Aims

The aims of this study were to determine the incidence and factors for developing periprosthetic joint infection (PJI) following hemiarthroplasty (HA) for hip fracture, and to evaluate treatment outcome and identify factors associated with treatment outcome.

Aims

Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK.

Aims. The aims of this study were to: 1) report on a cohort of skeletally mature patients with native hip and knee septic arthritis over a 14-year period; 2) to determine the rate of joint failure in patients who had experienced an episode of hip or knee septic arthritis; and 3) to assess the outcome following septic arthritis relative to the infecting organism, whether those patients infected by Staphylococcus aureus would be more likely to have adverse outcomes than those infected by other organisms. Methods. All microbiological samples from joint aspirations between March 2000 and December 2014 at our institution were reviewed in order to identify cases of culture-proven septic arthritis. Cases in children (aged < 16 years) and prosthetic joints were excluded. Data were abstracted on age at diagnosis, sex, joint affected (hip or knee), type of organisms isolated, cause of septic arthritis, comorbidities within the Charlson Comorbidity Index (CCI), details of treatment, and outcome. Results. A total of 142 patients were confirmed to have had an episode of septic arthritis in a native hip (n = 17) or knee joint (n = 125). S. aureus accounted for 57.7% of all hip and knee joint infections. There were 13 inpatient deaths attributed to septic arthritis. The median age of the patients who died was 77.5 (46.9 to 92.2) and their median age-adjusted CCI was 8 (6 to 12). A failure of the joint occurred in 26 knees (21%) and nine hips (53%). Of the knee joints infected by S. aureus (n = 71), 23 knees (32%) went into failure of joint, whereas of those infected by other organisms (n = 54), only three knees (6%) failed. Conclusion. Based on our study findings, hip and knee septic arthritis long-term outcomes were substantially worse than their immediate outcome suggested. Failure of knee joint is 6.1 times more likely to occur in those infected with S. aureus. Cite this article: Bone Jt Open 2024;5(9):785–792

Aims. Two-stage exchange revision total hip arthroplasty (THA) performed in case of periprosthetic joint infection (PJI) has been considered for many years as being the gold standard for the treatment of chronic infection. However, over the past decade, there have been concerns about its safety and its effectiveness. The purposes of our study were to investigate our practice, collecting the overall spacer complications, and then to analyze their risk factors. Methods. We retrospectively included 125 patients with chronic hip PJI who underwent a staged THA revision performed between January 2013 and December 2019. All spacer complications were systematically collected, and risk factors were analyzed. Statistical evaluations were performed using the Student's t-test, Mann-Whitney U test, and Fisher's exact test. Results. Our staged exchange practice shows poor results, which means a 42% mechanical spacer failure rate, and a 20% recurrent infection rate over the two years average follow-up period. Moreover, we found a high rate of spacer dislocation (23%) and a low rate of spacer fracture (8%) compared to the previous literature. Our findings stress that the majority of spacer complications and failures is reflecting a population with high comorbid burden, highlighted by the American Society of Anesthesiology grade, Charlson Comorbidity Index, and Lee score associations, as well as the cardiac, pulmonary, kidney, or hepatic chronic conditions. Conclusion. Our experience of a two-stage hip exchange revision noted important complication rates associated with high failure rates of polymethylmethacrylate spacers. These findings must be interpreted in the light of the patient’s comorbidity profiles, as the elective population for staged exchange has an increasing comorbid burden leading to poor results. In order to provide better results for this specific population, our conclusion suggests that comparative strategy studies are required to improve our therapeutic indication. Cite this article: Bone Jt Open 2022;3(6):485–494

Aims. It is imperative to understand the risks of operating on urgent cases during the COVID-19 (SARS-Cov-2 virus) pandemic for clinical decision-making and medical resource planning. The primary aim was to determine the mortality risk and associated variables when operating on urgent cases during the COVID-19 pandemic. The secondary objective was to assess differences in the outcome of patients treated between sites treating COVID-19 and a separate surgical site. Methods. The primary outcome measure was 30-day mortality. Secondary measures included complications of surgery, COVID-19 infection, and length of stay. Multiple variables were assessed for their contribution to the 30-day mortality. In total, 433 patients were included with a mean age of 65 years; 45% were male, and 90% were Caucasian. Results. Overall mortality was 7.6% for all patients and 15.9% for femoral neck fractures. The mortality rate increased from 7.5% to 44.2% in patients with fracture neck of femur and a COVID-19 infection. The COVID-19 rate in the 30-day postoperative period was 11%. COVID-19 infection, age, and Charlson Comorbidity Index were independent risk factor for mortality. Conclusion. There was a significant risk of contracting COVID-19 due to being admitted to hospital. Using a site which was not treating COVID-19 respiratory patients for surgery did not identify a difference with respect to mortality, nosocomial COVID-19 infection, or length of stay. The COVID-19 pandemic significantly increases perioperative mortality risk in patients with fractured neck of femora but patients with other injuries were not at increased risk. Cite this article: Bone Jt Open 2021;2(5):330–336

Aims. This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods. Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results. Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion. There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720

Aims. As our population ages, the number of octogenarians who will require a total hip arthroplasty (THA) rises. In a value-based system where operative outcomes are linked to hospital payments, it is necessary to assess the outcomes in this population. The purpose of this study was to compare outcomes of elective, primary THA in patients ≥ 80 years old to those aged < 80. Methods. A retrospective review of 10,251 consecutive THA cases from 2011 to 2019 was conducted. Patient-reported outcome (PRO) scores (Hip disability and Osteoarthritis Outcome Score (HOOS)), as well as demographic, readmission, and complication data, were collected. Results. On average, the younger cohort (YC, n = 10,251) was a mean 61.60 years old (SD 10.71), while the older cohort (OC, n = 609) was 84.25 years old (SD 3.02) (p < 0.001). The OC had greater surgical risk based on their higher mean American Society of Anesthesiologists (ASA) scores (2.74 (SD 0.63) vs 2.30 (SD 0.63); p < 0.001) and Charlson Comorbidity Index (CCI) scores (6.26 (SD 1.71) vs 3.87 (SD 1.98); p < 0.001). While the OC stayed in the hospital longer than the YC (mean 3.5 vs 2.5 days; p < 0.001), there were no differences in 90-day emergency visits (p = 0.083), myocardial infarctions (p = 0.993), periprosthetic joint infections (p = 0.214), dislocations (p = 0.993), or aseptic failure (p = 0.993). The YC was more likely to be readmitted within 90 days (3.88% vs 2.18%, Β = 0.57; p = 0.048). There were no observed differences in 12-week (p = 0.518) or one-year (p = 0.511) HOOS scores. Conclusion. Although patients ≥ 80 years old have a greater number of comorbidities than younger patients, they had equivalent perioperative complication rates and PRO scores. This study demonstrates the safety and success of elective THA in octogenarians. Cite this article: Bone Jt Open 2021;2(7):535–539

Introduction. A proportion of patients with hip and knee prosthetic joint infection (PJI) undergo multiple revisions with the aim of eradicating infection and improving quality of life. The aim of this study was to describe the microbiology cultured from multiply revised hip and knee replacement procedures to guide antimicrobial therapy at the time of surgery. Patients and Methods. Consecutive patients were retrospectively identified from databases at two specialist orthopaedic centres in the United Kingdom between 2011 and 2019. Patient were included who had undergone repeat revision total knee replacement (TKR) or total hip replacement (THR) for infection, following an initial failed revision for infection. Results. 106 patients were identified, of which 74 underwent revision TKR and 32 underwent revision THR. Mean age at first revision was 67 years (SD 10). Charlson Comorbidity Index was <2 for 31 patients, 3–4 for 57 patients, and >5 for 18 patients. All patients underwent >2 revisions, 73 patients received 3, 47 patients received 4, 31 patients received 5, and 21 patients received >6. After six revisions, 90% of patients cultured different organisms than the initial revision, and 53% of organisms were multi-drug resistant species. The most frequent organisms at each revision were coagulase negative Staphylococcus (36%) and Staphylococcus aureus (19%). Fungus was cultured from 3% of revisions and 21% of infections were polymicrobial. Conclusion. Patients undergoing multiple revisions for PJI are highly likely to experience a change in organisms and sensitivities with each subsequent revision. It is important to administer empirical antibiotics at each subsequent revision, appreciating known drug resistance from previous cultures. Our results do not support routine use of empirical antifungals

Periprosthetic joint infections (PJIs) centers are garnering the attention of different arthroplasty surgeons and practices alike. Nonetheless, their value has yet to be proven. Therefore, we evaluated weather PJI centers produce comparable outcomes to the national average of THA PJIs on a national cohort. We performed a retrospective review of patient data available on PearlDiver from 2015 – 2021. PJI THA cases were identified through ICD-10 and CPT codes. Patients treated by 6 fellowship trained arthroplasty surgeons from a PJI center were matched based on age, gender, Charlson Comorbidity Index and Elixhauser comorbidity index at a 1:1 ratio to patients from the national cohort. Compared outcomes included LOS, ED visits, number of patients readmitted, total readmissions. Sample sized did not allow the evaluation of amputation, fusion or explantation. Normality was tested through the Kolmogorov-Smirnov test. And comparisons were made with Students t-tests and Chi Square testing. A total of 33,001 THA PJIs and were identified. A total of 77 patients were identified as treated by the PJI center cohort and successfully matched. No differences were noted in regard to age, gender distribution, CCI or ECI (p=1, 1, 1 and 0.9958 respectively). Significant differences were noted in mean LOS (p<0.43), number of patients requiring readmissions (p=0.001) and total number of readmission events (p<0.001). No difference was noted on ED visits. Our study demonstrates that a PJI for THA cases may be beneficial for the national growing trend of arthroplasty volume. Future data, that allows comparison of patient's specific data will allow for further validation of PJI centers and how these can play a role in helping the national PJI growing problem

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021. We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences. The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant. We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs

Patients with a high comorbidity burden (high-risk) can achieve similar improvements in quality of life compared to low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences THA outcomes in high-risk patients has not been investigated. This study aimed to compare complication rates and implant survivorship in high-risk patients operated on by high volume (HV) and non-HV THA surgeons. Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologist Classification of 3 or 4 undergoing primary, elective THA between 2013 and 2021 were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Ninety day readmissions and revisions were compared between groups, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period. Years of experience were comparable between Non-HV and HV surgeons (p=0.733). The HV group had significantly shorter surgical times (p<0.001), and shorter length of stay (p=0.009) compared to the Non-HV group. The HV group also had significantly fewer 90-day readmissions (p=0.030), all-cause revisions (p=0.023) and septic revisions (p=0.020) compared to the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p=0.023) and septic revision (p=0.020) compared to the non-HV group. High-risk THA patients have fewer 90-day readmissions, all-cause revisions, septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a high comorbidity burden may benefit from referral to high-volume surgeons to reduce procedural risk and improve postoperative outcomes

Total hip arthroplasty (THA) is often performed in symptomatic patients with developmental dysplasia of the hip (DDH) who do not qualify for periacetabular osteotomy (PAO). The impact of osteoarthritis (OA) severity on postoperative outcomes in DDH patients who undergo THA is not well described. We hypothesized that DDH patients who undergo THA with mild OA have slower initial recovery postoperatively, but similar one-year patient reported outcome measures (PROMs) when compared to DDH patients with severe OA. We performed a retrospective review at a single academic institution over a six-year period of patients with DDH who underwent primary THA and compared them to patients without DDH who underwent THA. Within the DDH cohort, we compared PROMs stratified by DDH severity and OA severity. Diagnosis of DDH was verified using radiographic lateral center edge angle (LCEA). Minimum one-year follow-up was required. PROMs were collected through one-year postoperatively. Logistic and linear regression models were used adjusting for age, sex, body mass index, and Charlson Comorbidity Index. 263 patients with DDH were compared to 1,225 THA patients without DDH. No significant differences were found in postoperative PROMs or revision rates (p=0.49). When stratified by DDH severity, patients with LCEA<10° had worse preoperative pain (p=0.01), mental health (p<0.01) and physical function (p=0.03) scores but no significant difference in postoperative PROMs. Within the DDH group, when stratified by OA severity, patients with Grade 3 Tonnis score had worse preoperative pain (p=0.04) but no significant difference in postoperative PROMs. Recovery curves in DDH patients based upon severity of DDH and OA were not significantly different at 2-weeks, 6-weeks and 1-year. DDH patients who have mild OA have similar recovery curves compared to those with severe OA. THA is reasonable in symptomatic DDH patients who have mild arthritis and do not qualify for PAO

Mental disorders in particular depression and anxiety have been reported to be prevalent among patients with spinal pathologies. Goal of the current study was to analyze the relationship of Zung pre- and post-op score to other PROs and length of stay. Secondary outcomes included revision surgery and post-operative infections. Data from the international multicenter prospective spine degenerative surgery data repository, DegenPRO v1.1 (AO Spine Knowledge Forum Degenerative) were utilized. Patients undergoing cervical or lumbar procedure were included. Patient's demographics, Charlson Comorbidity Index, surgical information, Zung score, NDI, pain related PROs and EQ-5D, and complications at surgery and at various post-op time periods. Except for hospital duration, data were analyzed, using multivariable mixed linear models. A robust linear regression model was used to assess the association between Zung score and hospital duration. All models were adjusted for gender and age. 42 patients had Zung score administered. Among those patients 22 (52%) were within normal range, 18 (43%) were mildly and 2 (5%) severely depressed. 62% of the patients had a lumbar pathology with fusion procedures being the most common. Median EQ-5D (3L) score at surgery was significantly higher (0.7, IQR: 0.4-0.7) for patients within normal range than for those with mild (0.4, IGR: 0.3-0.7) or severe depression (0.3, IQR: 0.3-0.3, p-value: 0.05). Compared to patients within normal Zung range, mixed models, indicated lower EQ-5D (3L) score values and higher values for neck and arm pain at surgery with both PROs and EQ-5D (3L) improving in patients with depression over the follow-up time. No association was found between Zung score and hospital length of stay. The initial analysis showed that 43% of the patients were mildly depressed and mainly male patients. Zung score was correlated with post-operative improvements in EQ-5D and arm and neck pain PROs

Aim. Compare clinical outcomes following staged revision arthroplasty for periprosthetic joint infection (PJI) secondary to either multidrug resistant (MDR) bacteria or non-MDR (NMDR) bacteria. Method. Retrospective analysis of a prospectively collected bone infection database. Adult patients diagnosed and treated for hip or knee PJI, between January 2011 and December 2014, with minimum one-year follow-up, were included in the study. Patients were divided into two groups: MDR group (defined as resistance to 3 or more classes) and N-MDR group (defined as acquired resistance to two classes of antibiotic or less). The Charlson Comorbidity Index was used to stratify patients into low, medium and high risk. The diagnosis of PJI, and any recurrence following treatment, was made in accordance with the Musculoskeletal Infection Society criteria. Failure was defined as recurrence of infection necessitating implant removal, excision arthroplasty, arthrodesis or amputation. Results. The study population comprised 240 patients. 74 (31%) had an MDR infection. 14 patients were deceased at the time of data capture. All infections were treated by staged revision with interval antibiotic space and targeted systemic antibiotics under the supervision of a multidisciplinary team. Total number of failures in both groups was 39 (16%), 15 hips (12%) and 24 knees (21%). There were significantly more failures in the MDR group (n=24, 32%) than the non-MDR group (n=15, 9%)(p<0.0001). Using the Charlson Comorbidity Index within the N-MDR group there was no significant difference in outcomes between the low and medium groups (p=0.352), the low and high risk groups (p=1.000) and the high and medium risk groups (p=1.000). There was no statistically significant association discerned within the MDR group based on co-morbidity also. (p values = 0.1702, 0.665 and 0.1096 respectively). When comparing all cases, there was a statistically significantly higher rate of failure in patients with polymicrobial infection versus single organism infection (P<0.0001). When stratifying by the presence of an MDR organism versus an N-MDR organism, both polymicrobial sub groups showed a greater rate of failure than their single organism counterparts, however this was only significant in the MDR group and not the N-MDR group (p=0.0007 vs p=0.123). Furthermore the polymicrobial MDR group showed a statistically significant higher rate of failure versus the polymicrobial N-MDR group (p=0.002). Conclusions. The study suggests that the presence of an MDR organism may be a predictor of failure, independent of patient co-morbidity, in staged revision hip and knee arthroplasty for PJI

Highly crosslinked polyethylene (HXLPE) has been used with great clinical success in total hip arthroplasty (THA) since its debut in the late 1990's. However, reports regarding this bearing couple in its second decade of service are still scant. The aim of this study was to 1. Determine the long term clinical and radiological results and 2. Investigate what factors affect wear rates using a metal-on-HXLPE bearing articulation. 55 THA's using a single brand of HXLPE liner, cementless cup and 28mm hip ball were performed in 44 patients. Age, sex, and Charlson Comorbidity Index (CCI) and need for revision surgery were recorded. Linear and volumetric wear was determined using the Martell method. Mean age at operation was 51.2 (29–73 +/− 12.1) years. Mean duration of follow up was 16.9 years (range 15.0–20.1 +/− 1.1 years). Osteolysis was not present in the latest follow up radiographs. Median linear and volumetric wear rate was 0.035mm/year (95% CI 0.031–0.047) and 7.12mm. 3. /year (95% CI 6.92–17.25) respectively. Acetabular component position was not found to be related to both linear and volumetric wear. No significant difference was found in the linear and volumetric wear rates of thinner and thicker liners (8mm or below and > 8mm) (p=0.827 and p=0.843 respectively). HXLPE is associated with very low linear and volumetric wear rates which has virtually obviated osteolysis and has translated to excellent survivorship even at long term follow up. In-vivo oxidation does not appear to be of clinical concern at this point in its service cycle

Until today it is unknown whether preservation of the joint capsule positively affects patient reported outcome (PROs) in DAA-THA. A recent RCT found no clinical difference at 1 year. Since 2015 we preserve the capsule suture it at the end. We here evaluate whether this change had any effect on PROs and revisions, 2 years post-operatively. Two subsequent cohorts operated by the senior author were compared. The capsule was resected in the first cohort (January 2012 – December 2014) and preserved in the second cohort (July 2015 – December 2017). No other technical changes have been introduced between the two cohorts. Patient demographics, Charlson Comorbidity Index (CCI), and surgical data were collected from our clinical information system. 2-years PROs questionnaires (OHS, COMI Hip) were obtained. Data was analyzed with generalized multiple regression analysis. 430 and 450 patients were included in the resected and preserved cohorts, respectively. Demographics, CCI surgical time and length of stay were equal in both groups. Blood loss was less in the preserved cohort (p<.05). Four patients had a revision (1 vs 3, n.s.). Once corrected for demographics, capsule preservation had significant worse PROs: +0.24 COMI (p<.001) and −1.6 OHS points (p<.05), however, effects were much smaller than the minimal clinically important difference (0.95 and 5 respectively). The date of surgery (i.e. surgeon's age) was not a significant factor. In this large retrospective study, we observed statistically significant, but probably clinically not relevant, worse PROs with capsule preservation. It might be speculated that the not resected hypertrophied capsule could have caused this difference

Thru purpose of this study was to evaluate the clinical outcomes of a consecutive series of conversion total hip arthroplasty (cTHA) following previous hip fractures. A retrospective chart review of patients who underwent cTHAs from 2008–2017 at an urban academic teaching institution was performed. Eighty-eight patients were included in this study. The mean age at the cTHA was 66 years (range 27 to 89). 67% of the patients wre women. The mean BMI was 28 kg/m. 2. (range 17 to 41). The mean Charlson Comorbidity Index was 3 (range 0 to 9). The mean follow-up was 49 months (range 24 to 131). The mean duration from the hip fracture fixation to the cTHA was 51 months (range 10 to 144). The mean operating time was 188 minutes, (range 71 to 423) with a mean estimated blood loss of 780 ml (range 300 to 2500). Revision-type (long-stem) designs were used in 65% of the cases. The mean length of hospital stay was 8 days (range 2 to 61). The readmission rate was 37% within 90 days after the CTHAs. Of these, 57% were due to non-orthopaedic complications. There were 10 orthopaedic complications: 7 PJIs, all of which required I&D and 3 required staged revision. There were 2 dislocations treated with closed reduction and 1 case of intraoperative periprosthetic femur fracture during femoral component insertion. There was no revision for aseptic loosening within the follow-up period. The one-year mortality rate was 0%. cTHAs were associated with longer operating time, more blood loss, longer length of hospital stay, and higher readmission rates than the primary THAs in our institutional database. We believe utilizing a multi-disciplinary care protocol to optimize these patients is needed to reduce the high rate of readmissions, and the complications in this patient population

Aim. Fracture-related infection (FRI) is a severe post-traumatic complication which can be accompanied with a soft-tissue defect or an avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative since a vital soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of our study was to analyse plastic surgical aspects in the management of FRIs, including the type and outcome of soft-tissue reconstruction (STR), and to investigate the long-term outcome of FRI after STR. Method. Patients with a lower leg FRI requiring STR that were treated from 2010 to 2018 at our center were included in this retrospective analysis. STR involved the use of local, pedicled and free flaps. The primary outcome was the success rate of STR, and the secondary outcome was long-term fracture consolidation and cure of infection. Results. Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR. Muscle flaps were applied in 38, fascio-cutaneous flaps in 19 and a composite osteo-cutaneous flap in one case. All patients underwent successful STR (primary STR in 51/58 patients, 7/58 patients needed secondary STR). A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p=0.011). Patients with free-flap STR developed significantly more severe complications and needed more surgical interventions (Clavien-Dindo ≥IIIa; p=0.001). Out of the 43 patients that completed long-term follow-up (mean 24 months), fracture consolidation was achieved in 32 and infection eradication in 31. Polymicrobial infection was a significant risk factor for fracture non-union (p=0.002). American Society of Anesthesiologists (ASA) classification of 3 or higher (p=0.040) was a risk factor for persistence or recurrence of infection. Conclusions. In our population, 58/145 patients with FRI required STR. STR was successful in all patients eventually, in 7/58 patients secondary STR was necessary. Therefore, STR should be sought even if primary STR fails. Despite successful STR, the long-term composite outcome showed a high rate of failed fracture consolidation and failed eradication of infection, which was independent of primary STR failure

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Introduction. In the United States, cementless femoral fixation remains the dominant mode of fixation for femoral neck fractures, despite strong worldwide registry data that supports cemented fixation. The reason for this discrepancy remains unknown, controversial and often difficult to compare due to multiple variables. The purpose of this study was to evaluate a matched cohort of patients undergoing arthroplasty for femoral neck fractures and assess outcomes of revisions, periprosthetic fractures and mortality. Methods. This is an exact matched cohort study. Cemented fixation cases were exact matched to cementless fixation cases in a 1:1 fashion based on age, sex and Charlson Comorbidity Index (CCI). Outcome variables included: revision for periprosthetic fracture; all cause revision and mortality at any time point; all cause revision and mortality within 1-year and within 90-days. The primary independent variable was femoral fixation (cemented, cementless) and covariates included race (black, white, other), ethnicity (hispanic, non-hispanic), teaching status (minor, major, nonteaching) and bedsize (1–99, 100–399, >=400). Chi-square tests and multivariable logistic regression models were used for statistical analysis. Results. A total of 64,283 femoral neck fractures were evaluated. 17,138 cementless femoral stems were matched exactly to cemented femoral stems based on age, gender and Charleston comorbidity index (CCI). In the multivariate logistic regression analysis, compared to cementless femoral fixation, cemented fixation was associated with a 20% reduction in overall revision (OR 0.796, 0.675–0.939), a 30% reduction in revision at 1 year (OR: 0.709, 0.589–0.854) and a 86% reduction in revision for periprosthetic fracture (OR: 0.144, 0.07–0.294). However, cemented stem fixation was associated with a 23% (OR: 1.33, 1.134–1.338) and 16% (OR: 1.232, 1.134–1.338) increase in mortality at 90 days and 1 year post op respectively. Conclusions. In this exact matched cohort study, risk of early revision and revision for PPFx was dramatically reduced at all time points with the use of cemented stem fixation for elective THA and FNF. However, the increased risk of 90d and 1 year mortality following cemented stem fixation in the elective population warrants further investigation