Context Compensation, whether through workers' compensation or through litigation, has been associated with poor outcome after surgery; however, this association has not been examined by meta-analysis.Objective To investigate the association between compensation status and outcome after surgery. Data SourcesWe searched MEDLINE (1966MEDLINE ( -2003, EMBASE (1980EMBASE ( -2003, CINAHL, the Cochrane Controlled Trials Register, and reference lists of retrieved articles and textbooks, and we contacted experts in the field. Study SelectionThe review included any trial of surgical intervention in which compensation status was reported and results were compared according to that status. No restrictions were placed on study design, language, or publication date. Studies were selected by 2 unblinded independent reviewers. Data ExtractionTwo reviewers independently extracted data on study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Data SynthesisTwo hundred eleven studies satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (workers' compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and 1 described a benefit associated with compensation. A meta-analysis of 129 studies with available data (n = 20 498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval, 3.28-4.37 by random-effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all subgroups.Conclusions Compensation status is associated with poor outcome after surgery. This effect is significant, clinically important, and consistent. Because data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Compensation status should be considered a potential confounder in all studies of surgical intervention. Determination of the mechanism for this association requires further study.

Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion (4CF) are common motion-preserving, salvage procedures for the treatment of wrists with scaphoid nonunion (SNAC) or scapholunate advanced collapse (SLAC). A systematic review was undertaken to clarify controversies regarding which of these procedures has the better outcome. We collated 52 articles that examine outcomes for SNAC or SLAC patients undergoing PRC or 4CF. Although the lack of unbiased trials must be acknowledged, this systematic review confirms that both procedures give improvements in pain and subjective outcome measures for patients with symptomatic and appropriately staged SLAC or SNAC wrists. PRC may provide better postoperative range of movement and lacks the potential complications specific to 4CF (nonunion, hardware issues and dorsal impingement). However, the risk of subsequent osteoarthritis is significantly higher in PRC patients despite the majority being asymptomatic at the time of review. Grip strength, pain relief and subjective outcomes are similar in both treatment groups.

Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and is an important contributory factor to patellofemoral instability and recurrent dislocation. We studied prospectively a series of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, who were treated by a trochleoplasty by a single surgeon between June 2002 and June 2007. Pre- and post-operative scores were assessed by the patients and a satisfaction questionnaire was completed. Of the 54 patients (59 knees) in the series, 39 (44 knees) were female and 15 (15 knees) were male. Their mean age at surgery was 21 years and 6 months (14 years 4 months to 33 years 11 months). In 40 patients (42 knees) the mean follow-up was for 24 months (12 to 58). One patient was unable to attend for follow-up. An analysis of the results of those patients followed up for at least 12 months showed a statistically significant improvement in outcome (p < 0.001 for all scores). Overall, 50 patients (92.6%) were satisfied with the outcome of their procedure. The early results of trochleoplasty are encouraging in this challenging group of patients.

IV.

Objectives: Three dimensional (3D) printing technology has many current and future applications in orthopaedics. The objectives of this article are to review published literature regarding applications of 3D technology in orthopaedic surgery with a focus on knee surgery. Methods: A narrative review of the applications of 3D printing technology in orthopaedic practice was achieved by a search of computerised databases, internet and reviewing references of identified publications. Results: There is current widespread use of 3D printing technology in orthopaedics. 3D technology can be used in education, preoperative planning and custom manufacturing. Custom manufacturing applications include surgical guides, prosthetics and implants. Many future applications exist including biological applications. 3D printed models of anatomy have assisted in the education of patients, students, trainees and surgeons. 3D printed models also assist with surgical planning of complex injuries or unusual anatomy. 3D printed surgical guides may simplify surgery, make surgery precise and reduce operative time. Computer models based on MRI or CT scans are utilised to plan surgery and placement of implants. Complex osteotomies can be performed using 3D printed surgical guides. This can be particularly useful around the knee. A 3D printed guide allows pre osteotomy drill holes for the plate fixation and provides an osteotomy guide to allow precise osteotomy. 3D printed surgical guides for knee replacement are widely available. 3D printing has allowed the emergence of custom implants. Custom implants that are patient specific have been particularly used for complex revision arthroplasty or for very difficult cases with altered anatomy. Future applications are likely to include biological 3D printing of cartilage and bone scaffolds. Conclusion:3D printing in orthopaedic surgery has and will continue to change orthopaedic practice. Its role is to provide safe, reproducible, reliable models with reduced operative time and improves patient outcomes compared to traditional surgical techniques. Long term follow up of the techniques is still required.

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

IMPORTANCEThe burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.OBJECTIVE To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. DESIGN, SETTING, AND PARTICIPANTSIn this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. INTERVENTION Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).MAIN OUTCOMES AND MEASURES The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. RESULTS In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI −5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).CONCLUSIONS AND RELEVANCE This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.

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