The edition · Orthopaedics
Locking plates beat tension-band wiring for displaced patellar fractures
A blinded multicentre randomised trial gives high-level evidence for plate fixation of the patella, robotic assistance improves component position and early recovery in unicompartmental knee arthroplasty without changing two-year scores, and resistance exercise for knee osteoarthritis has an identifiable optimal dose.
The edition in brief
A patient- and assessor-blinded multicentre randomised trial assigned 122 adults with displaced patellar fractures to locking plate fixation or tension-band wiring. At 12 months, locking plates were superior on three of five KOOS sub-scales, each exceeding the minimal clinically important difference: symptoms by 10.4 points (95% CI 4.4 to 16.4), sport and recreation by 14.1 (3.4 to 24.7), and quality of life by 10.9 (2.7 to 19.0). Hardware removal, fixation failure and reoperation were all commoner after tension-band wiring. Follow-up completion was around 90% in both arms. A double-blinded randomised trial of 107 patients undergoing medial unicompartmental knee arthroplasty found robotic arm assistance gave more accurate femoral and tibial component positioning, lower inpatient pain scores, less opioid use and shorter stay. But Oxford Knee Score, KOOS and WOMAC were no different at two years; only the Forgotten Joint Score favoured robotics. Recruitment declined as patients and surgeons lost equipoise. A dose-response meta-analysis of 20 randomised trials and 791 patients with knee osteoarthritis located the peaks: greatest pain reduction around 6,000 total repetitions, best functional improvement around 2,600 repetitions at moderate intensity, and maximal strength gains around 1,600 repetitions. Certainty was low to very low. A meta-analysis of 15 studies and 4,183 participants found lower vitamin D in those with stress fractures, significant in military personnel and men but not in athletes or women. No new regulatory action for the desk; a synthesis of 51,394 patients quantifies the perioperative DMARD trade-off. Today's pearl: ask what the patient can do, not how the radiograph looks.
Plate the patella: locking plates beat tension-band wiring at 12 months
Use locking plate fixation rather than tension-band wiring for a displaced patellar fracture in an active adult — better knee function at 12 months and less reoperation.
Robotic unicompartmental knee arthroplasty: better position, faster recovery, same two-year scores
Robotic unicompartmental knee arthroplasty gives more accurate component position and a faster early recovery, but no better Oxford, KOOS or WOMAC scores at two years.
Resistance exercise for knee osteoarthritis has an optimal dose, and it is not maximal
Prescribe knee osteoarthritis exercise as a dose: around 6,000 repetitions over 12 weeks at moderate intensity, supervised where possible.
Ask what the patient can do, not how the radiograph looks
Agree three patient-specific functional goals at the first postoperative visit and ask about them at every review — surgeons systematically rate outcomes better than patients do.
Vitamin D and stress fractures: the association is real, and narrower than assumed
Check vitamin D in recruits and heavily training athletes, but do not present supplementation as stress fracture prevention — the association is modest and disappears where deficiency is widespread.
No new regulatory action for the desk today
Nothing new from the regulators today; when deciding on perioperative biologic DMARDs, weigh roughly a quarter less infection against roughly double the flare risk — and remember they blunt CRP.
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