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Objective: The aim of this study was to review the radiological alignment outcomes of patient Specific (PS) cutting blocks and Standard Instrumentation in Primary Total Knee Arthroplasty. Methods: We hypothesized that the use of PS techniques would significantly improve sagittal, coronal and rotational alignment of the prosthesis on short term. We performed a systematic review and a meta-analysis including all the randomised controlled trials (RCT) using PS and standard (ST) total knee arthroplasty to date. Results: A total of 538 PS TKA and 549 ST TKA were included in the study. Statistical analysis of the outliers for femoral component sagittal, coronal and rotational positioning, tibial component sagittal and coronal positioning and the overall mechanical axis were assessed. We found that there was no significant benefit from using PS instrumentation in primary knee arthroplasty to aid in the positioning of either the tibial or femoral components. Furthermore sagittal plane tibial component positioning was worse in the PS than the traditional ST group. Conclusion: Our results suggest that at present PS instrumentation is not superior to ST instrumentation in primary total knee arthroplasty. Level of evidence: Level 1, Systematic review of therapeutic studies. Keywords: Alignment, Meta-analysis, Patient-specific, Total knee arthroplasty

Injuries to the Lisfranc complex, although relatively rare carry a high morbidity and are often associated with other injuries. Despite a number published studies to determine the best operative management, there is an ongoing debate to whether open reduction and internal fixation (ORIF) or primary arthrodesis (PA) produces the best outcomes for patients. There have been further studies published in the last few years that have not been assessed as part of the wider literature and therefore we wished to perform an updated systematic review and meta-analysis with inclusion of outcomes not assessed in the previous studies.We performed a structured search for retrospective and prospective comparative papers and identified 8 relevant articles (2 RCT studies and 6 non-RCT studies) that compared the outcomes of ORIF versus PA; these studies included a total of 547 patients. Each of the studies was assessed for suitability and quality before inclusion. We performed a statistical analysis of the aggregated results as part of the review.We found no statistically significant difference between the outcomes of ORIF versus PA in terms of return to work or activity (Odds Ratio 0.80 (CI 95%, 0.32-2.02, P=0.64)) and satisfaction rates (Odds Ratio 0.15 (CI 95%, 0.01-.00, P=0.25)). Patients undergoing ORIF have a higher risk of undergoing further surgery to remove the metalwork (Odds Ration 13.13 (CI 95%, 7.65-22.54, P0.00001)) or to undergo secondary fusion, but, the overall complication rates appear to be equivalent in both groups (risk difference 0.03 (CI 95%, -0.15-0.21, P=0.76)).Although there were no significant differences in the functional outcomes, the overall power of the studies is low. The rates of metalwork removal and secondary fusion were higher in the ORIF group and this risk should be presented to the patient when counselling them for any procedure. We noted that there is a high level of heterogeneity in the type of injuries and measured outcomes included in each study and, therefore, further trials are needed to determine the best treatment across the spectrum of Lisfranc complex injuries.

The minimally invasive surgery (MIS) approach has been popularised as an alternative to the standard open approach in acute Achilles tendon repair. Advocates of MIS suggest earlier functional recovery, due to reduced trauma to adjacent soft tissues. Critics, however, argue that due to inadequate surgical exposure, complications of such surgery are higher compared to an open technique. A systematic review and meta-analysis of randomised, prospective studies weas conducted to compare MIS and open surgery in acute Achilles tendon ruptures. Thirteen studies were included in the meta-analysis with a total of 854 patients. Although re-rupture rates were not significantly different between the groups (P = 0.43), there were significantly more complications in the open surgery group (P =.00001). MIS in acute Achilles tendon ruptures result in similar re-rupture rates, sural nerve injury rates and return to sport time in comparison with open surgical method, but with significantly less post-operative complications.

Open Achilles tendon repairs (OATR) are associated with high complication rates. Minimally invasive surgery (MIS) techniques like the Achillon Achilles tendon repair (AATR) were developed to reduce this. We performed a systematic review and meta-analysis to compare OATR with AATR.We performed an extensive literature search including all studies that compared the two techniques. Outcomes assessed included overall complication rate, re-rupture rate, sural nerve injury, wound length, The American Orthopaedic Foot and Ankle Scores (AOFAS) scores and return to sports.Eight studies were suitable for inclusion totalling 210 patients in the AATR group vs 233 patients in the OATR group. Total complication rates were significantly reduced in the Achillon patients with odd ratio of 0.14 (CI 95%, 0.08-0.27, P0.00001) in favour. There were no significant differences in re-rupture rate, sural nerve injury, return to sports and AOFAS scores following repair between the two groups.AATR has fewer overall complications compared with OATR. It should be considered as an alternative to open surgical repair.

A tourniquet is often used in total knee arthroplasty resulting in improved visualization of structures, reduced intraoperative bleeding and better cementation. The risks include deep vein thrombosis and pulmonary embolism. To quantify the case for or against tourniquet use, we carried out a systematic review and meta-analysis of selected randomized controlled trials. Ten studies were included in the meta-analysis. Of the 8 outcomes analyzed (surgery duration; total, intraoperative, and postoperative blood losses; deep vein thrombosis; pulmonary embolism; and minor/major complications), the total and intraoperative blood losses were less using a tourniquet. Minor complications were more common in the tourniquet group. The remaining outcomes showed no difference between the groups. Using a tourniquet may be beneficial, but long-term studies of outcome are needed.

Although bioabsorbable pins have been used to successfully stabilize a wide range of osteotomies, to date there have been not published studies describing the results of their use for fixation of first metatarsal osteotomies in Mitchell's bunionectomy. The purpose of this retrospective investigation of 78 first metatarsal osteotomies was to evaluate the effectiveness of polydioxanone bioabsorbable pin fixation of the first metatarsal osteotomy in Mitchell's bunionectomy. The mean length of the first metatarsal preoperatively was 6.65 +/- 0.42 cm, and postoperatively it was 6.31 +/- 0.57 cm (P.0001). The mean first IMA preoperatively was 17.59 degrees +/- 3.51 degrees , and postoperatively it was 9.91 degrees +/- 2.58 degrees (P.0001). The mean HVA preoperatively was 29.74 degrees +/- 4.70 degrees , and postoperatively it was 12.89 degrees +/- 4.26 degrees (P.0001). The average time to bony union was 6.01 +/- 0.61 weeks. There were 5 (6.41%) superficial wound infections that resolved with oral antibiotics, 1 (1.28%) deep-seated infection requiring surgical debridement, and 2 (2.56%) patients complained of transfer metatarsalgia. Five (6.41%) patients displayed persistent localized translucency at some portion of the osteotomy site on postoperative radiographs, and there were no cases of progressive osteolysis. In this series there were no complications related to pin fracture or failure of osteotomy fixation. Based on the results observed in this study, it appears that the use of polydioxanone bioabsorbable pins provides satisfactory stabilization of the first metatarsal osteotomy in Mitchell's bunionectomy, and was not associated with any serious complications.2.

Fractures of the occipital condyle are rare. Their prompt diagnosis is crucial since there may be associated cranial nerve palsies and cervical spinal instability. The fracture is often not visible on a plain radiograph. We report the case of a 21-year-old man who sustained an occipital condylar fracture without any associated cranial nerve palsy or further injuries. We have also reviewed the literature on this type of injury, in order to assess the incidence, the mechanism and the association with head and cervical spinal injuries as well as classification systems, options for treatment and outcome.

A 65-year-old lady presented to the Accident and Emergency Department complaining of right hip pain and inability to weight bear following a mechanical fall at home. Her past medical history included chronic pancreatitis as a complication of acute pancreatitis 30 years ago. Due to severe chronic epigastric pain she had been self administering intramuscular pentazocine for a number of years. Examination revealed pain with limited movements of the affected hip, as well as reduced ranges of movement of the hip and knee on the contralateral side. On further examination there was found to be bilateral hard woody indurations in the anterior thigh muscles and gluteal region as well as the upper arms, although other muscle groups seemed to be spared (Figs. 1—3). Plain radiographs showed a right intracapsular fractured neck of femur with associated extensive soft tissue calcification of the muscles surrounding both femora (Figs. 1 and 2). In view of the patient’s age and poor mobility prior to the fall, the fracture was managed with a hemiarthroplasty. The patient was prepared for theatre in the normal manner

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.

The minimally invasive surgical (MIS) approach has been popularised as an alternative to the standard medial parapatellar approach (MPP) in total knee arthroplasty (TKA). Advocates of this technique suggest earlier functional recovery due to less injury to the surrounding tissues. Potential disadvantages however may include reduced overall exposure, component malalignment and damage to neurovascular structures. A systematic review and meta-analysis of randomised and quasi-randomised trials were conducted to compare the MIS and MPP approaches in primary TKA. Methodological features were rated independently by two reviewers. Seventeen studies were included involving 733 patients with mean age of 69 (SD ± 2.8) in the MIS group and 692 patients with mean age of 68.6 (SD ± 3.1) in the MPP group. Using a MIS approach led to significant increase in flexion within the first week after a TKA (mean difference (MD) of 9.9° (95% confidence interval (CI) 8.2–11.6, P

Proponents of a mid-vastus (MV) approach for primary total knee arthroplasties (TKA) stress its importance in preserving function of the extensor mechanism with earlier rehabilitation and decreased prevalence of lateral release. We conducted a meta-analysis of randomised and quasi-randomised controlled trials to compare functional outcomes of the standard medial parapatellar (PP) and mid-vastus (MV) approaches in primary knee arthroplasties.The study was conducted according to the guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions. Methodological features were rated independently by two reviewers.We included 18 studies involving 1040 patients with mean age of 69 (SD ± 2.7) for the MV and 68.8 (SD ± 2.8) for the PP group. Using a MV approach led to significant improvement in flexion (mean difference (MD) 8.88, 95% confidence interval (CI) 4.50 to 13.25, P0.01) and visual analogue scale score (MD -1.72 95% CI -2.08 to -1.36, P0.01) in the first week postoperatively and reduced the number of required lateral releases (risk difference -0.16 95% CI -0.30 to -0.01, P=0.03) with no increase in complication rates.We conclude that the MV approach may provide an alternative to the standard PP approach with earlier rehabilitation and decreased lateral release rates in primary TKA and no increase in complication rates.

A tourniquet is often used in total knee arthroplasty resulting in improved visualization of structures, reduced intraoperative bleeding and better cementation. The risks include deep vein thrombosis and pulmonary embolism. To quantify the case for or against tourniquet use, we carried out a systematic review and meta-analysis of selected randomized controlled trials. Ten studies were included in the meta-analysis. Of the 8 outcomes analyzed (surgery duration; total, intraoperative, and postoperative blood losses; deep vein thrombosis; pulmonary embolism; and minor/major complications), the total and intraoperative blood losses were less using a tourniquet. Minor complications were more common in the tourniquet group. The remaining outcomes showed no difference between the groups. Using a tourniquet may be beneficial, but long-term studies of outcome are needed.

Displaced metaphyseal and diaphyseal fractures of the distal radius are common in children. Using a plate-screw construct necessitates open reduction and a second operation to remove the metal work. Using a percutaneous Kirschner (K) wire can be attempted closed with an added advantage of a relatively minor procedure to remove the wire after fracture healing. However, using a straight wire may often be challenging due to the shallow angle the K wire needs to pass in order to engage the proximal fragment. Skin pressure and necrosis may also result at the insertion point. Rigidity of the K wire may result in ulnar deviation of the distal fragment and engaging the proximal fragment with a straight wire often necessitates starting the entry point at the tip of the radial styloid and thereby having to transgress the radial epiphysis (Figure 1).