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Purpose: The number of total knee replacements (TKRs) performed per year has been increasing annually and it is estimated that by 2030 demand would reach 3.48 million procedures per year in the United States Of America. The prevalence of periprosthetic fractures (PPFs) around TKRs has followed this trend with incidences ranging from 0.3% to 3.5%. Distal femoral PPFs are associated with significant morbidity and mortality. When there is sufficient bone stock in the distal femur and a fracture pattern conducive to fixation, locking compression plating (LCP) and retrograde intramedullary nailing (RIMN) are commonly used fixation strategies. Conversely, in situations with loosening and deficient bone stock, a salvage procedure such as a distal femoral replacement is recognized as an alternative. This meta-analysis investigates the rates of non-union, re-operation, infection, and mortality for LCPs and RIMNs when performed for distal femoral PPFs fractures around TKRs. Method: A search was conducted to identify articles relevant to the management of distal femoral PPFs around TKRs in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles meeting the inclusion criteria were then assessed for methodological quality using the methodological items for non-randomised studies (MINORS) criteria. Articles were reviewed, and data were compiled into tables for analysis. Results: 10 articles met the inclusion criteria, reporting on 528 PPFs. The overall incidence of complications was: non-union 9.4%, re-operation 12.9%, infection 2.4%, and mortality 5.5%. This meta-analysis found no significant differences between RIMN and LCP in rates of non-union (9.2% vs 9.6%) re-operation (15.1% vs 11.3%), infection (2.1% vs 2.6%), and mortality (6.0% vs 5.2%), respectively. Conclusion: This meta-analysis demonstrated no significant difference in rates of non-union, re-operation, infection, and mortality between RIMN and LCP and both remain valid surgical treatment options.

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INTRODUCTION: Total Hip Arthroplasty (THA) is being increasingly undertaken in younger and more active patients, with many of these patients wanting to return to sport (RTS) after surgery. However, the percentage of patients RTS and time at which they are able to get back to sport following surgery remains unknown. The objective of this meta-analysis was to determine the time patients RTS after THA. METHODS: A search was performed on PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trials on THA and RTS, in the English language, published from the inception of the database to October 2020. All clinical trials reporting on to RTS following THA were included. Data relating to patient demographics, methodological quality, RTS, clinical outcomes and complications were recorded. The PRISMA guidelines were used to undertake this study. RESULTS: The initial literature search identified 1720 studies. Of these, 11 studies with 2297 patients matched the inclusion criteria. 3 studies with 154 patients demonstrated an overall pooled proportion of 40.0% (95% CI, 32.5-47.9%) of patients RTS between 2 and 3 months after surgery. 4 studies with 242 patients demonstrated an overall pooled proportion of 76.9% (95% CI, 71.5-82.0) of patients RTS by 6 months after surgery. Pooled proportion analysis from 7 trials with 560 patients demonstrated 93.9% (95% CI, 82.7-99.5%) of patients RTS between 6 and 12 months after surgery. CONCLUSIONS: Pooled proportion analysis showed increasingly more patients were able to RTS after THA over the first 1 year after surgery. There remains marked inter and intra-study variations in time for RTS but the pooled analysis shows that over 90% of patients were able to RTS at 6-12 months after THA. These finding will enable more informed discussions between patients and healthcare professionals about time for RTS following THA.

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Limb alignment in total knee arthroplasty (TKA) influences periarticular soft-tissue tension, biomechanics through knee flexion, and implant survival. Despite this, there is no uniform consensus on the optimal alignment technique for TKA. Neutral mechanical alignment facilitates knee flexion and symmetrical component wear but forces the limb into an unnatural position that alters native knee kinematics through the arc of knee flexion. Kinematic alignment aims to restore native limb alignment, but the safe ranges with this technique remain uncertain and the effects of this alignment technique on component survivorship remain unknown. Anatomical alignment aims to restore predisease limb alignment and knee geometry, but existing studies using this technique are based on cadaveric specimens or clinical trials with limited follow-up times. Functional alignment aims to restore the native plane and obliquity of the joint by manipulating implant positioning while limiting soft tissue releases, but the results of high-quality studies with long-term outcomes are still awaited. The drawbacks of existing studies on alignment include the use of surgical techniques with limited accuracy and reproducibility of achieving the planned alignment, poor correlation of intraoperative data to long-term functional outcomes and implant survivorship, and a paucity of studies on the safe ranges of limb alignment. Further studies on alignment in TKA should use surgical adjuncts (e.g. robotic technology) to help execute the planned alignment with improved accuracy, include intraoperative assessments of knee biomechanics and periarticular soft-tissue tension, and correlate alignment to long-term functional outcomes and survivorship.

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Robotic-arm assisted arthroplasty (RAA) has gained popularity over the past decade because of its ability to provide more accurate implant positioning with less surgical trauma than conventional manual arthroplasty. It has shown better early functional outcomes, less postoperative pain and shorter inpatient stays. A multidisciplinary approach is crucial in improving overall outcomes and ensuring this technology is implemented efficiently and safely, but there is limited published literature on the nursing considerations for managing patients undergoing RAA. This article aims to provide a pragmatic approach for nursing care in the pre-, intra-, and postoperative phases of RAA.

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Cementless knee arthroplasty has seen a recent resurgence in popularity due to conceptual advantages, including improved osseointegration providing biological fixation, increased surgical efficiency, and reduced systemic complications associated with cement impaction and wear from cement debris. Increasingly younger and higher demand patients are requiring knee arthroplasty, and as such, there is optimism cementless fixation may improve implant survivorship and functional outcomes. Compared to cemented implants, the National Joint Registry (NJR) currently reports higher revision rates in cementless total knee arthroplasty (TKA), but lower in unicompartmental knee arthroplasty (UKA). However, recent studies are beginning to show excellent outcomes with cementless implants, particularly with UKA which has shown superior performance to cemented varieties. Cementless TKA has yet to show long-term benefit, and currently performs equivalently to cemented in short- to medium-term cohort studies. However, with novel concepts including 3D-printed coatings, robotic-assisted surgery, radiostereometric analysis, and kinematic or functional knee alignment principles, it is hoped they may help improve the outcomes of cementless TKA in the long-term. In addition, though cementless implant costs remain higher due to novel implant coatings, it is speculated cost-effectiveness can be achieved through greater surgical efficiency and potential reduction in revision costs. There is paucity of level one data on long-term outcomes between fixation methods and the cost-effectiveness of modern cementless knee arthroplasty. This review explores recent literature on cementless knee arthroplasty, with regards to clinical outcomes, implant survivorship, complications, and cost-effectiveness; providing a concise update to assist clinicians on implant choice. Cite this article: Bone Jt Open 2021;2(1):48-57.

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BACKGROUND: Surgical repair of proximal rectus femoris avulsion injuries is associated with prolonged periods of rehabilitation and highly variable risk of injury recurrence. Surgical tenodesis of these injuries is often reserved for recurrent injuries or revision surgery. To our knowledge, the outcomes of proximal rectus femoris avulsion injuries treated with surgical repair versus primary tenodesis have not been previously reported. HYPOTHESIS: Primary tenodesis of proximal rectus femoris avulsion injuries is associated with reduced risk of injury recurrence as compared with surgical repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included 25 patients (22 male and 3 female) who underwent surgical repair versus 30 patients (26 male and 4 female) who received primary tenodesis for proximal rectus femoris avulsion injuries. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 27.9 months (range, 24.0-31.7 months) from date of surgery. RESULTS: All patients returned to their preinjury levels of sporting activity. Primary tenodesis was associated with earlier return to preinjury level of sporting function as compared with surgical repair (mean ± SD, 12.4 ± 1.6 vs 15.8 ± 2.2 weeks; P < .001) and reduced risk of recurrence (0% vs 16%; P < .001). At 1-year follow-up, there was no difference in surgical repair versus primary tenodesis relating to patient satisfaction scores (12 very satisfied and 13 satisfied vs 16 very satisfied and 14 satisfied; P = .70), isometric quadriceps strength (95.6% ± 2.8% vs 95.2% ± 6.3%; P = .31), Tegner scores (median [interquartile range], 9 [8-9] vs 9 [8-9]; P = .54), and lower extremity functional scores (73 [72-76] vs 74 [72-75]; P = .41). High patient satisfaction, quadriceps muscle strength, and functional outcome scores were maintained and remained comparable between treatment groups at 2-year follow-up. CONCLUSION: Primary tenodesis was associated with reduced time for return to preinjury level of sporting function and decreased risk of injury recurrence when compared with surgical repair for proximal rectus femoris avulsion injuries. There were no differences in patient satisfaction, functional outcome scores, and quadriceps muscle strength between the treatment groups at 1- and 2-year follow-up.

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Psychosocial health may influence the outcomes after total knee arthroplasty (TKA). We investigated the hypothesis that multimodal therapy influences the quality of life and function in patients diagnosed with osteoarthritis of the knee joint. Secondly, in patients who then proceed to have TKA post-multimodal therapy, does the response to the multimodal therapy influence the overall functional outcome of surgery? Patients diagnosed with osteoarthritis of the knee were enrolled in the study and prospectively followed-up. A total of 526 patients were enrolled and available for the study. All participants were enrolled for 12 classes of 60-minute duration over 6-weeks. Apart from an exercise program, the class also included physiotherapist-led education and a 'weight management' lecture by a dietitian. In summary, the multimodal therapy program improved the SF-12, OKS, pain scores (visual analogue scale) and WOMAC scores significantly. The multimodal therapy protocol can optimize patients' psychological scores prior to TKA and may enhance ultimate functional outcome.

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Nonalcoholic fatty liver disease (NAFLD) is closely related to insulin resistance, metabolic syndrome, obesity, type 2 diabetes, and dyslipidaemia. Obesity and metabolic syndrome are associated with an increased cancer risk, and recent evidence demonstrated an association between NAFLD and colorectal cancer (CRC). The mechanism of how NAFLD can be associated with increased risk of CRC is not fully understood; however, NAFLD represents a condition of profound insulin resistance and a proinflammatory state. Insulin and insulin-like growth factors may promote the development of CRC through their proliferative and antiapoptotic effects. Patients with NAFLD have reduced expression of adiponectin, an adipokine with anti-inflammatory effects. Importantly, hypoadiponectinemia is associated with an increased risk of CRC. Decreased levels of adiponectin lead to increased insulin levels due to marked insulin resistance and in turn increased insulin growth factor-1 (IGF-1). Insulin binds to IGF-1 receptors and plays an important role in cell proliferation, apoptosis, and increased production of vascular endothelial growth factor, an angiogenic factor that supports cancer growth. Further studies are needed to establish (i) the pathophysiology of NAFLD with colorectal cancer, (ii) the benefit of early screening of CRC in NAFLD patients, and (iii) the impact of treatment of NAFLD in the modulation of the risk of colorectal cancer.

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Hepatorenal syndrome (HRS) is a reversible form of functional renal failure that occurs with advanced hepatic cirrhosis and liver failure. Despite mounting research in HRS, its etiology and medical therapy has not been resolved. HRS encompasses 2 distinct types. Type 1 is characterized by the rapid development of renal failure that occurs within 2 wk and involves a doubling of initial serum creatinine. Type 2 has a more insidious onset and is often associated with ascites. Animal studies have shown that both forms, in particular type 1 HRS, are often precipitated by bacterial infections and circulatory changes. The prognosis for HRS remains very poor. Type 1 and 2 both have an expected survival time of 2 wk and 6 mo, respectively. Progression of liver cirrhosis and the resultant portal hypertension leads to the pooling of blood in the splanchnic vascular bed. The ensuing hyperdynamic circulation causes an ineffective circulatory volume which subsequently activates neurohormonal systems. Primarily the sympathetic nervous system and the renin angiotensin system are activated, which, in the early stages of HRS, maintain adequate circulation. Both advanced cirrhosis and prolonged activation of neurohormonal mechanisms result in fatal complications. Locally produced nitric oxide may have the potential to induce a deleterious vasodilatory effect on the splanchnic circulation. Currently medical therapy is aimed at reducing splanchnic vasodilation to resolve the ineffective circulation and maintain good renal perfusion pressure. Terlipressin, a vasopressin analogue, has shown potential benefit in the treatment of HRS. It prolongs both survival time and has the ability to reverse HRS in the majority of patients. In this review we aim to focus on the pathogenesis of HRS and its treatment with terlipressin vs other drugs.

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