Data extracted from previously published studies suggest that asymptomatic osteonecrosis has a high prevalence of progression to symptomatic disease and femoral head collapse. While small, medially located lesions have a low rate of progression, the natural history of asymptomatic medium-sized, and especially large, osteonecrotic lesions is progression in a substantial number of patients. For this reason, it may be beneficial to consider joint-preserving surgical treatment in asymptomatic patients with a medium-sized or large, and/or laterally located, lesion.

Patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee.

Background Advances in the surgical treatment of musculoskeletal conditions have resulted in an interest in better defining and understanding patients' expectations of these procedures, but the best ways to do this remain a topic of considerable debate. Questions/purposes (1) What validated instruments for the assessment of patient expectations of orthopaedic surgery have been used in published studies to date? (2) How were these expectation measures developed and validated? (3) What unvalidated instruments for the assessment of patient expectations have been used in published studies to date? Methods A systematic literature search was performed using the OVID Medline and EMBASE databases, in duplicate, to identify all studies that assessed patient expectations in orthopaedic surgery. Sixty-six studies were ultimately included in the present review.Results Seven validated expectation instruments were identified, all of which use patient-reported questionnaires. Five were specific to a particular procedure or affected anatomic location, whereas two were broadly applicable. Details of reliability and validity testing were available for all but one of these instruments. Forty additional unvalidated expectation assessment tools were identified. Thirteen were based on existing clinical outcome tools, and the others were study-specific, custom-developed tools. Only one of the unvalidated tools was used in more than one study. Conclusions Several validated expectation instruments have been developed for use by patients undergoing orthopaedic surgery. However, many tools have been reported without evidence of testing and validation. The wide range of untested instruments used in single studies substantially limits the interpretation and comparison of data concerning patient expectations.

The primary goals of this critical literature review were to determine whether revision rates of primary total hip arthroplasty in patients with osteonecrosis differ based on the underlying associated risk factors and diagnoses, whether the outcomes of this procedure have improved over the past two decades, and to compare outcomes based on study level of evidence. A systematic literature review yielded 67 reports representing 3,277 hips in 2,593 patients who had a total hip arthroplasty for osteonecrosis of the femoral head. Stratification of outcomes by associated risk factors or diagnoses revealed significantly lower revision rates in patients with idiopathic disease, systemic lupus erythematosus, and after heart transplant, and significantly higher rates in patients with sickle cell disease, Gaucher disease, or after renal failure and/or transplant. There was a significant decrease in revision rates between patients operated upon before 1990 versus those in 1990 or later, with rates of 17% and 3%, respectively. The results for arthroplasties performed in 1990 or later were similar to those for all hips in publicly reported national joint registries. Certain risk factors were associated with higher revision rates in patients with osteonecrosis who were treated by total hip arthroplasty. However, most patients (82%) do not have these associated negative risk factors. Overall, this critical literature review provides evidence that osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty.

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Nearly 50% of elderly patients who underwent surgery for a fragility hip fracture developed perioperative delirium, which was associated with a significant incremental in-hospital length of stay and significant incremental episode-of-care costs. These findings highlight the importance of implementing cost-effective interventions to reduce the prevalence of perioperative delirium in elderly patients with a low-energy hip fracture.

Surgical site infections following elective knee arthroplasties occur most commonly as a result of colonisation by the patient's native skin flora. The purpose of this study was to evaluate the incidence of deep surgical site infections in knee arthroplasty patients who used an advance cutaneous disinfection protocol and who were compared to patients who had peri-operative preparation only. All adult reconstruction surgeons at a single institution were approached to voluntarily provide patients with chlorhexidine gluconate-impregnated cloths and a printed sheet instructing their use the night before and morning of surgery. Records for all knee arthroplasties performed between January 2007 and December 2008 were reviewed to determine the incidence of deep incisional and periprosthetic surgical site infections. Overall, the advance preoperative protocol was used in 136 of 912 total knee arthroplasties (15%). A lower incidence of surgical site infection was found in patients who used the advance cutaneous preparation protocol as compared to patients who used the in-hospital protocol alone. These findings were maintained when patients were stratified by surgical infection risk category. No surgical site infections occurred in the 136 patients who completed the protocol as compared to 21 infections in 711 procedures (3.0%) performed in patients who did not. Patient-directed skin disinfection using chlorhexidine gluconate-impregnated cloths the evening before, and the morning of, elective knee arthroplasty appeared to effectively reduce the incidence of surgical site infection when compared to patients who underwent in-hospital skin preparation only.

The aim of this review is to address controversies in the management of dislocations of the acromioclavicular joint. Current evidence suggests that operative rather than non-operative treatment of Rockwood grade III dislocations results in better cosmetic and radiological results, similar functional outcomes and longer time off work. Early surgery results in better functional and radiological outcomes with a reduced risk of infection and loss of reduction compared with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Although non-controlled studies report promising results for arthroscopic coracoclavicular fixation, there are no comparative studies with open techniques to draw conclusions about the best surgical approach. Non-rigid coracoclavicular fixation with tendon graft or synthetic materials, or rigid acromioclavicular fixation with a hook plate, is preferable to fixation with coracoclavicular screws owing to significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical ligament reconstruction with autograft or certain synthetic grafts may have better outcomes than non-anatomical transfer of the coracoacromial ligament. It has been suggested that this is due to better restoration horizontal and vertical stability of the joint. Despite the large number of recently published studies, there remains a lack of high-quality evidence, making it difficult to draw firm conclusions regarding these controversial issues.