IntroductionThe increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients.MethodsA search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI ≥ 40 kg/m2) that underwent primary TKA, compared to non-obese patients (BMI ≤ 30 kg/m2). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mann–Whitney test. Statistical significance was defined as p ≤ 0.05.ResultsNine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m2 (range 40–66 kg/m2) and 26.5 kg/m2 (range 11–30 kg/m2) respectively. The average follow-up time was 4.8 years (range 0.5–14.1) and 5.2 years (range 0.5–13.2) respectively, with a revision rate of 7% and 2% (p < 0.001) respectively. All functional scores improved after TKA (p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS (p = 0.78). Overall complication rates,  including infection, were higher in morbidly obese patients.ConclusionsThis review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora's lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions.

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AIMTo investigate the clinical and functional outcomes following total hip arthroplasty (THA) in patients with Paget’s disease.METHODSWe carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of THA in patients with Paget’s disease. Eight studies involving 358 hips were reviewed. The mean age was 70.4 years and follow-up was 8.3 years. There were 247 cemented THAs (69%), 105 uncemented THAs (29%) and 6 hybrid THAs (2%).RESULTSAll studies reported significant improvement in hip function following THA. There were 19 cases of aseptic loosening (5%) at a mean of 8.6 years. Three cases occurred in the uncemented cohort (3%) at a mean of 15.3 years and 16 cases developed in the cemented group (6%) at a mean of 7.5 years (P = 0.2052). There were 27 revisions in the 358 cases (8%) occurring at a mean of 7 years. Six revisions occurred in the uncemented cohort (6%) at a mean of 8.6 years and 21 in the cemented cohort (9%) at a mean of 6.5 years (P = 0.5117).CONCLUSIONThe findings support the use of THA in patients with Paget’s disease hip arthropathy. The post-operative functional outcome is largely similar to other patients; however, the revision rate is higher with aseptic loosening being the most common reason for revision. Uncemented implants appear to be associated with a lower failure rate, however, there were no modern stem designs fixed using current generation cementing techniques used in the reported studies, and as such, caution is advised when drawing any conclusions.

BackgroundApproximately 10% of patients with osteoarthritis (OA) of the knee have unicompartmental OA confined to the patellofemoral joint (PFJ). The main surgical options are total knee replacement (TKR) and PFJ replacement (PFJR). PFJR has a number of advantages over TKR, including being less invasive, preserving the unaffected parts of the knee, allowing faster recovery and better range of motion and function. We report our prospective mid-term results of the Avon PFJR for established isolated PFJ arthritis in 61 consecutive procedures.MethodsSixty-one Avon PFJRs were performed in 57 patients. The outcome measures were the new Oxford knee score (OKS), Hungerford and Kenna score (HKS), and Crosby Insall knee scores. Only patients with severe isolated PFJ OA were included. The diagnosis was based on a combination of clinical, radiological and, where available, arthroscopic findings.ResultsMean follow-up was 5.09 years (range, 12 to 124 years). There were 2 revisions in the first 5 years. The median HKS score was 80 (interquartile range, 70 to 95) and the mean OKS was 31.8 (± standard deviation, 8.7) at 5 years. These were significantly better (p < 0.001) than the preoperative scores.ConclusionsThe Avon prosthesis gives good functional outcomes in the medium term and survives well. Our data support other studies in the literature and is the largest independent prospective study to date.

The increasing prevalence of obesity has resulted in a marked increase in the number of total hip arthroplasties (THAs) carried out in patients with a high body mass index (BMI).THA in morbidly obese patients is often technically challenging owing to the associated co-morbidities and anatomical factors. Furthermore, the long-term clinical and functional outcomes of the procedure in these patients are not clear.The aim of this systematic review was to compare the long-term failure rate and functional outcomes of THA in morbidly obese versus non-obese patients.A literature search of PubMed, EMBASE and PubMed Central was conducted to identify studies that compared the outcomes of THA in patients defined as morbidly obese (BMI ≥ 35) to a control group (BMI < 30). The primary and secondary outcome measures were rate of revision and functional outcome, respectively, in the long term.Eight studies were included in this review. There were 66,238 THAs in morbidly obese patients and 705,619 THAs in patients with a BMI < 30. The overall revision rate was 7.99% in the morbidly obese patients versus 2.75% in the non-obese controls. The functional outcome was at least comparable to non-obese patients.This review suggests that morbidly obese patients have a slightly increased revision rate following THA. Importantly, these patients have a functional recovery at least comparable to those with a BMI < 30. Morbidly obese patients should be fully informed of these issues prior to undergoing surgery.Cite this article: EFORT Open Rev 2018;3:507-512. DOI: 10.1302/2058-5241.3.180011

Total knee arthroplasty (TKA) in patients affected by poliomyelitis is technically challenging owing to abnormal anatomical features including articular and metaphyseal angular deformities, external rotation of the tibia, excessive valgus alignment, bone loss, narrowness of the femoral and tibial canals, impaired quadriceps strength, flexion contractures, genu recurvatum and ligamentous laxity. Little information is available regarding the results and complications of TKA in this challenging group of patients.We carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of TKA in patients with poliomyelitis-affected knees. Six studies including 82 knees met the inclusion criteria and were reviewed. The mean patient age was 63 years (45 to 85) and follow-up was 5.5 years (0.5 to 13).All studies reported significant improvement in knee function following TKA. There were six failures requiring revision surgery in 82 cases (7%) occurring at a mean of 6.2 years (0.4 to 12). The reasons for revision surgery were aseptic loosening (17%, n=1), infection (33%, n=2), periprosthetic fracture (17%, n=1) and instability (33%, n=2). Thirty-six knees had a degree of recurvatum pre-operatively (44%), which was in the range of 5° to 30°. Ten of these knees (28%) developed recurrent recurvatum post-operatively.The findings support the use of TKA in patients with poliomyelitis-affected knees. The post-operative functional outcome is similar to other patients; however, the revision rate is higher. Quadriceps muscle power appears to be an important prognostic factor for functional outcome and the use of constrained implant designs is recommended in the presence of less than antigravity quadriceps strength.Cite this article: EFORT Open Rev 2018;3:358-362. DOI: 10.1302/2058-5241.3.170028