Publications

PURPOSE: Total knee arthroplasty (TKA) is a standard orthopaedic procedure for severe knee arthritis, often resulting in high patient satisfaction. However, complications, such as aseptic loosening, remain a significant concern, some thought to be linked to insufficient cement penetration. Using a tourniquet during surgery to improve cement penetration is a topic of debate, with evidence regarding its mixed effectiveness. This review aims to evaluate the impact of tourniquet application on cement penetration, TKA outcomes and related complications.

METHODS: A meta-analysis adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted, analyzing comparative studies from PubMed, Scopus, Web of Science and Embase. Eligibility criteria focused on studies assessing tourniquet effects on cement penetration, complications and other surgical outcomes. Data extraction and quality assessment followed standardized protocols. Statistical analyses employed a random-effects model to account for heterogeneity, including sensitivity analyses and publication bias assessments.

RESULTS: The meta-analysis included 16 studies encompassing 1516 observations. Tourniquet use significantly increased cement penetration in average and cumulative analysis (p value = 0.045 and 0.005, respectively). Tourniquet pressure-based subgroup analysis did not show statistically significant differences in cement penetration between groups. In secondary outcomes, a 52% reduction in blood transfusion likelihood was observed in the tourniquet group-no significant differences in haemoglobin levels (standardized mean difference [SMD] = 0.0; p = 1). No differences were noted in surgical time (SMD = -0.152; p = 0.26) or postoperative pain (visual analogue scale scores; p = 0.184).

CONCLUSIONS: Tourniquet usage enhanced cement penetration but did not significantly affect surgical duration and pain; instead, it reduced blood transfusion rates. However, variability in surgical techniques and methodologies among included studies has contributed to the results. Future research must use standardized methodologies to resolve inconsistencies and confirm these results.

LEVELS OF EVIDENCE: Level II.

The superficial circumflex iliac perforator flap (SCIP-f) is a thinned adaptation of the superficial circumflex iliac artery flap (SCIA-f) that may have superior use flexibility, smaller scar burden, and lesser need for revision, advantages well-suited to pediatric patients. Despite documented success in adults, the safety and utility of SCIP and SCIA-f are underexplored in pediatric populations.A systematic review of MEDLINE, Web of Science, Embase, and Cochrane databases identified 93 articles reporting SCIP/SCIA-f outcomes in patients ≤ 17 years of age. Patient demographics, clinical characteristics, and postoperative outcomes were collected. Cohorts were stratified by SCIP/SCIA and age group. Mann-Whitney U tests compared cohort outcomes.Thirty-one studies were included, constituting 107 SCIA-f and 57 SCIP-f, with ages 10 weeks to 17 years. Most cases were congenital or traumatic defects in upper/lower extremities. Compared with SCIA-f, SCIP-f demonstrated significantly lower rates of all-cause complications, total flap loss, major and minor complications, and debulking (p < 0.05). All-cause complication rates were also significantly lower across age groups (p < 0.001).This meta-analysis demonstrates favorable efficacy and safety of SCIP-f in children with congenital and traumatic defects, especially of the extremities. SCIP-f may be considered a reliable option for pediatric reconstruction. Additionally, fewer subsequent procedures for contouring may be required.

AIMS: Following resection of a primary bone tumour, reconstruction is commonly performed using either a megaprosthesis or biological reconstruction. Periprosthetic joint infection (PJI) remains one of the most frequent complications. Various treatment strategies exist for PJI, including debridement, antibiotics, and implant retention (DAIR), and single- and two-stage revision, although consensus on optimal management remains elusive. This study aimed to investigate the global practices regarding DAIR in tumour cases through an electronic survey among orthopaedic oncology surgeons.

METHODS: A global cross-sectional observational survey study was distributed to 272 orthopaedic oncology surgeons who attended the BOOM Consensus Meeting in January 2024. The survey contained 19 multiple choice questions focusing on DAIR practices. Responses were collected anonymously and analyzed using descriptive statistics.

RESULTS: The survey was completed by 173/272 surgeons (64%) from 44 countries. While 62% (169/272) routinely performed radical soft-tissue debridement in DAIR, only 39% exchanged all modular components, indicating variability in surgical approaches. DAIR was more commonly performed in acute rather than chronic infections, with 55% finding it very useful in acute cases. The use of local antibiotic delivery was supported by 56%, although only 49% found antibiotic cement coatings beneficial. Systemic antibiotic duration post-DAIR varied, with 39% favouring six weeks and 35% preferring three months.

CONCLUSION: The study highlights global inconsistencies in DAIR practices for PJI in orthopaedic oncology, with financial disparities impacting modular component exchange. Standardized definitions are lacking, and we propose that if only polyethylene is changed, then the procedure is referred to as 'poly exchange'; we recommend defining the procedure as DAIR when extensive debridement, lavage, and removal, wash, and reimplanting of all modular components is done while retaining stable stems, followed by suppressive antibiotic therapy; and finally, we recommend that if all the modular components are changed for new ones, the procedure is referred to as 'DAIR plus'.

BACKGROUND: The orientation of the acetabulum in the axial and coronal planes is well studied in the pathogenesis of impingement and instability of the hip. In contrast, the sagittal orientation of the acetabulum (SOA) is not well understood.

PURPOSE: To determine (1) the SOA in a large cohort of mature hips and (2) to assess the relationship between the SOA and acetabular version, acetabular center-edge angles (CEAs), and spinopelvic alignment.

STUDY DESIGN: Descriptive laboratory study.

METHODS: A total of 3695 patients (7390 mature hips) who underwent computed tomography (CT) scans for assessment of nonorthopaedic abdominal and pelvic conditions were studied. An automated measurement software was utilized to reconstruct 3-dimensional models from CT scans and to measure the SOA, functional SOA (not neutralizing pelvic position on sagittal plane), acetabular version, as well as acetabular CEAs and spinopelvic alignment, including the pelvic tilt (PT), sacral slope (SS), and pelvic incidence (PI).

RESULTS: The SOA was on average (± SD) 19.6°± 7.5°. The functional SOA (not neutralizing pelvic position on sagittal plane) was on average (± SD) 20.5°± 5.7°. The functional SOA had a statistically significant but negligible correlation with PI (r = 0.13; P < .001) and SS (r = -0.06; P < .001), and a weak positive correlation with PT (r = 0.23; P < .001). The SOA had a positive moderate correlation with the cranial (r = 0.41; P < .001) and central acetabular version (r = 0.39; P < .001) and a strong correlation (r = 0.63; P < .001) with caudal acetabular version. A 10° increase in SOA was associated with a 6.6° increase on the caudal acetabular version. The SOA had a moderate negative correlation (r = -0.48; P < .001) with the CEA at 3 o'clock (anterior for left and right hips). A 10° increase in SOA was associated with a 4.9° decrease in CEA at 3 o'clock.

CONCLUSION: The acetabulum is on average 19.5° cephalically oriented in the sagittal plane in asymptomatic individuals. The SOA correlates with acetabular version and cannot be presumed based on spinopelvic alignment.

CLINICAL RELEVANCE: The assessment of the SOA may aid in the diagnosis of hip impingement and instability, allowing a more precise correction of the acetabulum in hip arthroscopy and osteotomies.

AIMS: The aim of this study was to achieve consensus for important topics related to periprosthetic infection (PJI) in orthopaedic oncology, and to identify areas for future research.

METHODS: In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) held in Birmingham, UK, gathered 309 delegates from 53 countries to debate 20 consensus statements on PJI in orthopaedic oncology using a modified Delphi process.

RESULTS: Of 20 questions and statements on PJI in orthopaedic oncology, none achieved unanimous consensus, 18 achieved strong consensus, one achieved moderate consensus, and one achieved weak consensus. The statements that reached consensus with notable agreement were on the prophylaxis of infection, management of leaking wounds, and surgical strategies for the treatment of PJI. Short-duration antibiotic prophylaxis was deemed as effective as longer courses for lower-risk reconstructions, and aggressive management was recommended for wounds draining beyond five to seven days to prevent deep infection. Furthermore, single-stage, two-stage, and 1.5-stage revision were recognized as valid strategies, with two-stage revision remaining the most reliable. The statements that did not achieve consensus were on the role of debridement, antibiotics, and implant retention and prolonged antibiotic use post-revision.

CONCLUSION: The BOOM meeting achieved consensus for important topics on periprosthetic infection in orthopaedic oncology, but highlighted the low quality of the underlying evidence. This study has provided recommendations for the treatment of leaky wounds, duration of postoperative antibiotic prophylaxis, and choice of revision strategy.

BACKGROUND: Metallosis is a well-described complication of total hip arthroplasty (THA); however, its impact on periprosthetic joint infection (PJI) diagnosis and treatment remains unknown. We assessed whether coexisting metallosis at the time of revision THA is associated with delayed diagnosis and poorer PJI treatment outcomes.

METHODS: We retrospectively reviewed patients undergoing revision THA due to chronic and acute hematogenous PJI with coexisting metallosis (metallosis and PJI group). A matched cohort of patients with chronic and acute hematogenous PJI without metallosis was established (control group). The 2018 International Consensus Meeting criteria were used to define PJI. Metallosis was diagnosed based on the intraoperative findings or serum chromium/cobalt levels. The primary outcomes were culture positivity and survival free of reoperation or revision. Thirteen and 42 patients were included in the metallosis and PJI and the control groups, respectively.

RESULTS: The initial set of cultures was negative in 38% of patients in the metallosis and PJI group, compared to only 12% in the control group (P = .03). Time elapsed between presentation of symptoms and first positive culture was significantly longer in the metallosis and PJI group compared to the control (14.5 vs 0 days, P < .001). The revision rate was 46% in the metallosis and PJI group and 24% in the control group (P = .12). Revision-free survival in patients treated with debridement, antibiotics, and implant retention was 28% in the metallosis and PJI group and 79.7% in the control group, (P = .21).

CONCLUSIONS: Metallosis may increase the likelihood of initial false negative culture results and delay PJI diagnosis in patients undergoing revision THA.

PURPOSE: Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.

METHODS: Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.

RESULTS: Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.

CONCLUSIONS: Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

PURPOSE: "Grit" is defined as the perseverance and passion for long-term goals. Thus, grittier patients may have a better function after common hand procedures; however, this is not well-documented in the literature. Our purpose was to assess the correlation between grit and self-reported physical function among patients undergoing open reduction internal fixation (ORIF) for distal radius fractures (DRFs).

METHODS: Between 2017 and 2020, patients undergoing ORIF for DRFs were identified. They were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire before surgery and at 6 weeks, 3 months, and 1 year after surgery. The first 100 patients with at least 1-year follow-up also completed the 8-question GRIT Scale, a validated measure of passion and perseverance for long-term goals measured on a scale of 0 (least grit) to 5 (most grit). The correlation between the QuickDASH and GRIT Scale scores was calculated using Spearman rho (ρ).

RESULTS: The average GRIT Scale score was 4.0 (SD, 0.7), with a median of 4.1 (range, 1.6-5.0). The median QuickDASH scores at the preoperative, 6-week postoperative, 6-month postoperative, and 1-year postoperative time points were 80 (range, 7-100), 43 (range, 2-100), 20 (range, 0-100), and 5 (range, 0-89), respectively. No significant correlation was found between the GRIT Scale and QuickDASH scores at any time.

CONCLUSIONS: We found no correlation between self-reported physical function and GRIT levels in patients undergoing ORIF for DRFs, suggesting no correlation between grit and patient-reported outcomes in this context. Future studies are needed to investigate the influence of individual differences in character traits other than grit on patient outcomes, which may help better align resources where needed and further the ability to deliver individualized, quality health care.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

BACKGROUND:  Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

METHODS:  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

RESULTS:  In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05).

CONCLUSION:  While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

PURPOSE: Current estimates suggest that 1-2 million men in the United States have osteoporosis, yet the majority of osteoporosis literature focuses on postmenopausal women. Our aim was to understand men's awareness and knowledge of osteoporosis and its treatment.

METHODS: Semistructured interviews were conducted with 20 male patients >50 years old who sustained a low-energy distal radius fracture. The goal was to ascertain patients' knowledge of osteoporosis, its management, and experience discussing osteoporosis with their primary care physicians (PCP).

RESULTS: Participants had little knowledge of osteoporosis or its treatment. Many participants regarded osteoporosis as a women's disease. Most participants expressed concern regarding receiving a diagnosis of osteoporosis. Several patients stated that they believe osteoporosis may have contributed to their fracture. Families, friends, or mass media served as the primary information source for participants, but few had good self-reported understanding of the disease itself. The majority of participants reported never having discussed osteoporosis with their PCPs although almost half had received a dual x-ray absorptiometry scan. Participants expressed general interest in being tested/screened and generally were willing to undergo treatment despite the perception that medication has serious side effects. One patient expressed concern that treatment side effects could be worse than having osteoporosis.

CONCLUSION: Critical knowledge gaps exist regarding osteoporosis diagnosis and treatment in at-risk male patients. Specifically, most patients were unaware they could be osteoporotic because of the perception of osteoporosis as a women's disease. Most patients had never discussed osteoporosis with their PCP.

CLINICAL RELEVANCE: Male patients remain relatively unaware of osteoporosis as a disease entity. Opportunity exists for prevention of future fragility fractures by improving communication between patients and physicians regarding osteoporosis screening in men following low-energy distal radius fractures.