Aims

Approximately 10% to 20% of knee arthroplasty patients are not satisfied with the result, while a clear indication for revision surgery might not be present. Therapeutic options for these patients, who often lack adequate quadriceps strength, are limited. Therefore, the primary aim of this study was to evaluate the clinical effect of a novel rehabilitation protocol that combines low-load resistance training (LL-RT) with blood flow restriction (BFR).

Aims

Electromagnetic induction heating has demonstrated in vitro antibacterial efficacy over biofilms on metallic biomaterials, although no in vivo studies have been published. Assessment of side effects, including thermal necrosis of adjacent tissue, would determine transferability into clinical practice. Our goal was to assess bone necrosis and antibacterial efficacy of induction heating on biofilm-infected implants in an in vivo setting.

Periprosthetic joint infection (PJI) represents a complex challenge in orthopaedic surgery associated with substantial morbidity and healthcare expenditures. The debridement, antibiotics, and implant retention (DAIR) protocol is a viable treatment, offering several advantages over exchange arthroplasty. With the evolution of treatment strategies, considerable efforts have been directed towards enhancing the efficacy of DAIR, including the development of a phased debridement protocol for acute PJI management. This article provides an in-depth analysis of DAIR, presenting the outcomes of single-stage, two-stage, and repeated DAIR procedures. It delves into the challenges faced, including patient heterogeneity, pathogen identification, variability in surgical techniques, and antibiotics selection. Moreover, critical factors that influence the decision-making process between single- and two-stage DAIR protocols are addressed, including team composition, timing of the intervention, antibiotic regimens, and both anatomical and implant-related considerations. By providing a comprehensive overview of DAIR protocols and their clinical implications, this annotation aims to elucidate the advancements, challenges, and potential future directions in the application of DAIR for PJI management. It is intended to equip clinicians with the insights required to effectively navigate the complexities of implementing DAIR strategies, thereby facilitating informed decision-making for optimizing patient outcomes. Cite this article: Bone Joint J 2024;106-B(12):1377–1384

As advancements in total knee arthroplasty progress at an exciting pace, two areas are of special interest, as they directly impact implant design and surgical decision making. Knee morphometry considers the three-dimensional shape of the articulating surfaces within the knee joint, and knee phenotyping provides the ability to categorize alignment into practical groupings that can be used in both clinical and research settings. This annotation discusses the details of these concepts, and the ways in which they are helping us better understand the individual subtleties of each patient’s knee.

Cite this article: Bone Joint J 2024;106-B(12):1363–1368.

Aims

The evidence base within trauma and orthopaedics has traditionally favoured quantitative research methodologies. Qualitative research can provide unique insights which illuminate patient experiences and perceptions of care. Qualitative methods reveal the subjective narratives of patients that are not captured by quantitative data, providing a more comprehensive understanding of patient-centred care. The aim of this study is to quantify the level of qualitative research within the orthopaedic literature.

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Cite this article: Bone Joint J 2024;106-B(10):1100–1110.

It is not unusual for patients prior to their total hip arthroplasty (THA) to indicate that their symptoms worsen with certain meteorological conditions. However, the prevalence and evolution of weather-related pain (WRP) following THA remain poorly understood. The aim of this study was to investigate the prevalence of WRP both before and after primary THA, to assess the impact of THA on pre-existing WRP, and to identify potential risk factors associated with WRP. An in-person survey was conducted on 442 primary THAs, in 327 consecutive patients at the time of their postoperative follow-up. Each patient was assessed using a questionnaire specifically designed to address weather-related joint pain before and after their THA. The clinical evaluation included patient-reported outcome scores (PROMS). Preoperatively, 17% of THA hips experienced WRP, with 71% achieving complete resolution postoperatively (p < 0.001). In patients with WRP in multiple joints and their hip, the THA failed to alleviate the WRP in 31% of the cases. In addition, 8% of the THA patients developed de-novo WRP after surgery. Although the overall prevalence of WRP in hips post-THA was 12%, the prevalence was 29% in hips with WRP preoperatively and 31% in the hips of patients with WRP in multiple joints as well as their hip. WRP in other joints, the initial diagnosis, body mass index (BMI), and age were correlated with WRP following THA. WRP is not uncommon prior to and after THA. Although THA can effectively alleviate WRP in specific patient populations, it does not universally eliminate preoperative WRP or prevent the emergence of new WRP after surgery

Aims

Precise implant positioning, tailored to individual spinopelvic biomechanics and phenotype, is paramount for stability in total hip arthroplasty (THA). Despite a few studies on instability prediction, there is a notable gap in research utilizing artificial intelligence (AI). The objective of our pilot study was to evaluate the feasibility of developing an AI algorithm tailored to individual spinopelvic mechanics and patient phenotype for predicting impingement.

Aims

The aims of this study were: 1) to describe extended restricted kinematic alignment (E-rKA), a novel alignment strategy during robotic-assisted total knee arthroplasty (RA-TKA); 2) to compare residual medial compartment tightness following virtual surgical planning during RA-TKA using mechanical alignment (MA) and E-rKA, in the same set of osteoarthritic varus knees; 3) to assess the requirement of soft-tissue releases during RA-TKA using E-rKA; and 4) to compare the accuracy of surgical plan execution between knees managed with adjustments in component positioning alone, and those which require additional soft-tissue releases.

Introduction. Distal femur fracture fixation in elderly presents significant challenges due to osteoporosis and associated comorbidities. There has been an evolution in the management of these fractures with a description of various surgical techniques and fixation methods; however, currently, there is no consensus on the standard of care. Non-union rates of up to 19% and mortality rates of up to 26 % at one year have been reported in the literature. Delay in surgery and delay in mobilisation post-operatively have been identified as two main factors for high rate of mortality. As biomechanical studies have proved better stability with dual plating or nail-plate combination, a trend has been shifting for past few years towards rigid fixation to allow early mobilisation. Our study aims to compare outcomes of distal femur fractures managed with either single plate (SP), dual plating (DP) or nail-plate construct (NP). Methods. A retrospective review of patients aged above 65 years with distal femur fractures (both native and peri-prosthetic) who underwent surgical management between June 2020 and May 2023 was conducted. Patients were divided into three groups based on mode of fixation - single plate or dual plating or nail-plate construct. AO/OTA classification was used for non-periprosthetic, and Unified classification system (UCS) was used for periprosthetic fractures. Data on patient demographics, fracture characteristics, surgical details, postoperative complications, re-operation rate, radiological outcomes and mortality rate were evaluated. Primary objective was to compare re-operation rate and mortality rate between 3 groups at 30 days, 6 months and at 1 year. Results. A cohort of 32 patients with distal femur fractures were included in this study. 91% were females and mean age was 80.97 (range 68–97). 18 (53%) were non-periprosthetic fracture and 14 (47%) were periprosthetic fractures.18 patients underwent single plate fixation (AO/OTA 33A – 8, 33B/C – 2, UCS V3B – 5, V3C – 3),10 patients had dual plate fixation (AO/OTA 33A – 1, 33B/C – 4, UCS V3B – 3, V3C – 2) and 4 patients underwent nail-plate combination fixation (AO/OTA 33A – 4). 70.5% patients had surgery within 36 hours of admission and 90% within 48 hours. Analysis showed no re-operation at 30 days, 6 months in all 3 groups. At 1 year one patient had re-operation in dual-plating periprosthetic group (Distal femur replacement done for failed fixation). Three patients (16%) in single plate group had re-operation at 2 years (2 for peri-implant fracture and 1 for infection). None of the patients treated with Nail-plate combination had re-operation. Mortality rate at 30 days was 0% in among all the 3 groups. At 6 months, it was 16% in single plate group and 0% in DP and NP groups at 6 months and at 1 year mortality rate was 27% in SP group, 10% in DP and 0% in NP group. Combined mortality rate was 0% at 30 days, 9% at 6 months and 18.7% at one year. Conclusion. Our analysis provides insights into fixation methods of distal femur fractures in elderly patients. We conclude that a lower re-operation rate and mortality rate can be achieved with early surgery and rigid fixation with either dual plating or nail-plate construct to allow early mobilisation. Further prospective studies are warranted to confirm these findings and guide the selection of optimal surgical strategies for these challenging fractures

Aims

Patient dissatisfaction is not uncommon following primary total knee arthroplasty. One proposed method to alleviate this is by improving knee kinematics. Therefore, we aimed to answer the following research question: are there significant differences in knee kinematics based on the design of the tibial insert (cruciate-retaining (CR), ultra-congruent (UC), or medial congruent (MC))?

The June 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Reverse versus anatomical total shoulder replacement for osteoarthritis? A UK national picture; Acute rehabilitation following traumatic anterior shoulder dislocation (ARTISAN): pragmatic, multicentre, randomized controlled trial; acid for rotator cuff repair: a systematic review and meta-analysis of randomized controlled trials; Metal or ceramic humeral head total shoulder arthroplasty: an analysis of data from the National Joint Registry; Platelet-rich plasma has better results for long-term functional improvement and pain relief for lateral epicondylitis: a systematic review and meta-analysis of randomized controlled trials; Quantitative fatty infiltration and 3D muscle volume after nonoperative treatment of symptomatic rotator cuff tears: a prospective MRI study of 79 patients; Locking plates for non-osteoporotic proximal humeral fractures in the long term; A systematic review of the treatment of primary acromioclavicular joint osteoarthritis.

Introduction. Total ankle replacement (TAR) is performed for post-traumatic arthritis, inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1997. In this study, using data from the SAP, we look at trends in the use and outcomes of TAR in Scotland. Methods. We identified 499 patients from the SAP who underwent TAR between 1997 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and looked at trends in, implant type over the following time periods: 1998–2005; 2006–2010 and 2011–2015. Age, gender, indication and outcomes for each time period were examined and also trends with implant type over time. Results. There were 499 primary TAR procedures with an overall incidence of 0.5/10. 5. population per year. Eight different implants were identified with significant changes in the numbers of each type used over time. The peak incidence of TAR was in the 6th decade. The mean age of patients undergoing TAR from 59 years in 1997–2005, to 65 years in 2011–15 (p< 0.0001). The percentage of patients with inflammatory arthropathy was 52% in 1997–2005, compared with 10% in 2011–2015. Subsequent arthrodesis and infection rates appeared to be higher during the first time period. The female to male ratio also changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=< 0.0001). This may be due to a broadening range of indications and patient selection criteria, in turn due to increased surgeon experience and the evolution of implant design. Conclusion. This study examines a large number of TARs from an established arthroplasty registry. The rate of TAR has increased significantly in Scotland from 1997 to 2015. Indication and patient age has changed over time and this could potentially impact outcomes after ankle replacement

Introduction. Frame HI is the #Days for device removal/cm. IM Nail HI is less relevant (31–45 D/cm). Albizzia HI was 33 D/cm (1991–2003). Patients felt fine approximately 1M after end of lengthening (EoL), resuming normal life and sports. This sometimes resulted in implants fractures (e.g. skying before bone fusion). Ideally, the full fusion should occur at the EoL. We decided to shorten the HI to reach this target, optimising all parameters. Materials & Methods. The evolution of care has been monitored over a 32-year clinical experience with a fully weight-bearing nails (Albizzia then G-nail). Monitoring was with X-rays, DEXA, blood bone activity, and in London with special 5G CBCT Scans. We implemented several changes in the Care of patients and measured them according to the ‘Five Principles’ (stability, function, ‘Roads-vascular supply’, ‘Materials-calories’ and ‘Workers-BFC’, with actions on food intake, activity levels and on muscle and bone vascular growths. Results. Preop: training (vascularity, muscle force). Op & Postop: spine morphine, IM sawing preserving BFC, controlled hypo-pressure, low hydration, 50 cm leg elevation, walking, resistance bike, full motion (drainage, muscle reactivation), discharge 3–4h postop (including bilateral). Postop daily intense gym training. POD07-21: Distraction increased to fight non-linear hyper-ossification (44–50 mm gain at POD30) +/- aided by NSAIDs. HI decreased to 12–20D/cm, sometimes 8D/cm with some ‘soft fusion’ during lengthening, hardening within 1W after EoL. Conclusions. The surgeon is not a passive X-rays observer, but has an active role in changing the healing speed and decreasing HI for patient safety. Electro/Magnetic nails (torque 1 Nm) may be clocked by bone fusion, which does not occur with the G-Nail (19 Nm). An holistic vision for patients and treatments at several levels is essential to accelerate bone healing, and to return fast to full normal life, after a short ‘lengthening parenthesis’

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity.

Cite this article: Bone Joint J 2024;106-B(4):312–318.