Increasing Use of Total Wrist Arthroplasty-An Australian National Joint Registry Report.

Background and Purpose There is limited literature reporting the long-term results and outcomes of total wrist arthroplasty (TWA). The aim of this study was to describe the incidence, usage, and survival of wrist arthroplasty using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Methods Data included all primary TWA procedures from 2006 to 2021. The primary outcome assessed was revision surgery. Utilization of TWA, etiology leading to TWA, patient demographics, and surgical factors were also assessed. Results There were 439 primary TWA procedures performed across the 16-year reporting period. Four prostheses (Motec, Universal 2, Freedom, and ReMotion) have been used, with a recent increased usage toward the Motec, which accounted for 97.4% of prostheses implanted in 2021. There has also been an increase in the number of surgeons performing TWA over time. The most common underlying etiology was osteoarthritis (72.7%), followed by rheumatoid arthritis (15.9%). Implantation for inflammatory arthropathy remained relatively constant across time; however, TWA has been utilized with increasing frequency for the treatment of osteoarthritis and other indications more recently. The cumulative percent revision at 10 years was 18.3%. Loosening accounted for 25.6% of all revisions, followed by osteolysis (12.8%), pain (12.8%), and instability (7.7%). Attempted conversion to an arthrodesis occurred in 10.3% of all revisions. Conclusion There has been an increase in both the volume of TWA performed and the number of surgeons undertaking this procedure in Australia over the past 16 years. The Motec system has become the prosthesis of choice. Medium-term revision rates are inferior when compared with Australian data for hip, knee, and shoulder arthroplasty.

How to do an outside-in/outside-in microsuture for nerve repair.

Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.

Dual Construct Fixation of the Scaphoid.

Dual construct fixation has been increasingly used in complex peri-articular or peri-prosthetic long bone fractures, those with poor bone quality and in revision situations. We describe the utilisation of a screw-plate construct in the setting of a juxta-articular distal pole scaphoid fracture, review the literature and provide recommendations for future use. Level of Evidence: Level V (Therapeutic).

Acute-Onset Multifocal Hand Dysfunction Due to Alkaptonuria.

Alkaptonuria is a rare metabolic disorder characterized by the accumulation of homogentisic acid. Its effects on the central nervous system are well-recognized; however, cases of pathologic homogentisic acid deposition in the peripheral nervous system are less well-described. We report the case of a 72-year-old man with a prior history of alkaptonuria presenting with bilateral carpal tunnel and left-sided cubital tunnel symptoms. This case is of note because the patient demonstrated a rapid onset of symptoms due to pathology at multiple foci.

Acute Mallet Finger Injuries-A Review.

Acute disruptions of the terminal extensor tendon are common and can result in significant dysfunction if not recognized and treated appropriately. This article provides a topical review of the contemporary literature concerning acute mallet finger injuries. It also proposes a modification to the Doyle classification to make it more encompassing and less prone to interobserver error.

Outcomes of Acute Operative Repair of Complete Digital Proximal Interphalangeal Joint Collateral Ligament Ruptures: A Systematic Review.

Background: No consensus exists regarding the management of complete collateral ligament injuries of the proximal interphalangeal joint (PIPJ) of fingers. Methods: We aimed to systematically review the outcomes of Acute (< 1 month) surgical repairs of these injuries. Outcomes assessed included Stability, Pain, Range-of-Motion and Return to Function. The Modified Coleman Methodology Score (MCMS) was utilised in critical appraisal. Results: 70 patients with complete collateral ligament injuries of the PIPJ were identified in 5 studies. 49 were managed operatively and 21 non-operatively. All trials were methodologically flawed with a mean MCMS of 50.4, corresponding to a "Poor" Level of evidence. Conclusions: Whilst acute surgical repair of complete collateral ligament injuries of finger PIPJs are a described viable management option with promising results, there is insufficient high-quality evidence to inform current practice. Based on the current literature, no evidence-based conclusions can be made regarding superiority of acute surgical repair over conservative management or one method of surgical repair over another. Further high level studies are required.

Fracture dislocations of the carpometacarpal joints of the fingers.

OBJECTIVE: Fracture dislocations of the multiple carpometacarpal joints [CMCJ] of the fingers are uncommon injuries that can significantly compromise hand function and durability if managed sub-optimally. These injuries are at risk of being missed as they are commonly a part of major high energy trauma with associated more obvious and immediately threatening injuries getting all the attention. The clinical and radiological parameters which could help a surgeon to detect and analyse these injuries well are discussed. The management of these injuries with emphasis on the pattern of K-wire fixation is presented. METHOD: A review of multiple CMCJ dislocations at our institution found 39 hands in 38 patients (one case with bilateral injury) over a seven-year period (January 2010 to January 2017). The pattern of injury noted in these cases was assessed and categorized. Our preferred management plan for these injuries is discussed. RESULTS: The patterns of dislocations noted in a total of 39 cases were-dorsal (25), dorsal radial (6), volar (1), volar radial (5) and divergent (2). The dorsal dislocations were the commonest (25/39) and additional 6/39 were radial-dorsal, only six displaced in a volar direction. Divergent dislocation was seen in only two cases. CONCLUSION: The pattern of dislocations noted in 39 cases in our institute (Ganga Hospital- A tertiary level trauma center) is presented to provide an overview of the spectrum of the injuries which a surgeon could face. Early surgery is recommended and should be aimed to restore perfect anatomical alignment of the skeleton. Surgeon should have a low threshold for open reduction in case of gross swelling or inability to get an anatomical closed reduction. The method of K-wire fixation presented herein has resulted in good outcome in our practice; wherein we fix the dislocated CMCJ by inserting K-wires from the radial and ulnar borders of the hand and avoiding wires in the central part of the hand. This prevents extensor tendons tethering by the K-wires. The fixation achieved by multiple K-wires passed in this manner provides enough stability to allow for early active mobilisation of the fingers. The need for careful assessment to detect associated nerve injury and compartment syndrome; and post-operative strict hand elevation and prevention of stiffness of the MCP joints has been emphasized.The CMCJ dislocations have innumerable patterns possible; however, the management principles remain the same. In spite of the gross distortion of the anatomy seen in these injuries, anatomical reduction and adequate stabilization to allow early mobilization generally results in satisfactory outcomes.

Non-union in lateral locked plating for distal femoral fractures: A systematic review.

INTRODUCTION: This study aims to identify patient and intra-operative factors that contribute to non-union in locked lateral plating for distal femoral fractures. METHODS: Systematic searches of English-language articles in Ovid Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were undertaken in February 2018 according to the PRISMA guidelines. The search terms were (fracture or fracture*) AND (distal femur or distal femoral) AND (malunion or non-union). Eligible studies published at any time reported non-union rates and compared patient and intraoperative factors in patients who underwent locked lateral plating for traumatic distal femoral fractures. The quality of included papers was assessed using The Journal of Bone and Joint Surgery levels of evidence (Wright et al., 2003), and further appraised using the Downs and Black score (Downs and Black, 1998). RESULTS: Eight studies investigating 1380 distal femoral fractures were found to satisfy the inclusion and exclusion criteria. These studies analysed a variety of patient and intra-operative factors that may contribute to non-union. These include high BMI, open fracture, comminution, fracture infection, stainless steel plate material, shorter working length, open reduction and internal fixation when compared with minimally invasive plate osteosynthesis, high construct rigidity scores and purely locking screw constructs. CONCLUSION: This review has identified multiple factors which potentially contribute to non-union including stainless steel plate material, high construct rigidity scores and purely locking screw constructs. These findings may reflect that overly rigid plating constructs can contribute to non-union. However, they should be taken in the context of heterogeneity amongst included studies, with further research necessary to support these findings.

Non-Operative Rehabilitation of Isolated Popliteus Tendon Rupture in a Rugby Player.

Isolated rupture of the popliteus tendon is uncommon; instead, it is often seen as part of multi-ligamentous posterolateral corner injuries. In this report, we present a case of a 22-year-old professional rugby player who sustained a lateral blow to his semi-flexed knee in a tackle during a competitive game. A complete popliteus tendon rupture at its musculo-tendinous junction was diagnosed on magnetic resonance imaging despite a relatively unremarkable physical examination. The aims of this report are to highlight the diagnostic challenges with this rare injury as physical signs are often subtle and non-specific. Furthermore, we demonstrate the viability of conservative management in the setting of a direct contact mechanism. Indeed, our patient was successfully treated with a specific rehabilitation protocol via isometric quadriceps contractions, gastrocnemius-soleus and hamstring strengthening exercises and graded activity with successful return to full contact activities at 4 weeks and regular season matches shortly after.

A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair.

BACKGROUND: The Bankart repair and Latarjet procedure are both viable surgical options for recurrent traumatic anterior instability of the shoulder joint. The anatomic repair is the more popular option, with 90% of surgeons internationally choosing the Bankart repair as the initial treatment. There has been no previous review directly comparing the 2 techniques. Hence, we aimed to systematically review studies to compare the outcomes of Bankart repairs vs. the Latarjet procedure for recurrent instability of the shoulder. METHODS: Six electronic databases were searched for original, English-language studies comparing the Bankart and Latarjet procedures. Studies were critically appraised using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Data were extracted from the text, tables, and figures of the selected studies. RESULTS: Eight comparative studies were identified with 795 shoulders; 416 of them underwent open or arthroscopic Bankart repairs, and 379 were repaired by the open Latarjet procedure. Primary and revision procedures were studied. The Latarjet procedure conferred significantly lower risk of recurrence and redislocation. There was no significant difference in the rates of complication requiring reoperation between the two procedures. Rowe scores were higher and loss of external rotation lower in the Latarjet group compared with the Bankart repair group. CONCLUSIONS: Our studies demonstrate that the Latarjet procedure is a viable and possibly superior alternative to the Bankart repair, offering greater stability with no significant increase in complication rate. However, the studies identified were retrospective and of limited quality, and therefore randomized controlled trials with large populations of patients or prospective assessment of national orthopedic registries should be employed to confirm our findings.

Practical implications of the lumbar spine and its function on total hip arthroplasty.

Correct component placement is of significant importance to ensure optimal outcomes in total hip arthroplasty (THA). Traditionally, the Lewinnek plane has been referenced as an adequate "safe zone", formed between the anterior superior iliac spines and public tubercles to optimize acetabular orientation. However, recent evidence shows that the positioning of this plane may vary due to the biomechanical relationship between the lumbar spine and hip. Therefore, the plane acquired intraoperatively may not accurately recreate the actual functional plane and acetabular orientation encountered outside of the intraoperative environment. This review summarizes the hip-spine relationship and its implications on THA.

Dedicated hip fracture service: implementing a novel model of care.

BACKGROUND: Hip fracture is a common clinical problem with historically high morbidity and mortality, and various model of acute and subacute care have been employed. We describe 12-month results from the first dedicated hip fracture unit in Australia, and compare it with other models of care both locally and internationally. METHODS: This was performed as a prospective uncontrolled study over a 12-month period. After application of exclusion criteria, a total of 346 patients were yielded. Outcomes measured included performance indicators as well as morbidity and mortality data. RESULTS: Improvements in performance indicators (adequate preoperative medical assessment, time to surgery, return to premorbid residence, etc.) and morbidity and mortality data (such as pressure sores, infections and in-hospital death) are noted. CONCLUSIONS: Early results suggest more comprehensive preoperative assessment, shorter times to theatre, reduced post-operative complications and diminished mortality rates when the principles undermining this unit are instituted.