Cervical transforaminal epidural steroid injections for radicular pain : a systematic review.

AIMS: Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. METHODS: OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. RESULTS: Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. CONCLUSION: There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567-574.

Aspirin monotherapy is a suitable standard thromboprophylactic agent following total hip arthroplasty.

INTRODUCTION: Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA). METHODS: A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record. RESULTS: 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (p = 0.780) or VTE (p = 1) between groups. CONCLUSION: Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.

Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate.

AIMS: Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes. METHODS: All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up. RESULTS: The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%). CONCLUSION: We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333-1338.

Mid- to long-term survivorship of the cemented, semiconstrained Discovery total elbow arthroplasty.

BACKGROUND: The incidence of total elbow arthroplasty (TEA) is increasing, and an improved understanding of elbow kinematics and biomaterials has driven advances in implant design. In modern practice, cemented, semiconstrained devices are most frequently used. The Discovery TEA has demonstrated promising early results, although there are a paucity of follow-up studies and no dedicated mid- to long-term series. We therefore present the longest, most complete such study to date. METHODS: A prospectively maintained local joint registry was interrogated to yield a consecutive series of Discovery TEAs performed at a single non-design center. The minimum follow-up period was set at 5 years. Revision procedures and TEAs performed for acute trauma were excluded. The primary outcome was survivorship of the implant. The secondary outcomes included clinical, radiographic, and patient-reported outcomes. RESULTS: We identified 67 TEAs in 58 patients for inclusion at a mean of 98.5 ± 20.4 months from surgery. Four cases (6%) were lost to follow-up, and implant survival was censored accordingly. The implant was revised in 14 cases (20.9%). The Kaplan-Meier method showed an implant survivorship rate of 76.8% at 119 months. A significant difference in survival was found between dominant and nondominant elbows (P = .012, Breslow test), with elbow dominance conferring a 4.5-fold increased risk of revision (relative risk, 4.5; 95% confidence interval, 1.1-18.5). Pooled clinical outcomes (70.9% follow-up at minimum of 60 months and median of 77.8 months) were also determined. CONCLUSIONS: We present the longest-term and most complete single-center follow-up study of the Discovery TEA to date. Further long-term survival studies are required to elucidate the performance of this implant compared with more established designs. We have also demonstrated differences in implant survivorship owing to hand dominance for the first time.

Long Term Performance of an Uncemented, Proximally Hydroxyapatite Coated, Double Tapered, Titanium-Alloy Femoral Stem: Results From 1465 Hips at 10 years Minimum Follow-Up.

BACKGROUND: We assessed the survivorship of a proximally hydroxyapatite coated, double tapered, titanium-alloy femoral stem in a single center, at an average follow up of 12.5 years (10.1-15.8). The majority of stems were inserted as part of a Metal on Metal (MoM) Total Hip Replacement (THR). METHODS: Data was collected prospectively in a local database. A retrospective review was performed of all patients undergoing a primary THR with the prosthesis between 2003 and 2010. Primary outcome was revision of the stem for any cause. Analysis was also performed for stem revision for aseptic loosening, stem revision in the MoM setting and a worst case scenario whereby lost to follow up were presumed to have failed. True stem failure was considered if revision occurred for a stem related complication. RESULTS: 1465 stems were included (1310 patients, 155 bilateral). The bearing surface was cobalt chrome on cobalt chrome in 1351 cases (92%). Seven hips were lost to follow up. Thirty-two stems (31 part of a MoM THR) underwent revision for any cause. Kaplan Meier survival analysis demonstrates an overall 97.4% survivorship. Subset analysis demonstrates 100% survivorship for aseptic loosening, 97.3% in the MoM setting and 96.7% for the worst case senario. Of the 32 cases of stem revision, only 13 were classified as 'true' stem failure. CONCLUSION: This study represents the largest cohort of this uncemented femoral component with a minimum follow-up longer than 10 years. Our results demonstrate excellent long-term survivorship even in the presence of a challenging MoM environment.

Severe Neurovascular Compromise Associated with Plastic Deformation of Ulna Elastic Nail Following Forearm Re-fracture.

We present a case of periprosthetic re-fracture of the forearm in a child with previous intramedullary elastic nailing of the ulna and plate fixation of the radius for a both-bone forearm fracture. In-situ plastic deformation of the ulna elastic nail resulted in persistent angulation and subsequent severe neurovascular compromise. The angulation was resistant to emergent attempts at closed manipulation and therefore nail removal, open reduction, and internal fixation were performed. At final follow-up, fracture union was demonstrated and there was no residual neurological deficit.

The Outcome of Revision Surgery for Failed Metal-on-Metal Total Hip Arthroplasty.

BACKGROUND: Metal-on-metal total hip arthroplasties (MoM THAs) are frequently revised, though there is a paucity of functional outcome data. We report on outcomes and prognostic factors predictive of outcome from the largest series of MoM THA revisions to date. METHODS: A single-center consecutive series of revisions from MoM THAs was identified. The cohort was divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score [OHS]). Secondary outcomes were complication data, pre-revision and post-revision blood metal ions, and modified Oxford classification of pre-revision magnetic resonance imaging. RESULTS: One hundred eighty revisions at median follow-up of 5.48 years were identified. Median OHS improved from 29 to 37 with revision (P < .001). Symptomatic patients experienced the greatest functional benefit (ΔOHS 6.5 vs 1.4, P = .012), while the function of asymptomatic patients was unaffected by revision (P = .4). Use of a cobalt-chromium-containing bearing surface at revision and increased body mass index were predictive of poor functional outcome. CONCLUSION: Symptomatic patients experience greater functional benefit from revision surgery but do not regain the same level of function as patients who were asymptomatic prior to revision. Body mass index and use of cobalt-chromium-containing bearing surfaces are prognostic for poor functional outcome.

Mid-bundle positioning of the femoral socket increases graft rupture in anatomic single bundle anterior cruciate ligament reconstruction.

BACKGROUND: Anatomic anterior cruciate ligament (ACL) reconstructions are superior to non-anatomic graft placements with regard to controlling rotational laxity. Different techniques of anatomic single-bundle reconstruction exist. The femoral tunnel may be placed in a mid-bundle position (MB) or within the anteromedial bundle footprint (AM) with no definitive consensus as to the preferred position. Our institution, reflecting trends in surgical practice, has experience with both techniques. METHODS: Interrogation of our prospectively maintained database yielded all primary ACL reconstructions performed using the anatomic TransLateral single-bundle all-inside technique. A two year minimum follow-up was set. The failure rate of the MB and AM cohorts was compared as a primary outcome. Patient-reported outcomes across cohorts at several time-points were analysed as a secondary outcome. RESULTS: Two hundred and seventy-nine primary ACL reconstructions were identified at a median follow-up of 49 months. MB positioning was utilised in 113 cases (40.5%) and AM positioning in 166 (59.5%). There were significantly more failures in the MB cohort (p = 0.029). Logistic regression revealed mid-bundle femoral positioning was associated with greater than fourfold increase in graft failure (odds ratio 4.14, p = 0.039). CONCLUSION: Data from this case series suggests that amongst anatomic single-bundle ACL reconstructions, grafts with a mid-bundle femoral tunnel are more than four times more likely to fail versus those with a femoral tunnel placed four millimetres deeper within the anteromedial bundle footprint.

Combined All-Inside Anterior Cruciate Ligament Reconstruction and Minimally Invasive Posterolateral Corner Reconstruction Using Ipsilateral Semitendinosus and Gracilis Autograft.

The anterior cruciate ligament (ACL) is the most commonly injured knee ligament, particularly among adolescents and young adults. Unrecognized posterolateral laxity is understood as a major cause of ACL reconstruction failure, and concomitant injury to the posterolateral corner (PLC) is prevalent and underdetected. We advocate screening all ACL-deficient knees for PLC injury and present a technique combining minimally invasive PLC reconstruction with anatomic all-inside ACL reconstruction. The combined procedure uses only the ipsilateral hamstring tendons representing a major surgical advantage over traditional management approaches. The semitendinosus is quadrupled and attached to 2 adjustable suspensory cortical fixation devices to form the ACL graft. The gracilis tendon is looped through the fibula head and secured in a single femoral tunnel for the PLC reconstruction via 2 minimally invasive incisions. The use of a single femoral PLC tunnel combined with a single femoral ACL socket minimizes the risk of tunnel convergence.

Transmedial All-inside TriLink Posterior Cruciate Ligament Reconstruction.

Posterior cruciate ligament (PCL) injuries usually constitute part of a multiligament injury. Isolated PCL injuries account for only approximately 3% of all ligament injuries. No consensus on optimal surgical reconstruction exists. The PCL is a double-bundle structure that functions in an anisometric manner. Biomechanical studies have shown that re-creating the PCL femoral double-bundle configuration provides greater stability. We present a 3-socket approach for an anatomic "all-inside" double-bundle PCL reconstruction using our preferred option of a FiberTape (Arthrex, Naples, FL)-reinforced peroneus longus allograft fashioned to create a trifurcate graft: the TriLink technique. Cortical suspensory fixation devices are used, allowing differential tensioning of the anterolateral and posteromedial bundles. This enables more accurate replication of the native PCL and its biomechanical properties.

Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction.

BACKGROUND: This paper reports the outcomes of patients undergoing ACL reconstruction using a TransLateral single bundle, all-inside hamstring technique at a minimum of two year follow-up. METHODS: The semitendinosus alone is harvested, quadrupled and attached in series to two adjustable suspensory fixation devices. Femoral and tibial sockets are produced using a retrograde drill. The graft is deployed, fixed and tensioned on both tibia and femur. Patients were evaluated preoperatively using the KOOS, Lysholm and Tegner scores and at six, 12 and 24months postoperatively. Objective assessment of knee laxity was performed using the KT-1000 along with goniometric measurement of range or motion. RESULTS: One hundred and eight patients, mean age 30.9years (range 15 to 61) were included. Mean follow-up 49.8months (range 30-66). The mean increase in KOOS at two years was 30.3 points; Lysholm, 33.1 points; Tegner Activity scale, 2.0 levels. These were all statistically significant (p<0.001). Range of motion in the reconstructed knee approximated the uninjured knee by 12months and was restored by two years. KT-1000 showed significant reduction in side-side difference to no more than 2.4mm at all postoperative time points (p<0.001). Re-rupture rate in this series was 6.5%, all following episodes of significant additional postoperative trauma to the knee. CONCLUSIONS: TransLateral all-inside ACL reconstruction demonstrates good medium term subjective and objective outcomes with a low complication and failure rate.