Osteosynthesis, hemiarthroplasty, total hip arthroplasty in hip fractures: All I need to know.

Recent data from the UK's National Hip Fracture Database (NHFD) demonstrate an upward trajectory in the incidence of hip fractures, a trend which is expected to persist. In 2023 alone, the NHFD reported 72,160 cases, underscoring the prevalence of these injuries. These fractures are associated with significant morbidity, mortality, and economic costs. National guidelines for the surgical management of these fractures are established, although the implementation of total hip arthroplasty (THA) as a primary treatment modality varies. This review offers a narrative synthesis of contemporary literature on hip fractures, focusing on epidemiology, classification systems, and treatment options, with a particular emphasis on the outcomes of THA.

Effect of institution volume on mortality and outcomes in osteoporotic hip fracture care.

Hospitals that treat more patients with osteoporotic hip fractures do not generally have better care outcomes than those that treat fewer hip fracture patients. Institutions that do look after more such patients tend, however, to more consistently perform relevant health assessments. INTRODUCTION: An inveterate link has been found between institution case volume and a wide range of clinical outcomes; for a host of medical and surgical conditions. Hip fracture patients, notwithstanding the significance of this injury, have largely been overlooked with regard to this important evaluation. METHODS: We used the UK National Hip Fracture database to determine the effect of institution hip fracture case volume on hip fracture healthcare outcomes in 2019. Using logistic regression for each healthcare outcome, we compared the best performing 50 units with the poorest performing 50 institutions to determine if the unit volume was associated with performance in each particular outcome. RESULTS: There were 175 institutions with included 67,673 patients involved. The number of hip fractures between units ranged from 86 to 952. Larger units tendered to perform health assessments more consistently and mobilise patients more expeditiously post-operatively. However, patients treated at large institutions did not have any shorter lengths of stay. With regard to most other outcomes there was no association between the unit number of cases and performance; notably mortality, compliance with best practice tariff, time to surgery, the proportion of eligible patients undergoing total hip arthroplasty, length of stay delirium risk and pressure sore risk. CONCLUSIONS: There is no relationship between unit volume and the majority of health care outcomes. It would seem that larger institutions tend to perform better at parameters that are dependent upon personnel numbers. However, where the outcome is contingent, even partially, on physical infrastructure capacity, there was no difference between larger and smaller units.

Primary stability of a proximally coated and tapered stem.

AIMS: The aim of this prospective cohort study was to evaluate the early migration of the TriFit cementless proximally coated tapered femoral stem using radiostereometric analysis (RSA). METHODS: A total of 21 patients (eight men and 13 women) undergoing primary total hip arthroplasty (THA) for osteoarthritis of the hip were recruited in this study and followed up for two years. Two patients were lost to follow-up. All patients received a TriFit stem and Trinity Cup with a vitamin E-infused highly cross-linked ultra-high molecular weight polyethylene liner. Radiographs for RSA were taken postoperatively and then at three, 12, and 24 months. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and adverse events were reported. RESULTS: At two years, the mean subsidence of the head and tip for the TriFit stem was 0.38 mm (SD 0.32) and 0.52 mm (SD 0.36), respectively. The total migration of the head and tip was 0.55 mm (SD 0.32) and 0.71 mm (SD 0.38), respectively. There were no statistically significant differences between the three to 12 months' migration (p = 0.105) and 12 to 24 months' migration (p = 0.694). The OHS and EQ-5D showed significant improvements at two years. CONCLUSION: The results of this study suggest that the TriFit femoral stem achieves initial stability and is likely to be stable in the mid and long term. A long-term outcome study is required to assess late mechanisms of failure and the effects of bone mineral density (BMD) related changes. Cite this article: Bone Joint J 2021;103-B(4):644-649.

The effect of new oral anticoagulants and extended thromboprophylaxis policy on hip and knee arthroplasty outcomes: observational study.

The efficacy and safety of the new oral anticoagulants (NOAC) and the benefits of extended duration thromboprophylaxis following hip and knee replacements remain uncertain. This observational study describes the relations between thromboprophylaxis policies following hip and knee replacements across England's NHS and patient outcomes between January 2008 and December 2011. From the national administrative database, we analyzed mortality, thromboembolic complications, emergency readmission, and bleeding rates for 201,418 hip and 230,282 knee replacements. There were no differences in outcomes for either LMWH or NOAC. We found no advantage in favor of any single anticoagulation policy or in changing policy. This study supports the American Academy of Orthopaedic Surgeons' recommendation that the choice and duration of thromboprophylaxis prophylaxis be decided by the treating surgeon.

An unusual case of fibular (postaxial) polydactyly: extrametatarsal head with fused duplication of the proximal phalanx.

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. A number of morphologically and anatomically based classifications exist. We present an unusual case of fibular (postaxial) polydactyly characterized by an extrametatarsal head with fused duplication of the proximal phalanx. We describe the method of surgical correction and emphasize the need for careful preoperative planning to achieve a good functional and cosmetic outcome.

The use of nanotechnology in tendon regeneration and repair.

Tendon injuries are common and due to their limited capacity for self-healing, the biomechanical and functional properties of healed tendon are usually inferior to normal tissue. Tissue engineering offers the hope of regenerating tendon tissue with the same biomechanical properties of the native undamaged tissue by augmenting the regenerative process of in vivo tissue or producing a functional tissue in vitro that can be implanted into the defective tendon site. Current research on tendon tissue engineering has focused on the role of stem cell and tendon derived cell therapy, scaffolds, chemical and physical stimulation and gene-therapeutic approaches. In this review we review the important functional anatomy and pathomechanics of tendon injury and discuss the current advances in tendon tissue engineering.

Designing a 'neotissue' using the principles of biology, chemistry and engineering.

The traditional methods of treating musculoskeletal injuries and disorders are not completely effective and have several limitations. Tissue engineering involves using the principles of biology, chemistry and engineering to design a 'neotissue' that augments a malfunctioning in vivo tissue. The main requirements for functional engineered tissue include reparative cellular components that proliferate on a scaffold grown within a bioreactor that provides specific biochemical and physical signals to regulate cell differentiation and tissue assembly. In this review we provide an overview of the biology of common musculoskeletal tissue and discuss their common pathologies. We also describe the commonly used stem cells, scaffolds and bioreactors and evaluate their role in issue engineering.

The role of bioreactors in tissue engineering for musculoskeletal applications.

Tissue engineering involves using the principles of biology, chemistry and engineering to design a 'neotissue' that augments a malfunctioning in vivo tissue. The main requirements for functional engineered tissue include reparative cellular components that proliferate on a biocompatible scaffold grown within a bioreactor that provides specific biochemical and physical signals to regulate cell differentiation and tissue assembly. We discuss the role of bioreactors in tissue engineering and evaluate the principles of bioreactor design. We evaluate the methods of cell stimulation and review the bioreactors in common use today.

Advances in meniscal tissue engineering.

Injuries and lesions to the meniscal cartilage of the knee joint are common. As a result of its limited regenerative capacity, early degenerative changes to the articular surface frequently occur, resulting in pain and poor function. Currently available surgical interventions include repair of tears, and partial and total meniscectomy but the results are inconsistent and often poor. Interest in the field of meniscal tissue engineering with the possibilities of better treatment outcomes has grown in recent times. Current research has focused on the use of mesenchymal stem cells, fibrochondrocytes, meniscal derived cells and fibroblast-like synoviocytes in tissue engineering. Mesenchymal stem cells are multipotent cells that have been identified in a number of tissues including bone marrow and synovium. Current research is aimed at defining the correct combination of cytokines and growth factors necessary to induce specific tissue formation and includes transforming growth factor-ß (TGF-ß), Platelet Derived Growth Factor (PDGF) and Fibroblast Growth Factor 2 (FGF2). Scaffolds provide mechanical stability and integrity, and supply a template for three-dimensional organization of the developing tissue. A number of experimental and animal models have been used to investigate the ideal scaffolds for meniscal tissue engineering. The ideal scaffold for meniscal tissue engineering has not been identified but biodegradable scaffolds have shown the most promising results. In addition to poly-glycolic acid (PGA) and poly-lactic acid (PLLA) scaffolds, new synthetic hydrogels and collagen sponges are also being explored. There are two synthetic meniscal implants currently in clinical use and there are a number of clinical trials in the literature with good short- and medium-term results. Both products are indicated for segmental tissue loss and not for complete meniscal replacement. The long-term results of these implants are unknown and we wait to see whether they will be proved to have benefits in delaying arthritic change and chondral damage.

Evidence-based practice in arthroscopic knee surgery.

Knee arthroscopy is a minimally-invasive technique that allows intra-articular assessment and treatment of knee joint pathology. It has proven benefits of reduced patient morbidity, earlier recovery and mobilisation, and it is cost-effective. In this paper we review the anatomy of the knee joint, indications and contra-indications to knee arthroscopic use, and consider the main techniques of knee arthroscopy including types of anaesthetic, prophylactic antibiotics, theatre setup and arthroscopic portals, and post-operative care.

Tourniquet use in upper limb surgery.

Tourniquets are compressive devices that occlude venous and arterial blood flow to limbs and are commonly used in upper limb surgery. With the potential risk of complications, there is some debate as to whether tourniquets should continue to be routinely used. In this review, we first look at the different designs, principles, and practical considerations associated with the use of tourniquets in the upper limb. The modern pneumatic tourniquet has many design features that enhance its safety profile. Current literature suggests that the risk of tourniquet-related complications can be significantly reduced by selecting cuff inflation pressures based on the limb occlusion pressure, and by a better understanding of the actual level of pressure within the soft tissue, and the effects of cuff width and contour. The evidence behind tourniquet time, placement, and limb exsanguination is also discussed as well as special considerations in patients with diabetes mellitus, hypertension, vascular calcification, sickle cell disease and obesity. We also provide an evidence-based review of the variety of local and systemic complications that may arise from the use of upper limb tourniquets including pain, leakage, and nerve, muscle, and skin injuries. The evidence in the literature suggests that upper limb tourniquets are beneficial in promoting optimum surgical conditions and modern tourniquet use is associated with a low rate of adverse events. With the improvement in knowledge and technology, the incidence of adverse events should continue to decrease. We recommend the use of tourniquets in upper limb surgery where no contraindications exist.

Common fractures and injuries of the ankle and foot: functional anatomy, imaging, classification and management.

The ankle and foot are functionally important and complex joints. Bony fractures and ligamentous injuries are common. In this review paper we will discuss the functional anatomy, imaging, classification and the management of common ankle and foot injuries including ankle fractures, Achilles tendon ruptures, Lisfranc joint injuries, calcaneo fractures and fractures of the metatarsals and phalanges.

Psychosocial considerations of perioperative care in children, with a focus on effective management strategies.

Children are not just 'small adults'. They have specific physical, psychological and social requirements that must be identified and addressed to optimise their well-being in the perioperative period. The healthcare practitioner should be trained to understand the needs of the paediatric patient in hospital, including the ever increasing need to take into account cultural differences. Hospital policy should include a preoperative preparation programme, specially aimed at the paediatric population, where parental involvement is encouraged throughout.

The importance of correct patient positioning in theatres and implications of mal-positioning.

Patient positioning in theatre pertains to how a patient is transferred and positioned for a specific procedure. Patient safety is a central focus of care within the NHS and every healthcare practitioner must ensure that patients are protected from harm where possible. Mal-positioning of the patient has important implications in terms of associated problems of pressure sores, nerve compressions, deep vein thrombosis and compartment syndrome, and should be avoided.