, and type of prosthesis. During this time, we performed approximately 8000 THAs that were potentially available for matching based on complete followup beyond 2 years. We compared cases and control subjects using the Kaplan-Meier survivorship estimator as well as a comparison of the proportions in each group that developed major complications (including infection, dislocation, loosening, and heterotopic ossification) based a retrospective chart review. Results: The 10-year survivorship after THA was lower in patients with a previous acetabular fracture than in the matched cohort (70%, 95% confidence interval [CI], 64%–78%, versus 90%, 95% CI, 86–95%; p < 0.001). There was no difference in the 10-year survival rate for those patients whose acetabular fracture was initially treated conservatively and those treated by open reduction and internal fixation. Patients with previous acetabular fracture had a higher likelihood of developing infection (7% [five of 74] versus 0% [zero of 74]; odds ratio [OR], 11.79; p = 0.028), dislocation (11% [eight of 74] versus 3% [two of 74]; OR, 4.36; p = 0.048), or heterotopic ossification (43% [32 of 74] versus 16% [12 of 74]; OR, 3.93; p < 0.001). Conclusions: In this case-control study, patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary osteoarthritis or AVN. Given these findings, management of these complex cases should be in highly specialized units where the expertise of arthroplasty and trauma reconstruction is available. Level of Evidence: Level III, therapeutic study.

In an effort to reduce wait times associated with joint replacement surgery, the overall arthroplasty caseload in the province in Ontario has increased by more than 50% in the past 5 years.1,2 As a result, the number of total joint arthroplasties being performed during a surgical day has also increased. Many surgeons now perform 5 or 6 total joint operations in a single day, with operative working hours approaching 10. There is no doubt that this increased caseload has led to increased surgeon fatigue, particularly for cases performed at the end of the operating day compared with those performed at the beginning. There is growing support in the literature that patient outcomes are adversely affected by fatigue in operator-dependent cognitive and technical tasks. Adverse events and medical errors have been shown to occur more frequently in sleep-deprived physicians, and technical skills have also been shown to be negatively influenced by physician fatigue.3–9 More specifically, laparoscopic procedures,10 cardiac interventions,11 endotracheal intubation12 and colonoscopies13,14 have been shown to have inferior outcomes when performed later in the day. These findings potentially have implications for physician productivity, procedural outcome and, most importantly, patient safety. There are many factors that contribute to the outcome of total joint arthroplasty, including preoperative, intraoperative and postoperative variables. It is well established that preoperative variables, such as unrealistic patient expectations,15–18 diabetic control19,20 and obesity,21–23 can have a negative effect on radiologic and functional outcomes. Fortunately, these variables are modifiable and therefore have the potential to be optimized preoperatively. Postoperative variables, such as participation in rehabilitation and avoidance of limb positions that may predispose to hip dislocation, are also modifiable variables that have been shown to affect outcome.24,25 The influence of intraoperative variables on outcomes in total joint arthroplasty have been less extensively studied. Duration of the surgical procedure,26,27 blood loss28 and component alignment29–33 are modifiable intraoperative variables that influence patient outcomes and may be adversely affected by surgeon fatigue. To our knowledge, the extent to which fatigue affects the technical and cognitive skills of the surgeon and overall patient outcomes in total joint arthroplasty has not previously been studied. The purpose of this retrospective study was to determine whether there is a difference, in terms of perioperative and postoperative complications, between patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) at different times during the operative day.

Background: The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with abnormal femoral head anatomy. Methods: The current study examines whether a bone-preserving femoral component that is fixed into the femoral neck metaphysis provides a mechanical advantage in terms of resisting femoral neck fracture in comparison with a conventional hip resurfacing implant in a human cadaveric femoral model. Results: Femora with a BMHR femoral component failed at an average of 23% less load than those prepared with a conventional hip resurfacing component (mean and standard deviation, 5434 ± 2297 compared with 7012 ± 2619 N; p < 0.001). Conclusions: An uncemented, metaphyseal fixed, bone-conserving femoral implant does not provide superior mechanical strength or increased resistance to femoral neck fracture in comparison with a conventional hip resurfacing arthroplasty.

Background: The aim of this study was to assess the outcome of immediate plate osteosynthesis in the surgical treatment of open humeral shaft fractures. Methods: In a Level I trauma center and teaching hospital, we reviewed 53 patients with open humeral diaphyseal fractures who were treated with immediate open reduction and plate fixation from April 1988 to August 1998. Forty-six patients were available for adequate follow-up and assessment. All fractures were treated with a standard protocol that included irrigation and debridement, intravenous antibiotics, and immediate open reduction and plate fixation. Patients were assessed to determine whether bone grafts were needed during surgery, whether bone union was achieved, the state of the radial nerve, and postoperative complications. No quantitative functional outcomes were assessed, because this was beyond the scope of the study. It was hypothesized that immediate plate osteosynthesis would achieve safe and acceptable clinical results. Results: The 46 patients with adequate final follow-up were assessed at a mean time of 37.5 weeks (13-156 weeks). All fractures united primarily in satisfactory angulation

The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with compromised femoral head anatomy. The current study examined the effect of coronal implant alignment and femoral neck notching on proximal femoral strength with the BMHR. Neither relative valgus nor varus implant alignment had a significant impact on femoral strength compared to neutrally aligned, matched, paired cadaveric specimens. A 5-mm superior neck notch significantly weakened BMHR-implanted synthetic femurs compared to unnotched controls, whereas a 2-mm notch did not significantly affect ultimate failure load. Relative valgus alignment had a protective effect on a full-cortical-thickness superior neck notch. Mid-head resection arthroplasty may be more forgiving to minor preparatory errors than a typical hip resurfacing.

Nonunion of fractures about the femoral neck and intertrochanteric hip regions is uncommon. Patients who develop nonunions of these fractures typically exhibit marked pain and disability, thereby presenting a treatment challenge to the orthopaedic surgeon. Factors that guide the choice of salvage treatment include the anatomic site of the nonunion, the quality of the remaining proximal bone and articular surface, and patient factors (such as age and activity level). In the younger patients with a well-preserved hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. However, in older patients, it is more common to encounter poor remaining proximal bone stock or a badly damaged hip joint from hardware cutout. As such, conversion to hip arthroplasty is intended to help effectively restore function and relieve pain. With respect to salvage procedures for the femoral head, the major challenges in decision making include the choice of both internal fixation device and accurate preoperative planning. The challenges involved in planning to convert to hip arthroplasty include the need for acetabular resurfacing, selecting the femoral implant, and managing discontinuity of the greater trochanter. Furthermore, there are additional technical challenges that may be encountered, such as broken hardware, deformity, and femoral bone defects. Overall, salvage of nonunions of femoral neck and intertrochanteric hip fractures in properly selected patients can provide patients with good to excellent results.

Closing wedge high tibial osteotomy is a common, effective and well-established procedure to treat unicompartment osteoarthrosis of the knee. It is, however, not without its complications. This article will discuss some of these complications and present an overview of the current literature. It will examine current thoughts on aetiology, techniques to try to avoid, and methods of treatment of these complications.

Background: A variety of methods are available for the fixation of femoral shaft fractures after total hip arthroplasty. However, few studies in the literature have quantified the performance of such repair constructs. The aim of this study was to evaluate biomechanically four different constructs for the fixation of periprosthetic femoral shaft fractures following total hip arthroplasty. Methods: Twenty synthetic femora were tested in axial compression, lateral bending, and torsion to determine initial stiffness, as well as stiffness following fixation of a simulated femoral midshaft fracture with and without a bone gap. Four fracture fixation constructs (five specimens per group) were assessed: construct A was a Synthes locked plate (a twelve-hole broad dynamic compression plate) with locked screws; construct B, a Synthes locked plate (a twelve-hole broad dynamic compression plate) with cables and locked screws; construct C, a Zimmer nonlocking (eight-hole) cable plate with cables and nonlocked screws; and construct D, a Zimmer nonlocking (eight-hole) cable plate with allograft strut, cables, and nonlocked screws. Axial stiffness, lateral bending stiffness, and torsional stiffness were assessed with respect to baseline intact specimen values. Axial load to failure was also measured for the specimens. Results: Construct D demonstrated either equivalent or superior stiffness in all testing modes compared with the other constructs in femora with both a midshaft fracture and a bone gap. A comparison of constructs A, B, and C demonstrated equivalent stiffness in all test modes (with one exception) in femora with a midshaft fracture and a bone gap. Conclusions: A combination of a nonlocking plate with an allograft strut (construct D) resulted in the highest stiffness of the constructs examined for treating a periprosthetic fracture around a stable femoral component of a total hip replacement. Clinical Relevance: A locked plate (constructs A and B) should be used with caution as a stand-alone treatment for the fixation of a periprosthetic femoral shaft fracture following total hip arthroplasty, particularly with good bone stock.

Nonunion is a relatively common complication of proximal femoral fracture resulting from poor mechanical alignment of the fracture, failure of internal fixation, poor biologic factors, or infection. In this article, we discuss surgical procedures for the salvage of both femoral neck fracture and intertrochanteric hip fracture nonunion. These procedures include proximal femoral valgus osteotomy for femoral neck fracture nonunion, revision open reduction with internal fixation for intertrochanteric hip fracture nonunion, and hip arthroplasty. Preoperative planning, surgical technique, common complications, and results from the literature for these procedures are discussed.

Objective To identify whether patients in lower socioeconomic groups had worse pain and functional levels prior to total knee arthroplasty and then establish whether these patients had poorer post-operative outcomes following total knee arthroplasty. Method Data was obtained from a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in 13 centers in 4 countries. Pre-operative data was collected and patients were followed for 2 years post-operatively. Pre-operative details of the patients' demographics; socioeconomic status (SES) (education and income); height; weight and co-morbid conditions were obtained. The WOMAC scores were obtained preoperatively and during follow-up. Results Using multivariate linear regression analysis, patients with a lower income had a significantly worse pre-operative WOMAC Pain ( P = 0.021) and function score ( P = 0.039) than those with higher incomes. However, income did not have a significant impact on outcome at final follow-up after adjusting for other significant covariates. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. Conclusion Across all four countries, patients with lower incomes appeared to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to affect the final outcome following total knee arthroplasty. Patients with lower incomes appeared able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively. These findings are in contrast to studies on other medical conditions and surgical interventions, in which a lower SES has been found to have a negative impact on patient outcomes.

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Background: Many treatments for osteonecrosis of the femoral head, including the use of a free vascularized fibular graft, have been advocated in an attempt to delay the need for hip arthroplasty. The purpose of this study was to document the clinical and radiographic results of total hip arthroplasty performed following failure of a free vascularized fibular grafting procedure. Methods: Twenty total hip arthroplasties in eighteen patients who had previously undergone a free vascularized fibular grafting procedure for the treatment of osteonecrosis were retrospectively reviewed. A straight-stem femoral component was used in twelve hips, a tapered femoral component with removal of residual fibular graft was used in five hips, and a tapered stem without graft removal was used in three hips. The twelve hips with a straight-stem femoral component and previous vascularized fibular grafting were compared with thirty-six osteonecrotic hips in thirty other patients who had undergone total hip arthroplasty but had not had previous free vascularized fibular grafting. The radiographic outcomes with respect to initial femoral component alignment and subsequent migration and the clinical outcomes were compared. Results: Analysis of the immediate postoperative radiographs demonstrated significantly improved alignment of the femoral component when a high-speed burr had been used to remove residual fibular graft (p = 0.001), although doing so did significantly increase both the intraoperative blood loss (p = 0.017) and the operative time (p = 0.0002). There was no significant difference in the amount of migration of either the acetabular or the femoral component between the control and study groups at the time of the most recent follow-up. When comparing patients with or without a previous free vascularized fibular graft, the mean postoperative scores at three years were significantly worse in patients who had undergone a previous free vascularized fibular graft (p = 0.03). One revision occurred in the study group at seventy-two months due to acetabular wear, and one revision occurred in the control group at 108 months due to aseptic loosening. Conclusions: This study raises concern that the outcome of total hip arthroplasty in patients who previously underwent a free vascularized fibular graft for the treatment of osteonecrosis of the femoral head may be worse than that in patients without previous free vascularized fibular grafting. The intraoperative use of a high-speed burr can improve the alignment of the femoral component by removing more of the residual graft. However, this technique does increase intraoperative blood loss and operative time. Level of Evidence: Therapeutic Level IV. See Instructions to Authors on [jbjs.org][1] for a complete description of levels of evidence. [1]: http://jbjs.org

Background: Little is known about factors that might predict functional outcome following revision hip arthroplasty. The purpose of this study was to identify predictors of pain and physical function at two years following revision total hip arthroplasty and to evaluate whether the time that the patient waited for the surgery and whether the patient had complications were significant predictors of outcome. Methods: One hundred and twenty-six patients (126 hips) were entered prospectively into the study when their name was placed on the waiting list for surgery. Baseline measures included demographic factors, comorbidities, and the responses to the Short Form-36 (SF-36) and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaires. Follow-up was carried out at six-month intervals while the patient was waiting for the surgery; within one week prior to the surgery; and at six, twelve, and twenty-four months after the surgery. Patient age and gender, the preoperative WOMAC pain and function scores, the physical and mental component scores of the SF-36, comorbidities, the number of revisions, bilateral joint replacement, and the severity of the revision were evaluated as possible predictors of ultimate pain and function as measured with the WOMAC instrument. Results: The mean age of the patients was 68.6 years. Improvement in WOMAC pain and function scores plateaued at six months. The mean pain score (and standard deviation) improved from 9.4 ± 4.1 points preoperatively to 3.9 ± 3.9 points at six months postoperatively, and the mean function score improved from 35.4 ± 14.1 to 19.1 ± 13.2 points. Preoperative pain (p = 0.002) and comorbidity (p = 0.02) were significant predictors of pain at two years. There was a trend toward preoperative function predicting function at twenty-four months (p = 0.07). There was no significant deterioration in the WOMAC pain or function score while the patients waited for surgery. Twenty-eight patients had complications. When the time that the patient waited for the surgery and complications were added to the models, only complications were found to be predictive of outcome (p = 0.04 for pain and p = 0.05 for function). Four patients required repeat revision during the follow-up period. Conclusions: Patients with better preoperative pain scores and fewer comorbidities have better outcomes following revision total hip arthroplasty. Although the time that the patient waited for the revision was not predictive of the ultimate WOMAC pain and function scores, we believe that performing revision arthroplasty before the patient has substantial functional compromise potentially improves the outcome. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

The purpose of the study was to determine whether isolated revision of the acetabular component can be successfully performed without disturbing the femoral stem and to determine the fate of the unrevised femoral stem following revision. Fifty-seven hips in 55 patients underwent isolated acetabular revision without removal of the femoral component. Thirty-three hips with minimal acetabular deficiency required no bone grafting; the remaining 24 hips were treated by morselized or structural allograft in addition to a new acetabular component. Twenty-two of these 24 hips demonstrated incorporation of the bone graft. A mean follow-up of 5.8 (5–9) years, all femoral and acetabular components were judged to be stable and well fixed.

Total hip replacement is rarely used in the treatment of acute intertrochanteric fractures of the femur. Pathologic fractures with involvement of the femoral head and/or periacetabular pelvis may represent one such indication; rheumatoid arthritis with or without radiographic involvement of the joint space or end-stage osteoarthritis with substantial hip symptoms before fracture may represent other indications. Total hip replacement is mainly reserved for the treatment of complications such as nonunion or avascular necrosis of the femoral head.

© 2015 The Authors. Optimal component alignment in total knee arthroplasty has been associated with better functional outcome as well as improved implant longevity. The ability to align components optimally during minimally invasive (MIS) total knee replacement (TKR) has been a cause of concern. Computer navigation is a useful aid in achieving the desired alignment although it is limited by the error during the manual registration of landmarks. Our study aims to compare the registration process error between a standard and a MIS surgical approach. We hypothesized that performing the registration error via an MIS approach would increase the registration process error. Five fresh frozen lower limbs were routinely prepared and draped. The registration process was performed through an MIS approach. This was then extended to the standard approach and the registration was performed again. Two surgeons performed the registration process five times with each approach. Performing the registration process through the MIS approach was not associated with higher error compared to the standard approach in the alignment parameters of interest. This rejects our hypothesis. Image-free navigated MIS TKR does not appear to carry higher risk of component malalignment due to the registration process error. Navigation can be used during MIS TKR to improve alignment without reduced accuracy due to the approach

The management of proximal humeral fractures has been discussed in surgical textbooks for greater than 3000 years. Detailed descriptions of reduction and splinting are found in surgical texts from both Ancient Egypt and Greece [1]. Today, proximal humeral fractures account for up to 5 % of all fractures treated [2]. Between 50 and 80 % of these can be treated non-operatively and are non-displaced or minimally displaced 2-part fractures [3–8]. Three- and four-part fractures represent 15 % of all proximal humeral fractures. Seventy percent of three- and four-part fractures are seen in patients over 60 years old and 50 % of such fractures are seen in those over 70 years old [2]. The elderly are more susceptible to this type of fracture due to co-morbid conditions that predispose these patients to low energy falls. Such co-morbid conditions include poor vision, balance problems, loss of protective reflexes, and polypharmacy. Furthermore, poor bone quality in the elderly population accounts for a greater severity of injury with more complex fracture patterns in spite of little mechanical insult. With a growing elderly population, the rate of proximal humeral fractures has increased by an average of 13 % per year between 1970 and 2002 [2, 9–12]. The number of these fractures in the elderly population is expected to triple by 2030 [6].

Mid-head resection short-stem hip arthroplasty is a conservative alternative to conventional total hip replacement and addresses proximal fixation challenges in patients not suitable for hip resurfacing. It is unclear whether proximal femoral morphology impacts the ultimate failure load of mid-head resection implanted femurs, thus the aim of this study was to investigate the effect of native neck-shaft angle (NSA) and coronal implant alignment on proximal femoral strength. In total, 36 synthetic femurs with two different proximal femoral morphologies were utilized in this study. Of them, 18 femurs with a varus NSA of 120° and 18 femurs with a valgus NSA of 135° were each implanted with a mid-head resection prosthesis. Femurs within the two different femoral morphology groups were divided into three equal coronal implant alignment groups: 10° valgus, 10° varus or neutral alignment. Prepared femurs were tested for stiffness and to failure in axial compression. There was no significant difference in stiffness nor failure load between femurs implanted with valgus-, varus- or neutrally aligned implants in femurs with a NSA of 120° (p = 0.396, p = 0.111, respectively). Femurs implanted in valgus orientation were significantly stiffer and failed at significantly higher loads than those implanted in varus alignment in femurs with a NSA of 135° (p = 0.001, p = 0.007, respectively). A mid-head resection short-stem hip arthroplasty seems less sensitive to clinically relevant variations of coronal implant alignment and may be more forgiving upon implantation in some femoral morphologies, however, a relative valgus component alignment is recommended.

All of the current modalities have a place in the treatment of diaphyseal humeral fractures. Functional bracing renders a high rate of union and seems to be a safe method of treatment for most closed fractures. Type II and III open fractures seem to respond best to plate fixation or external fixation, particularly when there are associated neural or vascular pathologic findings. Patients with polytrauma who are unable to walk are also best treated with plate fixation. Plate fixation is also the best method of treatment when adequate alignment cannot be obtained with nonsurgical methods. Intramedullary nailing remains controversial because its complication rate is higher than that associated with either plate fixation or functional bracing. None of the treatments described is a panacea, and complications may occur with each one of them. An appropriate appreciation of the biologic response to the three modalities; an understanding of the indications, contraindications, and possible complications of the treatments; and a mastery of the techniques of application are essential for the attainment of satisfactory clinical results.

Objective-To establish whether hydroxyapatite (HA) coatings applied to metal total-hip-replacement components increased synovitis in the coxofemoral joint of dogs. Study Design-An in vivo research trial and histologic study. Animals-Twenty-three large, mixed-breed dogs. Methods-Arthroplasty components were implanted with HA on neither stem nor cup, or with HA applied to either the femoral component or with both stem and cup having HA applied in 23 dogs. Synovial inflammation was scored 3, 6, and 12 months after surgery. Synovial membrane thickness; polyethylene particulate load; fibrin exudate; membrane edema; mitotic index; giant-cell, mononuclear histiocyte, lymphocyte, and polymorph number; and collagen degeneration were scored and statistical analyses performed. Results-Operated-side synovial thickness was greatly increased relative to control. Fibrin deposition, intramembranous edema, and collagen degeneration were similar within each time interval among the various component groups. The majority of inflammatory scores among the groups were unchanged. In this 12-month study, the presence of HA coatings appear not to have a marked impact on the development of synovial inflammation. Conclusions-HA-coated components do appear to contribute somewhat to the inflammatory load within the periprosthetic environment, but this effect is not marked. Clinical Relevance-The major advantage of HA addition to arthroplasty components is enhanced osteoconductivity around metallic surfaces. The slight increase in particulate load seen in the presence of HA coatings may contribute to the development of aseptic loosening of arthroplasty components, but is unlikely to be the major causative factor. (C) Copyright 2001 by The American College of Veterinary Surgeons.

Objectives: To review the long-term functional results of the surgical treatment of tibial plateau fractures using standard techniques of open reduction and internal fixation. Design: Retrospective study. Setting: University hospital. Methods: Forty-seven displaced fractures of the tibial plateau in forty-six patients were treated with open reduction, interfragmental screw fixation of the articular fragments, and buttress plate fixation and had a minimum of five years of follow-up. All aspects of their care, including tibial plateau fracture type, operative management and associated injuries, were documented. Preoperative and postoperative follow-up radiographs were analyzed for fracture classification and adequacy of reduction. All patients were contacted and given functional outcome questionnaires using both a generic health status scale (Short Form 36 [SF-36]) (18) and a disability scale relating to knee osteoarthritis (Western Ontario and McMaster Universities Osteoarthritis index [WOMAC]) (1). Data were also collected regarding return to work and sporting activities. Assessment scores were analyzed with respect to age, fracture type and severity, and were compared to standardized age and sexmatched scores for the healthy population. The average age of the patients at the time of injury was forty years and the average follow-up period was 8.3 years. Of the forty-seven fractures studied, twenty-five were classified as Schatzker types I, II, or III, and the remaining twenty-two were types IV, V, or VI (15). All fractures received operative treatment within forty-eight hours and all but five fractures were acceptably reduced. Results: Compared to the standardized SF-36 categorical and aggregate scores, there was no statistically significant difference between the healthy age-matched population and twenty-four of twenty-six of the under-age-forty group regardless of fracture type. With regard to the over-age-forty group, scores statistically similar to the control population were found in only twelve of twenty-one patients. Although there was a large variance in WOMAC scores for all groups resulting in no statistically significant difference being found, a trend toward higher categorical and aggregate scores was seen with increasing age at presentation. There was no correlation between WOMAC scores and fracture type. Multiple-classifications analysis of all data revealed that presentation age was the most significant source of variation with respect to functional outcome. Fracture type had much less influence and adequacy of reduction had no significant influence on outcome, although the group of patients having an inadequate reduction by the authors' criteria was too small in number to reasonably comment upon. Conclusions: Open reduction and internal fixation is a satisfactory technique for the treatment of displaced fractures of the tibial plateau, particularly for patients younger than forty years.

In the past, foot injuries in patients with multiple trauma were thought to be of lesser importance than fractures of long bones. In a more recent prospective study from the authors' institution, 59 however, multiple trauma patients with foot injuries were shown to have a poorer functional outcome when compared with matched controls. To address these concerns, this article has two parts. The first part is an overview of general principles in the treatment of foot injuries in the polytrauma patient. The treatment of specific injuries is beyond the scope of this article, but an approach is highlighted that can be remembered when decisions are made regarding these severely injured patients. The second part reviews the findings from the authors' study, 59 focusing on functional outcomes of multiple trauma patients with foot injuries.

Background: The Patient-Specific Index is unique in that it reflects how individual patients weigh concerns in rating the outcome of total hip arthroplasty. The Patient-Specific Index was originally administered by an interviewer, which is not always feasible and can be costly. The purposes of the present study were (1) to create a self-reported version of the Patient-Specific Index, (2) to determine the reliability of this new self-reported version, and (3) to determine the relationship between the scores on the new self-reported version and those on the original interviewer-administered version. Methods: A self-reported version of the Patient-Specific Index was developed, and a pilot test was performed on ten patients. Patients who were scheduled for a total hip arthroplasty or who had recently had a total hip arthroplasty were eligible for the reliability and validity testing. A copy of the new self-reported Patient-Specific Index was mailed to the patients, and they completed it independently. The patients' ratings of the importance and severity of twenty-four concerns prior to total hip arthroplasty were added together to create a summary Patient-Specific Index score. To determine test-retest reliability, patients completed the self-reported Patient-Specific Index a second time, two weeks later. To determine criterion validity, participants also completed the interviewer-administered Patient-Specific Index. Results: Fifty-five patients completed the study. The random-effects intraclass correlation test-retest coefficient was 0.79 (greater than 0.75 represents excellent reliability). The mean Patient-Specific Index scores on the self-reported version and on the interviewer-administered version were 173 and 165 points, respectively (Student t test, p = 0.45). The self-reported Patient-Specific Index was concordant with the interviewer-administered Patient-Specific Index (intraclass correlation coefficient, 0.78). Conclusions: We concluded that a self-reported version of the Patient-Specific Index, which focuses on the concerns of individuals, is reliable and has criterion validity compared with an interviewer-administered version.

Objective: We sought to determine the effectiveness of intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction. Study Design: Prospective, randomized clinical trial. Methods: Eighty-five tibial shaft fractures (in seventy-nine patients) treated by intramedullary nailing were randomized either to manual traction with the leg draped free or to standard fracture table traction applied through a boot attachment. Results: We found that manual traction provided results, in terms of intraoperative parameters and quality of fracture reduction, similar to those with standard fracture table traction. Manual traction significantly reduced positioning time (twelve minutes versus twenty-five minutes, p = 0.002) and also allowed for multiple simultaneous or sequential procedures in polytrauma patients without the need for re-positioning or re-draping. This saved a further thirty-two minutes (mean) in 37 percent of cases treated by manual traction. Conclusion: Manual traction for intramedullary nailing of the tibia is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures. It is especially useful in polytrauma patients with multiple lower-extremity injuries.

Objective: To assess the functional outcome of multiply injured trauma patients with foot injuries and to determine which outcome measures are most appropriate for this assessment. Design: Prospective, matched pair analysis. Setting: University-affiliated Level I trauma center with a prospectively entered trauma database. Patients: Twenty-eight multiply injured patients with foot injuries were randomly identified in our prospective trauma database (Group 1), The patients in Group I were randomly matched in a blinded fashion to twenty-eight multiply injured patients without foot injuries who were selected from the entire group of patients in our trauma database (Group 2). The patients were matched by age, sex, length of follow-up, and Injury Severity Score. Main Outcome Measures: Three outcome tools were used: the Short Form 36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the modified Boston Children's Hospital Grading System. Results: The outcome of multiply injured patients with foot injuries was significantly worse than that of patients without foot injuries when using any of the three outcome measures (SF-36, p = 0.008; WOMAC, p = 0.00007; modified Boston Children's score, p 0.001). The outcome of patients with foot injuries was worse than that of those without foot injuries in five of the eight components of the SF-36 score (physical functioning, p = 0.0004; role physical, p = 0.01 : bodily pain, p = 0.01; social functioning, p = 0.01; role emotional, p = 0.006). The outcome of patients with foot injuries was worse than that of patients without foot injuries in all three components of the WOMAC (pain score, p = 0.0004; stiffness score, p = 0.007; physical function score, p = 0.00006). For the patients with foot injuries, there was strong correlation across all three scales (SF-36 VS. WOMAC, r = 0.84; SF-36 vs. modified Boston Children's Hospital, r = 0.88; WOMAC VS. modified Boston Children's Hospital, r = 0.78). Conclusions: The SF-36, WOMAC, and modified Boston Children' Hospital Grading System are all useful in assessing the outcome of multiply injured patients with foot injuries. The outcome of these patients is poor when using any of these measures. Foot injuries cause significant disability to multiply injured patients. More attention should be given to these injuries, and more aggressive management should be considered to improve the outcome of this group of multiply injured patients.

The purpose of our study was to assess the effect of comorbidity and duration of nonunion on the general health status and joint-specific outcome of a group of patients treated for nonunion of the humeral shaft. We identified 25 consecutive patients with nonunion of the humeral shaft, all treated with compression plating and bone grafting. Twenty-one patients returned for a comprehensive assessment including completion of the SF 36 Health Status Survey and determination of the Constant shoulder and Morrey elbow scores. Thirteen patients had > or = 1 comorbid conditions. Eleven patients had a nonunion of > 8 months' duration, and 10 had a nonunion of < 8 months' duration. Follow-up at a mean of 42 months (range 12 to 99 months) revealed that all nonunions united an average of 5 months after surgery. The mean Morrey elbow score was 94, Constant shoulder score 82, and "global" SF 36 score 59.4. The physical portion of the SF 36 score correlated well with the Constant and Morrey scores (p = 0.047 and p = 0.027, respectively). The presence of comorbid factors had a significant negative effect on the SF 36 scores (p = 0.001) but no effect on joint-specific Morrey or Constant scores. The duration of nonunion had no effect on SF 36 or joint-specific scores. Although the reliability of the SF 36 is illustrated by the close correlation between its "physical function" portion and standard (joint-specific) outcome measures, comorbidity has a significant negative effect on overall scores. This must be considered when such tools are used for assessment of orthopaedic intervention.

We examined donor site morbidity in thirty-nine patients with avascular necrosis of the femoral head treated by curettage and transplantation of a free ipsilateral fibular graft. Utilising our donor site morbidity questionnaire, scar, functional loss, wound healing, complications, and pain were analysed. Subjective complaints and objective findings were evaluated and compared. Subjective complaints were common and included a sense of instability in 42% and a sense of weakness in 37%. However, objective findings were limited. No clinical instability could be elicited and only great toe flexion (29%) and extension (43%) were found to be mildly weak. Only one patient required reoperation for a donor site problem (2%). Eighty-nine percent were pain free at time of follow-up, and 93% felt the scar was good. Range of motion of the knee and ankle of the donor site leg was not different from the nonoperated leg. Donor site morbidity for avascular necrosis of the femoral head is low.