Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature.

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

Patellar resurfacing in primary total knee replacement: a meta-analysis.

BACKGROUND: Treatment of the patella during total knee replacement is an area of continuing debate. We performed a meta-analysis of randomized controlled trials to address the hypothesis that patellar resurfacing in primary total knee replacement improved patient outcome. METHODS: Randomized controlled trials comparing patellar resurfacing with nonresurfacing in primary total knee replacement were included. The primary outcomes analyzed were knee scores, anterior knee pain, and patient satisfaction. We also investigated the prevalence of complications, revision surgery related specifically to the patellofemoral joint, the infection rate, operative time, and radiographic appearance. RESULTS: Sixteen randomized controlled trials assessing 3465 knee replacements were eligible; 1710 procedures included patellar resurfacing and 1755 did not. The knee component of the Knee Society Score was significantly higher in the resurfacing group (p = 0.005); however, no significant difference was observed for the function component of the Knee Society Score or for any other reported knee score. Anterior knee pain was reported in 13% of resurfaced knees and in 24% of nonresurfaced knees; this difference was not significant (p = 0.1). Patients were satisfied with the outcome after 485 (90%) of 539 procedures that included patellar resurfacing compared with 488 (89%) of 548 that did not; this difference was not significant. There were ninety-three reported patellofemoral complications in the resurfacing group and 205 in the nonresurfacing group; this difference was significant (p = 0.02) in a random-effect model. The rate of reoperation because of anterior knee pain (p < 0.00001) and the rate of reoperation because of any patellofemoral complication (p = 0.002) were significantly higher in the nonresurfaced group. No differences were found in the analyses of infection rate, operative time, or radiographic appearance. CONCLUSIONS: Patients who underwent patellar resurfacing experienced anterior knee pain and satisfaction with the arthroplasty procedure that were equivalent to those experienced by patients whose patella was not resurfaced; however, these patients underwent significantly fewer additional surgical procedures. Further long-term follow-up of modern prostheses in randomized studies measuring outcome with a patella-specific score is needed.

The Exeter Universal stem: a minimum ten-year review from an independent centre.

We reviewed 142 consecutive primary total hip replacements implanted into 123 patients between 1988 and 1993 using the Exeter Universal femoral stem. A total of 74 patients (88 hips) had survived for ten years or more and were reviewed at a mean of 12.7 years (10 to 17). There was no loss to follow-up. The rate of revision of the femoral component for aseptic loosening and osteolysis was 1.1% (1 stem), that for revision for any cause was 2.2% (2 stems), and for re-operation for any cause was 21.6% (19 hips). Re-operation was because of failure of the acetabular component in all but two hips. All but one femoral component subsided within the cement mantle to a mean of 1.52 mm (0 to 8.3) at the final follow-up. One further stem had subsided excessively (8 mm) and had lucent lines at the cement-stem and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. One stem was revised for deep infection and one for excessive peri-articular osteolysis. Defects of the cement mantle (Barrack grade C and D) were found in 28% of stems (25 hips), associated with increased subsidence (p = 0.01), but were not associated with endosteal lysis or failure. Peri-articular osteolysis was significantly related to the degree of polyethylene wear (p < 0.001), which was in turn associated with a younger age (p = 0.01) and male gender (p < 0.001). The use of the Exeter metal-backed acetabular component was a notable failure with 12 of 32 hips (37.5%) revised for loosening. The Harris-Galante components failed with excessive wear, osteolysis and dislocation with 15% revised (5 of 33 hips). Only one of 23 hips with a cemented Elite component (4%) was revised for loosening and osteolysis. Our findings show that the Exeter Universal stem implanted outside the originating centre has excellent medium-term results.