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R J M Morrison, W G Fishley, K S Rankin, and M R Reed


Vitamin D deficiency has been linked to poorer outcomes following hip (THR) and knee (TKR) replacement. We review the effect of peri-operative supplementation on clinical and patient-reported outcomes following THR/TKR.


This study was registered with PROSPERO (CRD42021238086). Searches of electronic databases were performed from inception to March 2021. All randomised, cohort, or case-controlled studies reported in English of adults undergoing THR/TKR where vitamin D supplementation was given peri-operatively and at least one outcome was reported were included. Studies reporting on vitamin D in relation to osteoporosis and hip fracture were excluded, as were conference abstracts and those involving preclinical models. Risks of bias were performed using the RoB-2 and ROBINS-I tools.


Three studies comprising 413 TKR patients were identified; two were randomised controlled trials and one was a prospective cohort study. No studies meeting the inclusion criteria reported on the outcomes following THR. Supplementation was associated with a statistically significant reduction in the IL6:IL10 ratio at 24- and 48h following surgery, but no effect was noted on Western Ontario and McMaster Universities Osteoarthritis Index scores or the rates of falls. All studies were judged to be limited by bias, with heterogeneity in the supplementation dose and timing of administration, as well as the reported outcome measures used.


Further adequately powered randomised-controlled trials using vitamin D supplementation and a specific clinically relevant or patient-reported outcome measure are required to assess if pre-operative vitamin D insufficiency is a modifiable risk factor to improve outcomes following THR/TKR.

Joost van Tilburg and Mikkel Rathsach Andersen


Due to substantial increase in obesity, the demand for total knee arthroplasty (TKA) in obese and morbidly obese patients is higher than ever. This review aims to investigate mid- to long-term complications, revision rates, and outcome for morbidly obese, compared with non-obese after TKA.


A systematic search was conducted in May 2021. Included studies reported revision rates for morbidly obese and non-obese with a mean follow-up of at least 2 years. Reported knee society score (KSS) has been used to compare the functional outcome. PRISMA protocol was followed, and PROSPERO registered (ID: CRD42021254119).


From 12 studies that met the inclusion criteria, a total of 1031 cases of morbidly obese and 9797 cases of non-obese controls were included. The risk ratio for revision was 1.48 for the morbidly obese, compared with non-obese (95% CI: 0.98 to 2.24; P = 0.06). Regarding aseptic and septic revision, the risk ratio was 1.44 (95% CI: 0.64 to 3.25; P  = 0.37) and 2.22 (95% CI: 0.89 to 5.57; P  = 0.09), respectively. The morbidly obese scored lower in Objective Knee Society Score (OKSS) and Functional Knee Society Score (FKSS) both preoperatively and postoperatively, compared with the non-obese; however, the two groups improved equally in function scores OKSS (P= 0.967) and FKSS (P  = 0.834). Overall risk ratio for complications was 1.56 (95% CI: 0.98 to 2.48; P  = 0.06).


The gained benefit in functional outcome surpasses the increase in risk of revision and complications for the morbidly obese in TKA surgery.

Mario Herrera-Pérez, Pablo Martín-Vélez, David González-Martín, Miguel Domínguez-Meléndez, Ahmed E Galhoum, Victor Valderrabano, and Sergio Tejero

  • Osteoporotic ankle fractures result from mechanical forces that would not ordinarily result in fracture, known as ‘low-energy’ trauma, such as those equivalent to a fall from a standing height or less.

  • Osteoporotic ankle fractures in frail patients are becoming more and more frequent in daily practice and represent a therapeutic challenge for orthopaedic surgeons.

  • The main problems with frail patients are the poor condition of the soft tissues around the ankle, dependence for activities of daily living and high comorbidity.

  • The decision to operate on these patients is complex because conservative treatment is poorly tolerated in unstable fractures and conventional open reduction and internal fixation is associated with a high rate of complications.

  • The authors conducted a narrative review of the literature on primary tibiotalocalcaneal nailing of ankle fractures in frail patients and categorized the different factors to consider when treatment is indicated for this conditon. Difficulty of ambulation, age over 65 years old, deteriorated baseline state and instability of the fracture were the most frequently considered factors.

  • Finally, the authors propose an easy and quick clinical scoring system to help in the decision-making process, although further comparative studies are required to explore its validity.

Matías Sepúlveda, Cecilia Téllez, Víctor Villablanca, and Estefanía Birrer

  • The physis of the distal femur contributes to 70% of femoral growth and 37% of the total limb growth; therefore, physeal injury can lead to important alterations of axes and length.

  • Distal metaphyseal corner-type fracture prior to walking is classically associated with child abuse. In children aged >10 years, sports-related fractures and car accidents are significant contributors.

  • Imaging includes a two-plane radiographic study of the knee. It is recommended to obtain radiographs that include the entire femur to rule out concomitant injuries. In cases of high suspicion of distal metaphyseal fractures and no radiographic evidence, CT or MRI can show the existence of hidden fractures.

  • Fractures with physeal involvement are conventionally classified according to the Salter–Harris classification, but the Peterson classification is also recommended as it includes special subgroups.

  • Conservative and surgical management are valid alternatives for the treatment of these fractures. Choosing between both alternatives depends on factors related to the fracture type.

  • As there is a high risk of permanent physeal damage, long-term follow-up is essential until skeletal maturity is complete.

Karl Stoffel, Christoph Sommer, Mark Lee, Tracy Y Zhu, Karsten Schwieger, and Christopher Finkemeier

  • For complex distal femoral fractures, a single lateral locking compression plate or retrograde intramedullary nail may not achieve a stable environment for fracture healing.

  • Various types of double fixation constructs have been featured in the current literature. Double-plate construct and nail-and-plate construct are two common double fixation constructs for distal femoral fractures.

  • Double fixation constructs have been featured in studies on comminuted distal femoral fractures, distal femoral fracture with medial bone defects, periprosthetic fractures, and distal femoral non-union.

  • A number of case series reported a generally high union rate and satisfactory functional outcomes for double fixation of distal femoral fractures.

  • In this review, we present the state of the art of double fixation constructs for distal femoral fractures with a focus on double-plate and plate-and-nail constructs.

Peter van Schie, Shaho Hasan, Leti van Bodegom-Vos, Jan W Schoones, Rob G H H Nelissen, and Perla J Marang-van de Mheen

  • In order to improve care for total hip and knee arthroplasties (THA/TKA), hospitals may want to compare their performance with hospitals in other countries. Pooling data across countries also enable early detection of infrequently occurring safety issues. We therefore aimed to assess the between-hospital variation and definitions used for revision, readmission, and complications across countries.

  • PubMed, Embase, Web of Science, Cochrane library, Emcare, and Academic Search Premier were searched from January 2009 to August 2020 for studies reporting on: (i) primary THA/TKA; (ii) revision, readmission, or complications; and (iii) between-hospital variation. Most recent registry reports of Network of Orthopedic Registries of Europe members were also reviewed. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the Integrated quality Criteria for the Review Of Multiple Study designs tool for studies and relevant domains for registries. We assessed agreement for the following domains: (i) outcome definition; (ii) follow-up and starting point; (iii) case-mix adjustment; and (iv) type of patients and hospitals included.

  • Between-hospital variation was reported in 33 (1 high-quality, 13 moderate-quality, and 19 low-quality) studies and 8 registry reports. The range of variation for revision was 0–33% for THA and 0–27% for TKA varying between assessment within hospital admission until 10 years of follow-up; for readmission, 0–40% and 0–32% for THA and TKA, respectively; and for complications, 0–75% and 0–50% for THA and TKA, respectively. Indicator definitions and methodological variables varied considerably across domains.

  • The large heterogeneity in definitions and methods used likely explains the considerable variation in between-hospital variation reported for revision, readmission, and complications , making it impossible to benchmark hospitals across countries or pool data for earlier detection of safety issues. It is necessary to collaborate internationally and strive for more uniformity in indicator definitions and methods in order to achieve reliable international benchmarking in the future.

Rui Zhang, Xiaoyu Wang, Jia Xu, Qinglin Kang, and Reggie C Hamdy

  • Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture.

  • If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. When the radial head is not reduced, several deformities develop at the humeroradial joint, including cubitus valgus and osteoarthritis.

  • Adequate radiographs are crucial when the surgeons deal with forearm injuries.

  • At present, proximal ulnar osteotomy and open reduction of chronic radial head dislocation provides satisfactory functional outcomes because of anatomic alignment reconstruction.

  • Supplementary procedures, including transcapitellar pinning and repair or reconstruction of the annular ligament, which are performed in order to enhance stability of the humeroradial joint, should be thoroughly assessed based on joint rotational stability after reduction and on potential complications.

Mariam S Alharbi

  • The aim of the study was to conduct a literature review on growth hormone therapy in short-stature patients with kyphoscoliosis.

  • The search strategy was performed in which all the relevant papers published in 20 years were included on Pub Med, Central, and Google scholar by using keywords short stature, growth hormones, adverse events of growth hormones in kyphoscoliosis, safety.

  • The study investigation supports the idea that giving human growth hormone (HGH) to a diverse population of short-statured children does not enhance the occurrence of scoliosis.

  • Patients on HGH therapy for progressing scoliosis had syndromes in which scoliosis was more prevalent in an age-matched group. Short stature attributed to progressive growth failure is prevalent in all mucopolysaccharidosis (MPS) disorders, as per the existing research on growth and growth hormone in MPS.

  • MPS should be explored in children who are being tested for short stature since growth failure might be the presenting symptom.

Mattia Loppini, Francesco Manlio Gambaro, Rob G H H Nelissen, and Guido Grappiolo

  • The study investigated the existing guidelines on the quality and frequency of the follow-up visits after total hip replacement surgery and assessed the level of evidence of these recommendations.

  • The review process was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional works were retrieved by direct investigation of the available guidelines of the most important orthopedic societies and regulatory agencies.

  • The current systematic review of the literature resulted in zero original papers, four guidelines for routine follow-up and three guidelines for special cases. Concerning the quality of evidence behind them, these guidelines were not evidence based but drafted from expert consensus.

  • The most important finding of this review is the large variation of recommendations in the follow-up schedule after total hip arthroplasty and the lack of evidence-based indications. Indeed, all the above-reported guidelines are the result of a consensus among experts in the field (level of recommendation class D ‘very low’) and not based on clinical studies.

J R W Crutsen, M C Koper, J Jelsma, M Heymans, I C Heyligers, B Grimm, N M C Mathijssen, and M G M Schotanus

  • Prosthetic hip-associated cobalt toxicity (PHACT) is caused by elevated blood cobalt concentrations after hip arthroplasty.

  • The aim of this study is to determine which symptoms are reported most frequently and in what type of bearing. We also try to determine the blood level of cobalt concentrations associated with toxicological symptoms.

  • A systematic review was conducted on the 10th of July according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A methodological quality assessment (risk of bias (RoB)) was performed. Primary outcomes were the reported symptoms of cobalt toxicity and the level of cobalt concentrations in blood. These levels were associated with toxicological symptoms. A total of 7645 references were found of which 67 relevant reports describing 79 patients.

  • The two most used bearings in which PHACT was described were metal-on-metal (MoM) bearings (38 cases) and revised (fractured) ceramic-on-ceramic (CoC) bearings where the former ceramic head was replaced by a metal head (32 cases).

  • Of all reported symptoms, most were seen in the neurological system, of which 24% were in the sensory system and 19.3% were in central/peripheral system, followed by the cardiovascular (22.1%) system.

  • The mean cobalt concentration for MoM-bearings was 123.7 ± 96.8 ppb and 1078.2 ± 1267.5 ppb for the revised fractured CoC-bearings.

  • We recommend not to use a metal-based articulation in the revision of a fractured CoC bearing and suggest close follow-up with yearly blood cobalt concentration controls in patients with a MoM bearing or a revised fractured CoC bearing.

  • Level of Evidence: Level V, systematic review