Home-based rehabilitation following anterior cruciate ligament reconstruction in the Kurdistan region of Iraq: epidemiology and outcomes.

PURPOSE: This study, set in in the Kurdistan region of Iraq, describes the epidemiology and outcomes of anterior cruciate ligament reconstruction (ACLR) followed by home-based rehabilitation alone. METHODS: A cohort observational study of patients aged ≥ 16 years with an ACL rupture who underwent an ACLR under a single surgeon. Followed by a home-based rehabilitation programme of appropriate simplicity for completion in the home setting; consisting of stretching, range of motion and strengthening exercises. Demographics, mechanism of injury, operative findings, and outcome data (Lysholm, Tegner Activity Scale (TAS), and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. RESULTS: The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. Post-operative TAS results showed an improvement in level of function, but did not reach pre-injury levels by final follow-up. At final follow-up, six (1.1%) patients required an ACLR revision. CONCLUSION: Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores 15 months post-operatively. To optimise resources, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low- to middle-income countries and the developed world.

The theoretical mortality risk of an asymptomatic patient with a negative SARS-CoV-2 test developing COVID-19 following elective orthopaedic surgery.

AIMS: The risk to patients and healthcare workers of resuming elective orthopaedic surgery following the peak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been difficult to quantify. This has prompted governing bodies to adopt a cautious approach that may be impractical and financially unsustainable. The lack of evidence has made it impossible for surgeons to give patients an informed perspective of the consequences of elective surgery in the presence of SARS-CoV-2. This study aims to determine, for the UK population, the probability of a patient being admitted with an undetected SARS-CoV-2 infection and their resulting risk of death; taking into consideration the current disease prevalence, reverse transcription-polymerase chain reaction (RT-PCR) testing, and preassessment pathway. METHODS: The probability of SARS-CoV-2 infection with a false negative test was calculated using a lower-end RT-PCR sensitivity of 71%, specificity of 95%, and the UK disease prevalence of 0.24% reported in May 2020. Subsequently, a case fatality rate of 20.5% was applied as a worst-case scenario. RESULTS: The probability of SARS-CoV-2 infection with a false negative preoperative test was 0.07% (around 1 in 1,400). The risk of a patient with an undetected infection being admitted for surgery and subsequently dying from the coronavirus disease 2019 (COVID-19) is estimated at approximately 1 in 7,000. However, if an estimate of the current global infection fatality rate (1.04%) is applied, the risk of death would be around 1 in 140,000, at most. This calculation does not take into account the risk of nosocomial infection. Conversely, it does not factor in that patients will also be clinically assessed and asked to self-isolate prior to surgery. CONCLUSION: Our estimation suggests that the risk of patients being inadvertently admitted with an undetected SARS-CoV-2 infection for elective orthopaedic surgery is relatively low. Accordingly, the risk of death following elective orthopaedic surgery is low, even when applying the worst-case fatality rate. Cite this article: Bone Joint J 2020;102-B(9):1256-1260.

Preliminary Presentation of Metastatic Non-Small Cell Carcinoma of the Lung as Atraumatic Avulsion Fracture of the Lesser Trochanter.

Traumatic avulsion fractures of the lesser trochanter are usually seen along with fractures of the proximal femur and with young adolescents involved in high-intensity sporting injuries. Atraumatic isolated lesser trochanter avulsion in adults are most commonly associated with malignancy. We describe a case of a female in her sixties who was previously fit and healthy with no systemic illness and no history of trauma presenting with groin pain. The X-ray demonstrated an isolated lesser trochanter avulsion fracture. Further imaging including MRI and a staging CT scan of the neck, chest, abdomen and pelvis revealed a pulmonary tumour. Biopsy later confirmed this as a non-small cell carcinoma of the lung. At the time of publication, she had been started on palliative chemotherapy (afatinib) with encouraging results.

Diffuse B Cell Non-Hodgkin's Lymphoma Presenting Atypically as Periprosthetic Joint Infection in a Total Hip Replacement.

The occurrence of extranodal primary B cell non-Hodgkin's lymphoma is rare. Total hip replacement is one of the most common orthopaedic procedures performed. There has been an increased incidence of primary lymphomas involving periprosthetic sites. Chronic inflammation due to metal debris arising from the prosthetic implants has been evidenced as one of the causes for the development of soft tissue lymphomas albeit rarely. We describe a case report of a 77-year-old patient who had underwent a cemented total hip replacement in the past who further developed large B cell primary non-Hodgkin's lymphoma. She presented initially with signs and symptoms highly suggestive of underlying periprosthetic infection. The radiological imaging was also indicative of periprosthetic infection. The diagnosis was eventually confirmed after an open biopsy. This case underlines the importance of considering and including soft tissue malignancy in the differential diagnosis of suspected chronic periprosthetic infection.

Dislodgement of a cemented exeter femoral stem during closed manipulative reduction of a dislocated total hip replacement.

INTRODUCTION: The incidence of cemented femoral stem migration and dislodgement even though has been described is extremely unusual. There is a high chance of polished femoral stem displacement happening while trying to reduce a dislocated total hip replacement by closed measures. PRESENTATION OF THE CASE: A 73 year old lady who had an Exeter cemented total hip replacement about two weeks back was admitted from Accident and Emergency with a dislocation. During the closed manipulative reduction under general anaesthesia it was noted that the femoral stem has dislodged from the canal. She underwent revision of the total hip replacement with good outcome. DISCUSSION: Femoral stem dislodgement occurs in total hip replacement if polished stem or inadequate cementing of the collar is carried out. CONCLUSION: Gentle manipulative reduction under general anaesthesia of dislocated total hip replacement should be carried out if the polished femoral stem is used.

Constrained captive acetabular cup for recurrent dislocation of hemiarthroplasty in elderly: A case series.

INTRODUCTION: Hemiarthroplasty of the hip is one of the commonest procedures done for intracapsular fractures of the neck of femur in elderly. Dislocation of the hemiarthroplasty is a recognised and significant complication. This is associated with considerable morbidity and mortality. The treatment options include closed manipulation, skin and skeletal traction, conversion to total hip replacement, exploration and open reduction and leaving it out of the acetabulum. PRESENTATION OF CASE: A retrospective review of ten patients with recurrent and failed closed manipulative reduction of hemiarthroplasty who underwent revision using a cemented captive acetabular cup and cement to cement revision of femoral component with Exeter CDH stem was carried out. The follow up period was two years and the functional outcomes were assessed using Harris hip scores. DISCUSSION: The management of recurrent dislocations of hemiarthroplasty in elderly patient are very challenging. Even though various treatment options are described most of them are associated with increased morbidity and mortality and prevent these patients from early mobilisation. The use of captive acetabular avoid repeated dislocations, prolonged bed rest, wearing of a brace and all the complications associated with sustained immobilization. The drawbacks of using constrained cups are hip pain, limited hip movements and loosening. CONCLUSION: We describe a new method of treatment of this difficult condition with a cemented constrained acetabular captive cup and cement to cement revision using a CDH femoral stem. This method prevents further dislocations and will give good functional outcomes thus reducing the high morbidity and mortality.

Safety of total hip replacement following an intra-articular steroid hip injection--an audit.

The aim of this study was to determine the deep infection rates in patients who underwent a total hip replacement after having had a prior diagnostic steroid injection into the same hip. We identified and reviewed the case notes, relevant radiographs and microbiology reports of all patients who underwent a total hip replacement after a diagnostic steroid hip injection in our unit from 1 January 2007 to 31 April 2009. There were 40 patients. (10 males and 30 females) Their mean age was 68.4 (52-82) years. The mean time interval from the injection to the joint replacement was 6.2 (2-23) months. The mean follow-up was 23.2 (11-37) months. None of the patients in the study group developed a deep infection during this followup period. Diagnostic intra articular steroid and local anaesthetic injection prior to total hip replacement appears to be safe.

Unexpected long femur in adults with acetabular dysplasia.

Femoral length symmetry is assumed when assessing a patient with a dysplastic acetabulum. An unexpected long femur has been observed in some adults with acetabular dysplasia. We undertook a retrospective observation study of 18 adults with unilateral and 11 adults with bilateral acetabular dysplasia. Femoral lengths were assessed using CT measurements. The ipsilateral femur was found to be 5-10 mm longer in 66% (12 patients) with unilateral dysplastic acetabulae. Femoral lengths varied greatly in the presence of bilateral dysplastic acetabulae. In the presence of a acetabular dysplasia, asymmetry of femoral lengths is common and unpredictable. Femoral and total limb length assessment (with CT) is advised preoperatively. This will alert the surgeon and patient to the possible risk of post operative ipsilateral limb lengthening.

The Denham prosthesis in revision knee surgery: a 10 year follow-up.

We studied the Denham knee prosthesis (Biomet, Warsaw, IN) in revision of total knee arthroplasty (TKA) in situations of extreme bone loss or ligamentous disruption including revision from previous hinged implants. We reviewed 34 patients (38 knees) at an average of 7. 5 years after surgery (range 4-12 years). No patient was lost to follow-up although 15 unrelated deaths occurred during the study. There were six failures, of which five were due to infections in patients who received a revision for infection. A further two patients experienced a poor result. The remaining 30 patients had an excellent or good result. In our setting, the Denham TKA effectively addressed problems of loss of bone stock and ligamentous disruption with simple instrumentation and a remarkably small number of implants.

Intramedullary nailing of multiple long-bone fractures of the lower extremity at the same surgery: a single-center experience.

We evaluated the outcome of multiple intramedullary nailing at the same surgery for traumatic long-bone fractures. All but 2 of 27 patients (average age 40) had been involved in motor vehicle accidents, and 17 of them presented with other associated nonorthopedic injuries. Ten patients had open fractures. Sixty-one nails were used. The average time from accident to fixation was 8.16 h, and the average time in the operating room was 5.4 h. No patients died; all required blood transfusion; and eight patients were admitted for at least 24 h to the intensive care unit. The average hospital stay was 27 days, the mean time to full weight-bearing was 4 months, and the average time to radiographic healing was 7.5 months. Three patients required dynamization to achieve fracture union; three underwent exchange nailing for nonunion and one for nail breakage. Thus, early fixation of multiple long-bone fractures by intramedullary nailing in polytrauma patients is an acceptable treatment method.

Femoral exchange nailing for aseptic non-union: not the end to all problems.

We report the results of a single centre prospective study of exchange nailing for aseptic non-union of a femoral fracture. Eighteen patients with 19 aseptic femoral non-unions had exchange nailing performed in our institution. We collected data on mechanism of injury, original fracture type, and indication for exchange nailing, further surgery and major complications. In 11 non-unions (58%), the exchange nail procedure alone resulted in fracture union with a mean time to radiographic union of 9 months (range 3-24 months). The non-union did not heal in five patients, two patients developed an infected non-union, and one patient required dynamisation of the exchange nail. Fracture healing was eventually achieved in 18 non-unions (95%). Complications following exchange nailing occurred in 11 fractures (58%), in which further surgery was required (four repeat exchange nailings, two Ilizarov frame applications and five nail removals). The role of reamed exchange nailing in the treatment of femoral non-union needs to be re-evaluated. Although fracture healing is eventually achieved in most patients, a significant number of them required additional surgery to achieve union or to deal with complications arising from the exchange nailing.

The role of caudal epidural injections in the management of low back pain.

The value of caudal epidural steroid injections (CEI) in treatment of low back pain and sciatica is controversial. It is believed that CEI are mainly effective in treating acute radiculopathy at intermediate term follow up and have no long-term benefit. The objective of this study was to evaluate the role of CEI in the management of low back pain. This study reviews all patients with low back pain and sciatica treated with CEI in a one-year period (1997) in the orthopaedic department at Aberdeen. The case notes of 163 out of a possible 175 patients (87 female 76 male) with mean age of 51 years (range: 17 to 88 years) were reviewed. Data collected included primary symptoms, presentation time, presumed diagnosis, MRI diagnosis, grade of the surgeon ordering and performing the procedure, the quality and duration of response, and final outcome. Patients were regarded as having an Excellent response if they had good or excellent pain relief for more than 3 months, a Good response (6 weeks to 3 months), Fair (4 to 6 weeks), Brief (any pain relief for less than 4 weeks), and No relief. Forty-one percent of patients had either an excellent/good response to CEI while 34% were no better or worse. Patients presenting acutely or with predominantly leg pain symptoms did not respond any better to the CEI than chronic presentations or low back pain alone. Only 36 of 73 patients who were discharged had an Excellent/Good response. Therefore the response to CEI did not influence the decision to discharge half of the patients. The experience of the surgeon performing the procedure did not make a difference in the outcome. We found that the outcome of CEI was unpredictable. The clinical value of CEI remains unproven. The decision to perform the procedure may well remain a matter of personal choice and experience.

Fractures in children younger than age 1 year: importance of collaboration with child protection services.

The medical records of all children less than 1 year of age presenting to the Accident and Emergency Department over a 5-year period (1995-1999) with a fracture were retrospectively reviewed for possible abuse. Seventy-four children presented with fractures during the study period, with a mean age at presentation of 5 months (range 2 weeks to 1 year). Of these children, 46 had skull fractures and 28 had long bone fractures. Children were classified into one of seven categories: definite abuse, likely abuse, suspicious, likely accident, definite accident, neglect, or unknown cause. A three-tier system of grading for possible abuse was then used to analyze variance. The first tier consisted of the initial assessment by staff clinicians, the second retrospectively by an orthopaedic registrar, and the third retrospectively by a designated doctor in child protection (consultant pediatrician), all using the same information from the case notes. The use of the three-tier system of grading demonstrated a variance in the diagnosis of nonaccidental injury. The possibility of abuse was underestimated at the time of the original injury in over a quarter of cases (28.4%) when compared with the assessment by the consultant pediatrician. In 34 children (46%), there was no written documentation that nonaccidental injury was ever considered. While management depends on local guidelines and arrangements, the authors would advise that all children under 1 year of age with a fracture should be admitted to the hospital and referred to a pediatrician for child protection assessment.