Riaz J.K. Khan

Treatment of Acute Achilles Tendon Ruptures. A Meta-Analysis of Randomized, Controlled Trials

BACKGROUND There is a lack of consensus regarding the best option for the treatment of acute Achilles tendon rupture. Treatment can be broadly classified as operative (open or percutaneous) or nonoperative (casting or functional bracing). Postoperative splinting can be performed with a rigid cast (proximal or distal to the knee) or a more mobile functional brace. The aim of this meta-analysis was to identify and summarize the evidence from randomized, controlled trials on the effectiveness of different interventions for the treatment of acute Achilles tendon ruptures. METHODS We searched multiple databases (including EMBASE, CINAHL, and MEDLINE) as well as reference lists of articles and contacted authors. Keywords included Achilles tendon, rupture, and tendon injuries. Three reviewers extracted data and independently assessed trial quality with use of a ten-item scale. RESULTS Twelve trials involving 800 patients were included. There was a variable level of methodological rigor and reporting of outcomes. Open operative treatment was associated with a lower risk of rerupture compared with nonoperative treatment (relative risk, 0.27; 95% confidence interval, 0.11 to 0.64). However, it was associated with a higher risk of other complications, including infection, adhesions, and disturbed skin sensibility (relative risk, 10.60; 95% confidence interval, 4.82 to 23.28). Percutaneous repair was associated with a lower complication rate compared with open operative repair (relative risk, 2.84; 95% confidence interval, 1.06 to 7.62). Patients who had been managed with a functional brace postoperatively (allowing for early mobilization) had a lower complication rate compared with those who had been managed with a cast (relative risk, 1.88; 95% confidence interval, 1.27 to 2.76). Because of the small number of patients involved, no definitive conclusions could be made regarding different nonoperative treatment regimens. CONCLUSIONS Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared with nonoperative treatment, but operative treatment is associated with a significantly higher risk of other complications. Operative risks may be reduced by performing surgery percutaneously. Postoperative splinting with use of a functional brace reduces the overall complication rate. LEVEL OF EVIDENCE Therapeutic Level I.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

Computer-assisted techniques versus conventional guides for component alignment in total knee arthroplasty: a randomized controlled trial.

BACKGROUND Optimal alignment of the prosthesis in total knee arthroplasty results in improved patient outcomes. The goal of this study was to determine the most accurate technique for component alignment in total knee arthroplasty by comparing computer-assisted surgery with two conventional techniques involving use of an intramedullary guide for the femur and either an intramedullary or an extramedullary guide for the tibia. METHODS One hundred and seven patients were randomized prior to surgery to one of three arms: computer-assisted surgery for both the femur and the tibia (the computer-assisted surgery group), intramedullary guides for both the femur and the tibia (the intramedullary guide group), and an intramedullary guide for the femur and an extramedullary guide for the tibia (the extramedullary guide group). Measurements of alignment on hip-to-ankle radiographs and computed tomography (CT) scans made three months after surgery were evaluated. The operative times and complications were compared among the three groups. RESULTS The coronal tibiofemoral angle demonstrated, on average, less malalignment in the computer-assisted surgery group (1.91°) than in the extramedullary (3.22°) and intramedullary (2.59°) groups (p = 0.007). The coronal tibiofemoral angle was >3° of varus or valgus deviation in 19% (seven) of the thirty-six patients treated with computer-assisted surgery compared with 38% (thirteen) of the thirty-four in the extramedullary guide group and 36% (thirteen) of the thirty-six in the intramedullary guide group (p = 0.022). The increase in accuracy with computer-assisted surgery came at a cost of increased operative time. The operative time for the computer-assisted surgery group averaged 107 minutes compared with eighty-three and eighty minutes, respectively, for the surgery with the extramedullary and intramedullary guides (p < 0.0001). There was no significant difference in any of the outcomes between the intramedullary and extramedullary guide groups. CONCLUSIONS This study provides evidence that the implant alignment with computer-assisted total knee arthroplasty, as measured with radiography and computed tomography, is significantly improved compared with that associated with conventional surgery with intramedullary or extramedullary guides. This finding adds to the body of evidence showing an improved radiographic outcome with computer-assisted surgery compared with that following conventional total knee arthroplasty.

A comparison of three methods of wound closure following arthroplasty: a prospective, randomised, controlled trial.

We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee.OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements.

Surgical Interventions for Treating Acute Achilles Tendon Rupture: Key Findings from a Recent Cochrane Review

Acute Achilles tendon rupture is a relatively common injury resulting in substantial morbidity in young, active patients. It occurs most frequently in male individuals, and the incidence is thought to be increasing1. There has been a lack of consensus among orthopaedic surgeons regarding the best ma

A constrained acetabular component for recurrent dislocation

We treated 34 patients with recurrent dislocation of the hip with a constrained acetabular component. Roentgen stereophotogrammetric analysis was performed to assess migration of the prosthesis. The mean clinical follow-up was 3.0 years (2.2 to 4.8) and the radiological follow-up was 2.7 years (2.0 to 4.8). At the latest review six patients had died and none was lost to follow-up. There were four acetabular revisions, three for aseptic loosening and one for deep infection. Another acetabular component was radiologically loose with progressive radiolucent lines in all Gruen zones and was awaiting revision. The overall rate of aseptic loosening was 11.8% (4 of 34). Roentgen stereophotogrammetric analysis in the non-revised components confirmed migration of up to 1.06 mm of translation and 2.32 degrees of rotation at 24 months. There was one case of dislocation and dissociation of the component in the same patient. Of the 34 patients, 33 (97.1%) had no further episodes of dislocation. The constrained acetabular component reported in our study was effective in all but one patient with instability of the hip, but the rate of aseptic loosening was higher than has been reported previously and requires further investigation.

Motivation to quit smoking among hospitalised individuals with and without mental health disorders

Background: Persons with mental health disorders (MHD) have higher rates of smoking and poorer cessation of smoking outcomes than those without MHD. A decreased level of motivation may partially explain lower cessation rates, but there is little information on motivation among inpatients with MHD. Objectives: Primary aims were to compare (1) motivation to cease smoking among those hospitalised with MHD or non-MHD, (2) the proportion that attempted smoking cessation, and (3) use of aids to cessation. A secondary aim was to assess cessation up to six months post-discharge. Methods: Smokers were recruited at a tertiary hospital in Perth, Western Australia. Surveys were administered upon admission and at 5 and 14 days and 6 months post-discharge. Results: We recruited 64 MHD inpatients and 43 non-MHD inpatients. At baseline there were no significant differences between the groups on any measures of the five measures of motivation. Significantly more of the MHD sample attempted smoking cessation than those in the non-MHD sample (34 versus 13: χ2(1)=5.472, P=0.028). Nicotine replacement therapy (NRT) alone was used by 70% of those attempting to quit but was only provided as part of discharge medication to two people and few persons (<21%) in either group used NRT post-discharge. By 14 days, three (4.7%) of the MHD group and none (0%) of the non-MHD group reported abstinence, at 6-months one from each group reported continuous abstinence since discharge from hospital. Conclusions: Motivation to cease smoking among inpatients with MHD was similar to those without MHD, as was use of NRT while hospitalised. The low provision of post-discharge NRT may contribute to the poor cessation of smoking outcomes and does not fulfil evidence based guidelines.

Functional outcomes following total knee arthroplasty: A randomised trial comparing computer-assisted surgery with conventional techniques

BACKGROUND A number of trials have shown improved radiological alignment following total knee arthroplasty using computer-assisted surgery (CAS) compared with conventional surgery. Few studies, however, have looked at functional outcomes. METHODS We prospectively studied a cohort of 107 patients that underwent TKA by a single surgeon. Patients were randomised into 3 groups: computer-assisted surgery for both the femur and the tibia, intramedullary guides for both the femur and the tibia, and an intramedullary guide for the femur and an extramedullary guide for the tibia. Patients were followed-up post-operatively with the Short Form Health Survey (SF-12) and Oxford Knee Score (OKS) questionnaires. RESULTS At a median follow-up of 46 months (range 30-69 months), there was a trend towards higher OKS results in the CAS group, with a mean score of 40.6 in the CAS group compared to 37.6 in the extramedullary group and 36.8 in the intramedullary group. The difference seen in the OKS between CAS and the conventional groups had a significant unadjusted p-value (0.024), and approached significance when adjusted for age and sex (0.054). There was a significant improvement in the OKS when the mechanical axis was within ±3° of neutral, versus those outside this range (median of 41.0 compared to 38.3, p=0.045). DISCUSSION This study shows that clinically significant differences are being seen in functional scores of patients treated with CAS versus conventional guides, at medium-term follow up. Our findings reinforce the tenet that a coronal mechanical axis of within 3° of neutral equates to significantly better functional outcomes.

The natural history of metallosis from catastrophic failure of a polyethylene liner in a total hip

We report on a case of metallosis initially presumed to be heterotopic ossification based on radiologic findings. A 68-year-old man with a total hip arthroplasty experienced failure of the polyethylene liner, resulting in articulation of the ceramic head with the titanium acetabular shell. During revision surgery, extensive metallic debris was evident macroscopically throughout the periprosthetic tissue and was confirmed histologically to be metallosis.

Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature

BACKGROUND Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA. METHODS Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction. RESULTS This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains. CONCLUSION Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them.