Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique.

PURPOSE: The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis-Ilizarov method (ILF), or with Masquelet technique (MIF). METHODS: Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF). RESULTS: The average defect length was 5.6 cm (2.6-9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459-£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9. CONCLUSIONS: The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

Reliability and validity of the Unified Classification System for postoperative periprosthetic femoral fractures around cemented polished taper-slip stems.

AIMS: This aim of this study was to assess the reliability and validity of the Unified Classification System (UCS) for postoperative periprosthetic femoral fractures (PFFs) around cemented polished taper-slip (PTS) stems. METHODS: Radiographs of 71 patients with a PFF admitted consecutively at two centres between 25 February 2012 and 19 May 2020 were collated by an independent investigator. Six observers (three hip consultants and three trainees) were familiarized with the UCS. Each PFF was classified on two separate occasions, with a mean time between assessments of 22.7 days (16 to 29). Interobserver reliability for more than two observers was assessed using percentage agreement and Fleiss' kappa statistic. Intraobserver reliability between two observers was calculated with Cohen kappa statistic. Validity was tested on surgically managed UCS type B PFFs where stem stability was documented in operation notes (n = 50). Validity was assessed using percentage agreement and Cohen kappa statistic between radiological assessment and intraoperative findings. Kappa statistics were interpreted using Landis and Koch criteria. All six observers were blinded to operation notes and postoperative radiographs. RESULTS: Interobserver reliability percentage agreement was 58.5% and the overall kappa value was 0.442 (moderate agreement). Lowest kappa values were seen for type B fractures (0.095 to 0.360). The mean intraobserver reliability kappa value was 0.672 (0.447 to 0.867), indicating substantial agreement. Validity percentage agreement was 65.7% and the mean kappa value was 0.300 (0.160 to 0.4400) indicating only fair agreement. CONCLUSION: This study demonstrates that the UCS is unsatisfactory for the classification of PFFs around PTS stems, and that it has considerably lower reliability and validity than previously described for other stem types. Radiological PTS stem loosening in the presence of PFF is poorly defined and formal intraoperative testing of stem stability is recommended. Cite this article: Bone Joint J 2021;103-B(8):1339-1344.

Direct medical costs of interprosthetic femoral fracture treatment: A cohort analysis.

INTRODUCTION: Periprosthetic femoral fractures (PPFs) represent a challenging clinical problem with a fast-rising incidence. Interprosthetic fractures (IPFs) represent one of its most difficult variants. There is a paucity of data regarding the financial burden of PPFs, and none for IPFs. This study aims to estimate the direct medical cost of the surgical treatment of IPFs in NHS, and analyse the factors influencing this when using different methods of surgical treatment. METHODS: A cohort of patients with IPFs treated in a single academic unit over a period of 8-years with different surgical methods was studied. In-hospital details, as well as outpatient follow-up data, were gathered relevant to their clinical and radiological outcome until discharge. Local and national NHS data were acquired from the financial department, as well as industry-related resources. The economic analysis was structured as a cost identification analysis (CIA) of the overall cohort, but also as a comparative best-case scenario (uncomplicated course till discharge) comparison between the 3 main different management strategies (a) revision arthroplasty (RTHA), b) plate fixation (ORIF), c) combination of implants (COMBO). RESULTS: Data from 28 patients (22 females) with IPFs were analysed with a median age of 78.4 years. The overall direct medical cost of treating this cohort of patients was £468,330, with a median of £15.625 (range £10,128 to 33,060). Comparing the three different surgical modalities, the median cost in groups a, b, and c was £20,793 (range £12,110 to £24,116), £12,979 (range £10,128 to £20,555), and £22,316 (range £10,938 to £23,081) respectively. In all groups, the 2/3 of the identified costs were relevant to the inpatient stay. Transfusions were the highest (3 units of cRBC on average) to the patients that received a revision THA vs the other two groups (p=0.022). There was statistically significant higher mean overall cost between the RTHA and the ORIF groups (£19,453 vs. £14,201, p=0.0242), but not when compared with the COMBO cases (£19,453 vs. £18,788, p=0.86). CONCLUSION: The first cost identification study and "best case scenario" comparative analysis for IPFs demonstrated a significant overall direct medical cost, when managing these complex fractures with variable contemporary techniques. Evidence based reimbursement strategies should be developed to allow the sustainability of the clinical service we offer in this challenging patient population.

Caveats of bisphosphonate abuse.

BACKGROUND: Bisphosphonates (BPs) are the common drugs used for the treatment of postmenopausal osteoporosis. Short term benefits of the BPs are well known. However, there are concerns regarding their long term use. The aim of the study was to analyze the association between atypical femoral fractures and BP misuse/abuse as well as study the outcome of management of these fractures. MATERIALS AND METHODS: A retrospective study of a prospectively studied patients who presented with atypical femoral fractures between January 2010 and August 2012 and were followed up upto June 2014. The cohort consisted of nine female patients (12 fractures) with an average age of 71 years (range 58-85 years). Analysis was done for the indications, duration of BP use, configuration of associated fractures and method of treatment. RESULTS: The mean duration of BP use was 6.6 years (range 4-10 years). BP treatment was initiated without sufficient indication and continued without proper review and followup in most cases. Most patients did not followup and continued to consume BPs without any review by the doctors. All patients had prodromal thigh pain of various duration, which was inadequately investigated and managed before the presentation. Two cases with an incomplete fracture and no thigh pain were managed successfully with conservative treatment. The rest were treated by surgery with intramedullary nailing. The average union time was longer and two fractures went into nonunion which required further surgical intervention. CONCLUSION: Atypical femoral fractures appear to be strongly related to abuse of BPs. Great care is to be exercised at initiation as well as the continuation of BP therapy, and regular review is required. There is a need for improved awareness among physicians about the possibility of such fractures, and interpretation of thigh pain and radiological findings, especially if the patient has been on BPs therapy. Internal fixation for complete fractures and for incomplete fractures with thigh pain is needed. Delayed union is common.

Internal iliac artery pseudoaneurysm in primary total hip arthroplasty.

Vascular injury is one of the rare complications of primary total hip arthroplasty (THA). We report an unusual case of lobulated pseudoaneurysm arising from one of the branches of the left internal iliac artery during acetabulum preparation in THA, which was successfully treated with coil embolization and multidisciplinary care. After 6 years follow up, patient did not have any symptoms related to the hip replacement. We recommend that surgeons should be extremely cautious while drilling medial wall of the acetabulum for depth assessment. Aggressive multidisciplinary approach, including possible support from an interventional radiologist is required for the treatment of such vascular injuries.

Functional outcome following a large head total hip arthroplasty: A retrospective analysis of mid term results.

BACKGROUND: One of the reasons that hip resurfacing and large head metal on metal (MOM) total hip arthroplasty (THA) became popular in Asia was the possible increased range of movement and thereby improved function of the hip joint. Due to concerns of MOM articulation an alternative bearing was sought. Hence, a shift from large head MOM to large head ceramic on ceramic (COC) was made. The aim of this study was to compare the functional outcome including range of motion (ROM) and dislocation rates following large head MOM and large head COC THA. MATERIALS AND METHODS: Retrospectively, 39 primary THA with large head MOM with a mean age of 56 years (range 36-72 years) and average followup of 54 months (range 38-70 months) were compared with 23 primary THA with large head COC bearing with a mean age of 48 years (range 36-68 years) and an average followup of 18 months (range 12-26 months). Functional outcome was assessed using the Modified Harris Hip Score. Dislocation rate and ROM were compared. RESULTS: Global ROM averaged 248 degrees with MOM group and 252 degrees with the COC group. One patient with metal bearing had dislocation at an average 3 year followup which required revision THA while there were no complications in the COC group. MHHS averaged 89 points in MOM and 94 in COC THR. CONCLUSION: This study has shown that large head ceramic on ceramic THA is a good alternative to large head metal on metal THA with comparable dislocation rates and range of movements and without complications of metallosis in Asian patients.

Patellar clunk syndrome in a current high flexion total knee design.

This retrospective study of 208 (204 patients) total knee arthroplasties evaluated the incidence of patellar clunk syndrome for two high-flex posterior stabilized knee prostheses; a high-flex fixed bearing prosthesis and a high-flex mobile bearing prosthesis. Patients were followed for up to two years and were evaluated for patellar clunk and component position. Knees receiving the mobile bearing had a significantly higher (p < 0.001) incidence of patellar clunk (15%) than knees receiving the fixed bearing (0%). There was a significantly higher incidence of patellar clunk in males (34.1%; p < 0.01) compared to females (8.6%). Fibrous nodules were treated surgically in 11 of the knees with patellar clunk. The design of this particular mobile bearing knee seems to contribute to patellar clunk syndrome.

Posttraumatic pseudoaneurysm of popliteal artery following total knee arthroplasty.

We report a case of posttraumatic false aneurysm of popliteal artery after a total knee arthroplasty in an 82-year-old woman. This case is characterized by the distinct history of trauma to the popliteal fossa in the immediate postoperative period and the location of false aneurysm. In addition, the clinical symptoms were similar to those of deep vein thrombosis. The ultrasonographic examination and computed tomography (CT) angiography confirmed the diagnosis on 6(th) day after the surgery. Ultrasonographic examination 1 day later revealed no increase in the size of false aneurysm. She was treated with open surgical repair. Presenting the difficulty in the diagnosis, unusual location, etiology, and its management is the intention of this case report.

Osteochondral Fracture Lateral Femoral Condyle Treated with ORIF Using Z-Plasty: A Modification of Coonse and Adams Approach.

Osteochondral fractures of lateral femoral condyle are common in adolescents and young adults. They are usually caused by direct trauma or twisting injuries of the knee. We present a case of large osteochondral fracture of lateral femoral condyle involving the articular surface in a fifteen-year-old male with a positive history of significant weight gain of 5 kilograms in last six months. Blood investigations reported low vitamin D and testosterone levels with elevated alkaline phosphatase. Adequate exposure was achieved by doing Z-plasty of quadriceps apparatus. The fracture was treated with open reduction and internal fixation using Herbert's screws. Medical management in the form of vitamin D and calcium along with testosterone was given. After the surgery, full weight-bearing was allowed at three months. At one year followup, patient has good quadriceps function without any weakness of the muscle.

Osteoarticular tuberculosis--diagnostic solutions in a disease endemic region.

BACKGROUND: We conducted a study of osteoarticular tuberculosis in patients from private and public settings in a disease endemic area. Our objective was to assess the role of mycobacterial culture and polymerase chain reaction (PCR) in the diagnosis of osteoarticular tuberculosis (TB) in settings where only clinical and imaging diagnosis form the basis for treatment. METHODOLOGY: Ninety-three consecutive specimens collected from clinically suspected patients of osteoarticular TB were screened for bacterial culture, mycobacterial culture and in-house nested PCR. In addition, specimens were examined by imaging and histopathology. Ten specimens collected from patients suffering from other bone diseases were included as negative controls. RESULTS: Of the 93 clinically suspected TB patients, mycobacterial culture was positive for Mycobacterium tuberculosis (MTB) in 47 (51%) patients who were confirmed as definite TB cases. Of the remaining patients, 16 (17%) were diagnosed as probable, 19 (20%) as possible, and 11 (12%) as only clinically suspected TB cases. In-house nested PCR was positive in 65 (70%) cases. Fifteen patients were resistant to one or more anti-tuberculous drugs; twelve patients were multi-drug resistant, two of whom were extensively drug resistant. CONCLUSION: Mycobacterial cultures using liquid media with susceptibility should form the backbone of management of osteoarticular TB. Nested PCR enhances the sensitivity if performed in addition to culture.