J Bone Joint Surg Br
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Options for the treatment of subcapital femoral neck fractures basically fall into two categories: internal fixation or arthroplasty (either hemiarthroplasty or total hip arthroplasty). Historically, the treatment option has been driven by a diagnosis-related approach (non-displaced neck fractures versus displaced neck fractures). More recently, the traditional paradigm has changed. Instead of a diagnosis-related approach, it has become more of a patient-related approach. Treatment options take in to consideration the patient's age, functional demands, and individual risk profile. ⋯ The younger patient should be treated with urgent ORIF with the goal of an anatomic reduction. For displaced femoral neck fractures in the elderly, cognitive function should be determined. For those who are cognitively functioning, total hip arthroplasty appears to be the best option. In the cognitively dysfunctional, a bipolar hemiarthroplasty or a total hip arthroplasty with use of larger heads (32 mm or 36 mm) and/or constrained sockets are a viable option.
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J Bone Joint Surg Br · Nov 2012
The effects of rivaroxaban on the complications of surgery after total hip or knee replacement: results from the RECORD programme.
Post-operative complications after total hip or knee replacement can delay recovery, prolong hospitalisation, increase rates of re-admission and, in the most severe cases, lead to long-term disability or even death. In this analysis of pooled data from four large, randomised, phase III clinical trials that compared the oral, direct Factor Xa inhibitor rivaroxaban with subcutaneous enoxaparin for the prevention of venous thromboembolism after total hip or knee replacement (n = 12,729), the incidence of complications, including bleeding and adverse events related to surgery (such as wound infection, wound dehiscence and haemarthrosis) are reported. Interventions and procedures relating to surgery are also compared between the groups. ⋯ Over the total study duration, adverse surgical events occurred at a similar rate in the rivaroxaban group compared with the enoxaparin group after total knee replacement (2.26% vs. 2.69%, respectively) and total hip replacement (1.48% vs. 1.65%, respectively). Blood loss, wound drainage and transfusion requirements were also similar between the two groups. This analysis shows that the incidence of adverse surgical events with rivaroxaban was similar to enoxaparin.
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J Bone Joint Surg Br · Nov 2012
Malleolar fractures and their ligamentous injury equivalents have similar outcomes in supination-external rotation type IV fractures of the ankle treated by anatomical internal fixation.
It has previously been suggested that among unstable ankle fractures, the presence of a malleolar fracture is associated with a worse outcome than a corresponding ligamentous injury. However, previous studies have included heterogeneous groups of injury. The purpose of this study was to determine whether any specific pattern of bony and/or ligamentous injury among a series of supination-external rotation type IV (SER IV) ankle fractures treated with anatomical fixation was associated with a worse outcome. ⋯ There were no clinically relevant differences between the four possible SER IV fracture pattern groups with regard to the FAOS or range of movement. In this population of strictly defined SER IV ankle injuries, the presence of a malleolar fracture was not associated with a significantly worse clinical outcome than its ligamentous injury counterpart. Other factors inherent to the injury and treatment may play a more important role in predicting outcome.
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J Bone Joint Surg Br · Nov 2012
Multicenter StudyPain management protocols, peri-operative pain and patient satisfaction after total knee replacement: a multicentre study.
In a prospective multicentre study we investigated variations in pain management used by knee arthroplasty surgeons in order to compare the differences in pain levels among patients undergoing total knee replacements (TKR), and to compare the effectiveness of pain management protocols. The protocols, peri-operative levels of pain and patient satisfaction were investigated in 424 patients who underwent TKR in 14 hospitals. The protocols were highly variable and peri-operative pain levels varied substantially, particularly during the first two post-operative days. ⋯ Of the methods of managing pain, the combined use of peri-articular infiltration and nerve blocks provided better pain relief than other methods during the first two post-operative days. Patients managed with peri-articular injection plus nerve block, and epidural analgesia were more likely to have higher satisfaction at two weeks after TKR. This study highlights the need to establish a consistent pain management strategy after TKR.
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J Bone Joint Surg Br · Nov 2012
ReviewThe Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty.
Since 1996 more than one million metal-on-metal articulations have been implanted worldwide. Adverse reactions to metal debris are escalating. Here we present an algorithmic approach to patient management. ⋯ Imaging should include ultrasound or metal artifact reduction sequence MRI, specifically evaluating for fluid collections and/or masses about the hip. If adverse reaction to metal debris is suspected then revision to metal or ceramic-on-polyethylene is indicated and can be successful. Delay may be associated with extensive soft-tissue damage and hence poor clinical outcome.