Synthetic substitutes for ligament reconstruction surgery have been widely used in orthopaedic surgery; however, many have been susceptible to mechanical failure and associated with osteolysis. A 58-year-old male underwent total knee arthroplasty (TKA) for valgus knee osteoarthritis on the background of a Gore-Tex anterior cruciate ligament reconstruction over 30 years prior. Radiographic imaging preoperatively demonstrated extensive osteolysis, particularly on the tibial side. At the time of arthroplasty, the extent of osteolysis was noted to be greater than that on the preoperative imaging. The patient underwent a robotic-assisted TKA with the use of a cemented stemmed tibial prosthesis and bone grafting. The patient was prescribed a period of protected weightbearing following the procedure. Our recommendations for undertaking arthroplasty with a Gore-Tex graft in situ are as follows: (1) thorough preoperative workup including computed tomography imaging to identify tunnel widening and osteolysis; (2) ensure that additional bone allograft is available for the procedure; (3) use of cemented implants where there has been significant osteolysis; (4) removal of the entire synthetic graft with copious irrigation post-removal to ensure the joint does not remain exposed to particulate debris; (5) grafting of the tunnels and bone defects post-removal of synthetic graft; (6) use of a stemmed prosthesis to bypass any cortical defects and reduce the risk of subsidence of the component.
Aims This study aimed to compare outcomes of internal fixation and non-operative management in younger adults. Methods A retrospective cohort study was undertaken in patients aged 18–55 with 2-part or 3-part proximal humerus fractures at a Level 1 trauma centre from January 2010 to December 2018. Outcome measures were the Oxford shoulder score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Statistical analysis included univariable analysis and multivariable analysis performed using binary logistic regression and linear regression. Results A total of 184 eligible patients were included; 99 underwent operative fixation and 85 were managed with sling immobilisation. The mean (SD) age in the operative group was 39.3 ± 10.6 and in the non-operative group was 43.2 ± 10.8 ( p = 0.02). Seventy-seven percent completed a minimum 12-month follow-up (median 3.2 years, IQR 2–6.5 years). Most 3-part fractures were treated surgically (78%), as opposed to 44% of 2-part fractures. All open fractures, all segmental fractures, eight head split fractures (89%), and 12 fracture-dislocations (80%) were treated surgically. There was no difference in mean OSS (43.7 operative vs 42.1 non-operative, p = 0.27), mean EQ-5D-5L utility score (0.81 vs 0.78, p = 0.32) or proportion returned to work (83% vs 75%, p = 0.34). Adjusted for case-mix, there was no difference in OSS (adjusted mean difference 0.24, 95%CI −2.73 to 3.22, p = 0.87) or EQ-5D-5L utility score (adjusted mean difference 0.00, 95%CI −0.06 to 0.07, p = 0.96). The complication rate was high (36% non-operative, 27% operative, p = 0.24). A higher rate of varus malunion was observed in the non-operative group (24.0% vs 41.4%, p < 0.001). Following operative management, 23% underwent subsequent surgery compared with 7% of the non-operative group ( p = 0.002). Conclusion In younger adults with proximal humerus fractures no differences in patient reported outcome measures were observed between groups. Operative management was associated with improved radiological outcomes, but a higher rate of subsequent surgery.
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