Complications and Functional Outcome of Femoral Head Fracture-Dislocation In Delayed and Neglected Cases.

INTRODUCTION: Delayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome. MATERIALS AND METHODS: This retrospective study was designed to evaluate the outcome and complications of 138 patients with femoral head fracture dislocation treated by a single surgeon over a period of 22 years. Only seven patients presented within 24 h of injury and remaining all presented late. The hip joints could be reduced by closed manoeuvre in 105 patients, and 33 patients needed open reduction. The patients were managed conservatively or surgically. The mean follow-up period was 3.57 years (1-18 years). RESULTS: There were 119 males and 19 females. The mean age was 35.71 years (range, 18-70 years). Forty-two patients were managed conservatively, and 96 patients needed surgical treatment. The Kocher-Langenbeck approach was used in 40 patients, the trochanteric flip osteotomy in 14 patients, the Smith-Peterson approach in 31 patients, and the Watson-Jones approach in one patient. The femoral head fragment was fixed in 47.82% patients and excised in 11.59% patients. Primary total hip replacement (THR) was performed in 7.24% of patients through the posterior approach. 24.63% of patients developed complications with 14.49% of hip osteonecrosis, 2.89% posttraumatic osteoarthritis and 2.17% femoral head resorption. 55% of patients who developed osteonecrosis were operated through the posterior approach. Secondary procedures were needed in 14.48% of patients. The clinical outcome, as evaluated using the modified Harris Hip Score, was good to excellent in 52.89% of patients and poor to fair in 47.11% of patients. CONCLUSION: The incidences of osteonecrosis and secondary procedures are increased in delayed and neglected femoral head fracture dislocation. Osteonecrosis is commonly seen in Brumback 2A injuries and posterior-based approaches. All Brumback 3B fractures in such delayed cases should be treated with THR. Osteosynthesis or conservative treatment should be reserved for other types of injuries. A careful selection of treatment plan in such delayed cases can result in a comparable functional outcome as reported in the literature.

Joint awareness after unicompartmental knee arthroplasty and total knee arthroplasty: a systematic review and meta-analysis of cohort studies.

PURPOSE: The purpose of this systematic review and meta-analysis is to evaluate the joint awareness after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). It was hypothesized that patients with UKA could better forget about their artificial joint in comparison to TKA. METHODS: A search of major literature databases and bibliographic details revealed 105 studies evaluating forgotten joint score in UKA and TKA. Seven studies found eligible for this review were assessed for risk of bias and quality of evidence using the Newcastle-Ottawa Scale. The forgotten joint score (FJS-12) was assessed at 6 months, 1 year, and 2 years. RESULTS: The mean FJS-12 at 2 years was 82.35 in the UKA group and 74.05 in the TKA group. Forest plot analysis of five studies (n = 930 patients) revealed a mean difference of 7.65 (95% CI: 3.72, 11.57, p = 0.0001; I2 = 89% with p < 0.0001) in FJS-12 at 2 years. Further sensitivity analysis lowered I2 heterogeneity to 31% after exclusion of the study by Blevin et al. (MD 5.88, 95%CI: 3.10, 8.66, p < 0.0001). A similar trend of differences in FJS-12 between the groups was observed at 6 months (MD 32.49, 95% CI: 17.55, 47.43, p < 0.0001) and at 1 year (MD 25.62, 95% CI: 4.26, 46.98, p = 0.02). CONCLUSIONS: UKA patients can better forget about their artificial joint compared to TKA patients. LEVEL OF EVIDENCE: III.

Postoperative outcomes of initial varus versus initial valgus proximal humerus fracture: A systematic review and meta-analysis.

OBJECTIVES: Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the effect of initial varus or valgus displacement of proximal humerus on the outcomes of patients with proximal humerus fractures treated with open reduction and internal fixation. METHODS: In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing postoperative outcomes associated with initial varus versus initial valgus displacement of proximal humerus fracture. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. RESULTS: We identified two retrospective cohort studies and one retrospective analysis of a prospective database, enrolling a total of 243 patients with proximal humerus fractures. Our analysis showed that initial varus displacement was associated with a higher risk of overall complication (RR 2.28, 95% CI 1.12-4.64, P = 0.02), screw penetration (RR 2.30, 95% CI 1.06-5.02, P = 0.04), varus displacement (RR 4.38, 95% CI 2.22-8.65, P < 0.0001), and reoperation (RR 3.01, 95% CI 1.80-5.03, P < 0.0001) compared to valgus displacement. There was no significant difference in avascular necrosis (RR 1.43, 95% CI 0.62-3.27, P = 0.40), infection (RR 1.49, 95% CI 0.46-4.84, P = 0.51), and non-union or malunion (RR 1.37, 95% CI 0.37-5.04, P = 0.64). CONCLUSIONS: The best available evidence demonstrates that initial varus displacement of proximal humerus fractures is associated with higher risk of overall complication, screw penetration, varus displacement, and reoperation compared to initial valgus displacement. The best available evidence is not adequately robust to make definitive conclusions. Further high quality studies, that are adequately powered, are required to investigate the outcomes of initial varus and valgus displacement in specific fracture types. LEVEL OF EVIDENCE: Level II.