Bilateral atraumatic femoral neck fractures resulting from transient osteoporosis of the hip.

A woman in her mid-30s presented to the orthopaedic team, unable to mobilise, shortly after her caesarean section. On questioning, she reported 10 weeks of atraumatic right hip pain. A radiograph revealed a displaced right subcapital neck of femur fracture. An MRI confirmed this, as well as identifying a minimally displaced left subcapital neck of femur fracture. She underwent a right total hip replacement and internal fixation of the left hip. A dual energy X-ray absorptiometry (DEXA) scan showed severe osteoporosis, and a diagnosis of transient osteoporosis of the hip was made. She was seen by the bone metabolism team and given calcium and vitamin D medication. Although atraumatic hip fractures are rare in young patients, disproportionate or persisting hip pain in pregnant patients should raise the index of suspicion and prompt further investigation in the form of an MRI. This will allow timely management of hip fractures and improve patient outcomes.

Surgical Management of Osteochondral Defects of the Knee: An Educational Review.

PURPOSE OF REVIEW: Numerous surgical techniques are available to treat osteochondral defects of the knee. The aim of this review is to analyse these procedures, including their methodology, outcomes and limitations, to create a treatment algorithm for optimal management. RECENT FINDINGS: Osteochondral defects of the knee significantly alter the biomechanics of the joint. This can cause symptomatic and functional impairment as well as considerable risk of progressive joint degeneration. Surgical interventions aim to restore a congruent, durable joint surface providing symptomatic relief and reducing the risk of early arthritic changes. These methods include fixation, chondroplasty, microfracture, autologous matrix-induced chondrogenesis, autograft transplants, allograft transplants and autologous chondrocyte implantation. There is currently much debate as to which of these methods provides optimal treatment of osteochondral defects. The overall evidence supports the use of each technique depending on the individual characteristics of the lesion. New technologies provide exciting prospects; however, long-term outcomes for these are not yet available.

Return to sport following scaphoid fractures: A systematic review and meta-analysis.

BACKGROUND: Scaphoid fracture is the most commonly fractured carpal bone in the athletic patient, accounting for over 85% of all sport-related carpal bone fractures, and is particularly common in sports involving high impact injuries to the wrist. The management of such injuries comprises both conservative and surgical techniques, as guided by fracture location and type. Athletes demonstrate a unique challenge with regards to the management of scaphoid fractures due to their requirement to return to sport, as soon as able. AIM: To review systemically all studies recording return to sport following scaphoid fractures, to collate information on return rates to sport (RRS) and mean return times (RTS) to sport and to determine differences in sporting outcome for the various treatment methods. METHODS: A systematic search of MEDLINE, EMBASE, CINAHAL, Cochrane, Google Scholar, Physiotherapy Evidence Database, SPORTDiscus, Web of Science and Scopus was performed in August 2018 using the keywords "scaphoid", "fracture", "acute", "carpal", "athletes", "sports", "non-operative", "conservative", "operative" and "return to sport". All studies that recorded RRS and RTS following scaphoid fractures were included. RTS was recorded as the length of time from commencement of either primary conservative management or primary surgical procedure to return to sport. RESULTS: Eleven studies were included: Two randomised controlled trials, six retrospective cohort studies and three case series. Seven studies reported on conservative management (n = 77), and eight studies reported on surgical management (n = 83). For conservative management, RRS was 90% (69/77), and the mean RTS was 9.6 wk. Three studies allowed to return to sport in cast [RRS 89% (25/28); RTS 1.9 wk], and four studies required completion of cast treatment prior to returning to sport [RRS 90% (44/49); RTS 13.9 wk]. Four studies recorded fracture union data: Union rate 85% (47/55); mean time to union 14.0 wk. For surgical management, RRS was 98% (81/83), and RTS was 7.3 wk. Three studies reported on Percutaneous Screw Fixation [RRS 97% (32/33); RTS 6.5 wk], and five studies reported on Open Reduction Internal Fixation [RRS 98% (49/50); RTS 7.9 wk]. Six studies recorded fracture union data: Union rate 97% (69/71); mean time to union 9.8 wk. On meta-analysis, RRS (RR = 1.09; 95% confidence interval (CI): 1.00-1.18; P < 0.045), RTS (MD 2.3 wk; 95%CI: 0.79-3.87; P < 0.002), union rates (RR = 1.14; 95%CI: 1.01-1.28; P < 0.030) and mean times to union (MD 4.2 wk; 95%CI: 3.94-4.36; P < 0.001) were all significantly better for the surgical cohort compared to the conservative cohort. CONCLUSION: Surgical management of scaphoid fractures can provide significantly improved RRS and RTS to sport compared to conservative management. Both treatments, however, remain acceptable options, and athletes should be fully informed of the benefits and risks of both prior to deciding treatment plans. Immediate return to sport in a cast should be avoided due to the significant risk of non-union.

Percutaneous pinning versus volar locking plate fixation for dorsally displaced distal radius fractures- reoperation rates over an eight year period.

PURPOSE: To compare reoperation rates between closed reduction with percutaneous pinning (CRPP) and internal fixation with a volar locking plate (VLP) for the treatment of distal radius fractures. METHODS: A retrospective review of all patients with dorsally displaced distal radius fractures presenting to a hospital over an eight-year period. RESULTS: 1364 procedures were reviewed after applying the exclusion criteria; 663 underwent CRPP and 701 underwent VLP. The results showed that CRPP had higher rates of revision surgery due to fixation failure than VLP (p = 0.003), however there was no statistical significance in overall reoperation rates when all complications were considered (p = 0.060). This was due to higher rates of tendon related problems (p = 0.003), neurological complications (p = 0.005) and hardware removal (p = 0.01) in the VLP group. CONCLUSION: Overall reoperation rates were similar between both techniques however there were differences in complication profile and nature of revision surgery. This information is useful when discussing treatment options with patients to help guide selection of the best procedure for that individual.

Mycobacterium tuberculosis of the elbow joint.

Mycobacterium tuberculosis(TB) affecting the elbow joint is rarely reported in the developed world. We present the case of an 85-year-old Caucasian female who complained of a chronically discharging and painful wound across her left elbow during her admission for an ischaemic stroke. This was initially deemed to be either a bursitis or local manifestation of amyloid by her general practitioner and dermatologist respectively prior to admission. She was commenced on flucloxacillin by the medical team for presumed cellulitis with minimal response. A synovial fluid sample and repeated wound swabs yielded no growth from routine bacterial culture. Radiological assessment together with knowledge of her husband having previous TB raised the possibility of TB arthritis. Synovial fluid aspirate was subsequently sent for acid-alcohol fast bacilli microscopy and mycobacterial culture that confirmed M. tuberculosis She was consequently started on multidrug TB therapy, over a year after the onset of her symptoms.