A comparison of hemiarthroplasty versus dynamic hip screw fixation for intertrochanteric femoral fractures: a systematic review.

INTRODUCTION: Intertrochanteric fractures are predominantly treated by dynamic hip screw (DHS) fixation. However, recent evidence has found acceptable clinical results following hemiarthroplasty for these fractures. Thus, a systematic review was conducted to compare hemiarthroplasty with DHS fixation for intertrochanteric fractures. METHODS: A computerised search was performed, using the databases Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials, with supplementation from Google Scholar and appropriate reference lists. Studies with comparative data comparing clinical outcomes of hemiarthroplasty versus DHS fixation were included. Data were extracted and quality assessment of the papers performed by 2 reviewers. RESULTS: 320 articles were independently reviewed by the investigators. A total of 10 studies met the inclusion criteria, comprising 2 randomised controlled trials and 8 cohort designs. 7 of the studies assessed unstable fracture patterns. There was no difference in operating time (SMD -1.169 min; 95% CI, -0.657 to 0.689) or blood transfusion volume (SMD-0.110 units; 95% CI, -0.520 to 0.891) between modalities. There was also no difference in length of stay (SMD -0.778 days; 95% CI, -0.606 to 0.336), mortality (RR 0.942; 95% CI, 0.749-1.183) or major complications. Hemiarthroplasty conferred significantly better Harris Hip Scores at 12 months (SMD 12.3; 95% CI, 0.0135-2.789) and allowed earlier weight-bearing than DHS fixation. DISCUSSION: Qualitative and quantitative compilation of the included studies demonstrates hemiarthroplasty to result in better functional scores and a quicker time to weight-bearing than DHS fixation for intertrochanteric fractures. Results are comparable for other major parameters, including operative time, length of stay and mortality. Thus, hemiarthroplasty is a suitable alternative to DHS fixation for unstable intertrochanteric fractures in elderly patients.

Comparative Analysis of Dorsal Nerve Relocation versus Dorsal Neurectomy in the Surgical Management of Morton's Neuroma.

This clinical study compares the use of dorsal nerve relocation (DNR; also known as dorsal nerve transfer) and dorsal neurectomy (DN) in the surgical management of Morton's neuroma within the surgical directorate of an NHS Hospital Trust (Princess Royal University Hospital) in the South East of England between 2002 and 2009. Approaches to the surgical management of Morton's neuroma are dependent on the views of individual surgeons, rather than empirical evidence and varied considerably, so this study was essentially all about checking whether best practice is being followed and making improvements. Data were collected using an in-depth review of patients' case notes and patient questionnaires. In total, there were 47 cases (51 web spaces), 25 (28 web spaces) in the DNR group, and 22 (23 web spaces) in the DN group. The key indication for surgery in all cases reviewed was failure of the condition to improve using conservative methods. The mean follow-up duration was 36 months (12-89) in the DNR group and 41 months (12 69) in the DN group. Coughlin's criterion was used to analyze individual records. The results suggest that DNR is more effective (92%) than DN in the surgical management of Morton's neuroma (82%). Key advantages of DNR include earlier return to wearing routine footwear, earlier return to normal routine/work, and better resolution of sensory symptoms in the toes. Although DNR is a slightly longer procedure than DN, minor difficulties were encountered relating to nerve mobilization because of overlying prominent veins or multiple nerve branches rather than a single nerve. DNR avoids the risk of a stump neuroma formation. Our results, although supporting the literature, are not statistically significant. There are no direct comparative studies between DNR and DN in the literature, and therefore potential for more studies in the form of prospective randomized trials to establish a robust evidential basis for the surgical management of Morton's neuroma are needed.

Non-operative management of an isolated lateral collateral ligament injury in an adolescent patient and review of the literature.

We present a rare case of isolated traumatic pure ligamentous rupture of the lateral collateral ligament of the knee in an adolescent high-level footballer managed non-operatively with a good functional outcome and return to sport in 4 months.

Outcomes for Elderly Patients With Atypical Femoral Fractures Compared to Typical Femoral Fractures for Length of Stay, Discharge Destination, and 30-Day Mortality Rate.

INTRODUCTION: Despite increasing recognition of atypical femoral fractures (AFFs), there's conflicting evidence about incidence, aetiology, and short-term outcomes of these injuries. This study reports the incidence of AFFs at our center and compares the early postoperative outcomes against typical femoral fractures (TFFs). METHODS: A retrospective observational cohort study of patients presenting to our trauma unit between November 2015 and July 2016 was undertaken. Inclusion criteria required radiologically confirmed proximal femoral fracture, which was then categorized as AFF or TFF. Primary outcome measures included length of stay, discharge destination, and 30-day mortality. RESULTS: Two hundred thirty-nine patients presented to our trauma unit over 9 months with either a fractured neck of femur or proximal femoral fracture. A total of 122 were identified as pertrochanteric, subtrochanteric, or proximal femoral shaft fractures of which 25 (20.5%) displayed atypical radiographic features consistent with AFF. The 2 groups were similar for average age (TFF 85.3 years vs AFF 85.0 years), gender (19% vs 16% male gender), American Society of Anaesthesiology grade (3.0 vs 3.0), cognitive score (abbreviated mental test score = 7.03 vs 7.08), and preinjury place of residence (88.9% vs 92.0% lived in own home). Typical fractures were fixed with either dynamic hip screw or intramedullary nailing, all atypical fractures were fixed with intramedullary nailing. There was no statistical difference between the 2 groups for length of stay (12.8 days vs 14.3 days; P > .05), discharge to preinjury residence (45.1% vs 36%; P > .05), or 30-day mortality (8.1% vs 12%; P > .05). DISCUSSION: In our predominantly geriatric population atypical radiographic features were observed in around 10% of patients presenting with proximal femoral fractures or fractured neck of femur. Previous studies have reported poor outcomes for pain, mobility, and length of stay after AFF. However, we observed no difference in short-term outcome measures when compared to patients with typical proximal femoral fracture patterns at our trauma unit. CONCLUSION: With modern principles of trauma care outcomes achieved following AFFs may be equivalent to typical femoral fractures in the geriatric population.

Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?

INTRODUCTION: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. METHODS: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. RESULTS: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. CONCLUSION: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.

Bilateral heel pain in a patient with Diamond-Blackfan anaemia.

A rare case of bilateral calcaneal stress fractures in a patient with Diamond-Blackfan anaemia is described. This has not been previously reported in the literature. A calcaneal stress fracture is an important differential diagnosis in a patient presenting with heel pain. Bilaterality of symptoms should not exclude this diagnosis and clinicians should be especially vigilant with predisposed patients.

The 30-year wait for treatment of an acutely painful knee.

A 63-year-old retired man presented to our clinic reporting a severely painful, localised knee pain present for around 30 years and associated with a spontaneous palpable lump. He was prompted to seek medical advice at this point because his symptoms were exacerbated when his young grandchildren bumped into the knee. While radiographs were unhelpful, ultrasonography revealed a well-defined, subcutaneous soft tissue mass at the anterior aspect of the knee. Surgical excision was performed as a day case. Histological examination of the mass showed a glomus tumour. This patient had suffered for many years as a result of this painful mass but full resolution of his pain occurred immediately after excision.

Evaluation of a patient specific femoral alignment guide for hip resurfacing.

A novel alternative to conventional instrumentation for femoral component insertion in hip resurfacing is a patient specific, computed tomography based femoral alignment guide. A benchside study using cadaveric femora was performed comparing a custom alignment guide to conventional instrumentation and computer navigation. A clinical series of twenty-five hip resurfacings utilizing a custom alignment guide was conducted by three surgeons experienced in hip resurfacing. Using cadaveric femora, the custom guide was comparable to conventional instrumentation with computer navigation proving superior to both. Clinical femoral component alignment accuracy was 3.7° and measured within ± 5° of plan in 20 of 24 cases. Patient specific femoral alignment guides provide a satisfactory level of accuracy and may be a better alternative to conventional instrumentation for initial femoral guidewire placement in hip resurfacing.

Can fluoroscopy-based computer navigation improve entry point selection for intramedullary nailing of femur fractures?

BACKGROUND: The entry point is crucial to an accurate reduction in femoral nailing. Fluoroscopy-based navigation was developed to aid in reducing femur fractures and selecting entry points. QUESTIONS/PURPOSES: We asked: (1) Can the piriformis fossa (PF) and tip of the greater trochanter (TT) be identified with high reproducibility? (2) What is the range of nonneutral images clinically acceptable for entry point selection? (3) Does navigation improve accuracy and precision of landmarking the TT and PF? And (4) does off-angle fluoroscopy within the acceptable range affect landmark accuracy? METHODS: Three orthopaedic surgeons digitized the PF and TT under direct visualization on 10 cadaveric femurs, quantifying the reproducibility of the targeted PF and TT landmarks. Arcs of acceptable AP and lateral images of each femur were acquired in increments of 5° with a C-arm. An experienced orthopaedic surgeon rejected or accepted images for entry point selection by qualitatively assessing the relative positions and sizes of the greater trochanter, lesser trochanter, and femoral neck. Entry points were identified on each image using fluoroscopy and navigation. Hierarchical linear modeling was used to compare accuracy and precision between navigation and fluoroscopy and the effects of image angle. RESULTS: A 29° average arc of acceptable images was found. Reproducibility of the target landmarks for the PF and TT under direct visualization was excellent. Navigation had similar accuracy to fluoroscopy for PF localization but less for TT. Navigation increased precision compared to fluoroscopy for both PF and TT. Image angle affected accuracy of the PF and TT under fluoroscopy and navigation. CONCLUSIONS: Nonorthogonal images reduce accuracy of PF and TT identification with both navigation and fluoroscopy. Navigation increased precision but decreased accuracy and cannot overcome inaccuracies induced by nonorthogonal images.

Geometric variations of acetabular component design and its effect on radiographic osseointegration.

The Reflection uncemented acetabular component (Smith & Nephew, Memphis, Tenn) for total hip arthroplasty is available in 2 geometric variants. The first has a completely hemispherical design; the second has a peripheral rim expansion designed to increase initial press fit and aid osseointegration. The clinical and radiologic outcomes of 527 consecutive primary total hip arthroplasties were reviewed to investigate the differences in component design. Of the components, 95.6% survived at 96 months with revision for aseptic loosening as the end point, with no significant difference between the 2 component designs. Eighty percent of hemispherical and 57% of peripherally expanded components were considered completely osseointegrated at final radiologic review. The midterm radiologic outcome of peripherally expanded acetabular components is inferior to that of a completely hemispherical design.

The suitability of an uncemented hydroxyapatite coated (HAC) hip hemiarthroplasty stem for intra-capsular femoral neck fractures in osteoporotic elderly patients: the Metaphyseal-Diaphyseal Index, a solution to preventing intra-operative periprosthetic fracture.

This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted.A 5 year prospective cohort of 560 consecutive patients, undergoing hemiarthroplasty (cemented or uncemented), was evaluated. A nested case-control study to determine risk factors affecting intra-operative fracture was carried out. The Vancouver Classification was used to classify periprosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al's Canal Bone Ratio (CBR) score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes. Four hundred and seven uncemented and one hundred and fifty-three cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture. Sixty-two periprosthetic fractures occurred in the uncemented group (15.2%), nine occurred in the cemented group (5.9%), P < 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, P < 0.001 and 90 day mortality 19.7%, P < 0.03. MDI's AUC was 0.985 compared to CBR's 0.948, P < 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. Multivariate regression analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r = 0.99, P < 0.001. JRI uncemented hemiarthroplasty has a significantly higher intra-operative fracture rate. We recommend cemented arthroplasty for hip fractures. We propose a radiographic system that may allow surgeons to select patients who are good candidates for uncemented arthroplasty, but it needs prospective validation.

A case report of three peripheral schwannomas attached to the Achilles paratenon.

BACKGROUND: Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. OBJECTIVE: To report a case of multiple schwannomas arising form the achilles paratenon. METHODS: A 38 year old man presented lumps on the dorsum of his leg. He was clinically evaluated, subjected to imaging studies and surgery. RESULTS: 3 separate lumps where removed measuring 10, 12, and 12mm. They here confirmed to be schwannomas on hitochemical staining. CONCLUSION: A schwannoma must be considered in the differential of lumps in the lower leg. This is the first report of schwanommas associated with the paratenon. Removal of such masses is warranted to prevent local erosion.

Post-operative stress fractures complicating surgery for painful forefoot conditions.

A stress fracture is caused by repetitive or unusual loading of a bone leading to mechanical failure. Fatigue type stress fractures occur in normal bone exposed to abnormally high repetitive loads, whereas insufficiency type stress fractures occur in abnormal bone exposed to normal loads. We describe three cases of insufficiency stress fractures that have complicated surgery for painful forefoot conditions. The diagnosis and management of these cases are discussed. Stress fractures should be included in the differential diagnosis of any patient who continues or develops pain after surgery to the forefoot.

Neuromuscular scoliosis as a sequelae of Guillain-Barré syndrome.

The neuromuscular sequaelae of Guillain-Barré syndrome are well documented in the literature. Persistent distal muscular weakness and loss of peripheral limb reflexes are common in those affected. We report a case of a 14-year-old boy who developed the Miller-Fisher variant of Guillain-Barré syndrome at the age of 8 years. Six years after the acute episode, he had persistent lower limb areflexia and mild weakness. He had also developed a neuromuscular scoliosis. The scoliosis was successfully treated with posterior instrumentation and fusion surgery. Neuromuscular scoliosis is rare following Guillain-Barré syndrome, with no previous reports associated with the Miller-Fisher variant that we are aware of. When evaluating patients post Guillain-Barré syndrome, structural spinal examination is essential to identify rare deformity that may need surgical correction.

The surgical management of osteochondroma on the ventral surface of the scapula.

Hereditary multiple exostosis is an autosomal dominant disorder characterized by the formation of multiple cartilaginous osteochondromata in the immature skeleton. Indications for operative intervention include mechanical dysfunction of a joint or tendon relating to the size of the lesion, and sarcomatous change. Ventral scapular osteochondromas have been reported to cause mechanical symptoms and should be considered as a differential to a 'winged' scapula. The surgical treatment of such lesions has not widely been reported in the orthopaedic literature. We report the surgical treatment of two osteochondroma from the ventral surface of the scapula in a 16-year-old girl. Preoperative evaluation, imaging, surgical technique and outcome are discussed. Ventral scapular osteochondroma can be successfully treated using the straightforward surgical technique described.