Purpose and background. Work-related musculoskeletal disorders, particularly back pain, are a significant issue for healthcare workers, with patient handling being the most frequently reported risk factor. Patient handling is often performed without assistive devices or equipment, which can cause healthcare staff to maintain awkward postures or experience high loads. This review aimed to comprehensively map the literature surrounding manual patient handling (without assistive devices) by healthcare practitioners to identify the current evidence-base on moving and handling of patients and explore what primary research had been conducted. Methods and results. JBI methodology for scoping reviews and an a priori registered protocol (DOI 10.17605/OSF.IO/8PR7A) was followed and AMED, CINAHL, MEDLINE, SPORTDiscus and EMBASE databases were searched. Literature published in English between 2002 and 2021 was included. Forty-nine records were included: 36 primary research studies, 1 systematic review and 12 ‘other’ including narrative and government reports. Primary research predominantly used observational cross-sectional designs (n = 21 studies). Most studies took place in hospitals (n = 13) and laboratories (n = 12). Nurses formed the largest population group (n = 13), with very little research on physiotherapists and other allied health professionals. Conclusion. This scoping review comprehensively reviewed the available literature in the area. Most of the included primary research was observational. Nurses were often investigated in hospitals and laboratories. Qualitative research investigating moving and handling and further biomechanical investigation into therapeutic handling by healthcare staff were identified as areas for further research. Conflicts of interest. None. Sources of funding. None. This work has been published in Physiotherapy: Johnson, K., Swinton, P., Pavlova, A. and Cooper, K., 2023. Manual patient handling in the healthcare setting: a scoping review. Physiotherapy. (120) 60–77 . https://doi.org/10.1016/j.physio.2023.06.003

Objectives. Distal humerus fractures in elderly population are often comminuted and presents multiple challenges. When managed with fixation the results are often complicated with stiffness, pain, and reduced function while total elbow replacement is fraught with lifelong restrictions on load bearing which can significantly affect elderly patients who rely assistive devices for ambulation. Elbow hemiarthroplasty however, presents a viable alternative in these cases. This series evaluates the results of the distal humerus hemiarthroplasty in a single centre. Designs and methods. Data was collected retrospectively. Comprehensive case reviews were done to collect demographic, intra-operative and post-operative data. Fractures were classified as per AO classification. The primary outcome was functional outcome and range of motion (ROM). The secondary outcomes were complications and patient satisfaction. Results. 22 cases were included in this study from 2016 – 2023 majority being females (n=18). Mean age was 74years (SD −11.2). Majority fractures were AO type C3 (n=15) with two A2 type fractures managed for non-union. Pre-existing bone on bone arthritis was present in 3 cases and CT scan was done for 12 patients to assess fracture configuration. Excluding those treated for non- union the median time between fracture and surgery was 8.5 days. Follow-up of more than 6 months was available for 16 patients with median follow-up of 18 months. ROM was available for 17 patients with 13 (50%) patients having functional ROM. No patients had full extension and there was a mean lag of 20. 0. Mean flexion was 118.2. 0. Nearly 2/3. rd. patients (73%- n=16) were satisfied with the surgery with no problems in activity of daily living. Complications seen were ulnar neuropathy (n=3), heterotopic ossification(n=2) and periprosthetic fracture (n=1). Conclusion. This single centre study suggests good outcomes following distal humerus hemiarthroplasty. It is a reasonable alternative to fixation and total elbow arthroplasty in complex fractures

Aim. Antibiotics have limited activity in the treatment of multidrug-resistant or chronic biofilm-associated infections, in particular when implants cannot be removed. Lytic bacteriophages can rapidly and selectively kill bacteria, and can be combined with antibiotics. However, clinical experience in patients with surgical infections is limited. We investigated the outcome and safety of local application of bacteriophages in addition to antimicrobial therapy. Method. 8 patients (2 female and 6 male) with complex orthopedic and cardiovascular infections were included, in whom standard treatment was not feasible or impossible. The treatment was performed in agreement with the Article 37 of the Declaration of Helsinki. Commercial or individually prepared bacteriophages were provided by ELIAVA Institute in Tbilisi, Georgia. Bacteriophages were applied during surgery and continued through drains placed during surgery three times per day for the following 5–14 days. Follow-up ranged from 1 to 28 months. Results. Median age was 57 years, range 33–75 years. Two patients were diagnosed with a persistent knee arthrodesis infection, one chronic periprosthetic joint infection (PJI), one cardiovascular implantable electronic device (CIED) infection and four patients with left ventricular assist device (LVAD) infection. The isolated pathogens were multi-drug-resistant Pseudomonas aeruginosa (n=3), methicillin-sensitive Staphylococcus aureus (n=4), methicillin-resistant Staphylococcus aureus (MRSA) (n=1) and methicillin-resistant Staphylococcus epidermidis (MRSE) (n=1). 4 infections were polymicrobial. 5 patients underwent surgical debridement with retention of the implant, 1 patient with PJI underwent the exchange of the prosthesis and one patient with LVAD infection was treated conservatively. All patients received intravenous and oral antibiotic therapy and local application of bacteriophages. At follow-up of 12 month, 5 patients were without signs or symptoms of infection, whereas in one patient with LVAD infection, a relapse was observed with emergence of phage-resistant Pseudomonas aeruginosa. In this patient, no surgical revision was performed. Conclusions. Bacteriophage therapy may represent a valid additional approach, when standard antimicrobial and surgical treatment is not possible or feasible, including in difficult-to-treat infections. In our case series, 5 of 6 patients were infection free after 1 year. Further studies need to address the optimal bacteriophage administration route, concentration, duration of treatment and combination with antimicrobials

Aim. In recent years, the number of victims of road traffic accidents (RTAs) and resulting surgeries have been on the rise in low income countries. Treatments are often long and costly; resources required to treat fracture related infections (FRI) continue to be a limiting factor in low income countries and standardized management protocols are lacking. This retrospective study reports our facility's experience of femoral FRI management in a low income country and evaluates the surgical outcomes with a minimum follow up of five years. Methods. The clinical and radiographic records of patients who underwent surgery for femoral FRI in our facility between 2005–2016 were analyzed. Twenty-six patients were included (15 males), with a median age of 29 years (range 4–71). The initial fracture was caused by RTA in 22 patients, gunshot in 2, accidental fall in 1 and acute osteomyelitis in 1. Polytrauma was observed in 10. All patients but one were referred for limb reconstruction from other institutions. Surgical treatment was instituted in all: site debridement (SD) alone was performed in 2 patients; SD and hardware removal in 4; SD and external fixation in 4; SD, hardware removal and external fixation in 16. In this latter group, complex treatments such as bone transport (BT) and vascularized fibula flap (VFF) were utilized in 4 and 3 patients respectively. Results. The mean follow-up was 8.4 years. Bone union was achieved in all cases with eradication of the infection in all but one. A total of 109 surgeries were carried out with an average of 4 surgeries per patient (range 1–13). The external fixation stayed in place for an average of 9.2 months (range 3–20). Complications were common at the last follow-up: limb length discrepancy (LLD) was observed in 18 patients; stiff knee was noted in 16; stiffness of ipsilateral knee and hip in 3; stiff hip in 1 and fused knee in 3. All patients ambulated without assistive devices. Conclusions. The treatment of femoral FRI is complex, long and often requires the combined effort of the orthopedic and plastic surgical teams. Despite limited resources, our institution achieved good long term surgical outcomes through a variety of methods. Further studies are required across multiple sites to better outline optimal management of femoral FRI in low income countries

Purpose. Total and partial joint arthroplasty has been clinically proven to successfully relieve pain and improve function in patients with hip and knee degenerative arthrosis. It has been shown that early return to ambulation correlates well with functional scores. Moreover, the benefits of reduced narcotic use are multi-fold and range from reduced risk of addiction, gastrointenstinal and cardiopulmonary side effects. Establishing realistic pre-operative expectations regarding functional improvement and pain control will nevertheless impact patient satisfaction. Thus, the purpose of this study was to establish safe, achievable and data-driven benchmarks for post-operative ambulation and pain control in patients undergoing elective total joint arthroplasty. Methods. A retrospective chart review was performed for of all patients who underwent elective primary total or partial joint replacement by a single fellowship trained academic joint replacement surgeon from 2/1/2015 to 2/29/16. Patients under the age of 18 as well as those who underwent arthroplasty to treat a traumatic injury or to revise an arthroplasty were excluded. Charts were reviewed for the method of ambulation (no ambulation, wheelchair, assistive devices, no devices) and use of prescription pain medications by 6 weeks post-operatively. Results. 82 patient undergoing elective primary arthroplasty were identified and included in the analysis. 38% of patients underwent TKA (31 of 82) and 62% of patients (51 of 82) underwent THA via the direct anterior approach. Post-operatively 63% (52 of 82) patients were ambulating without assist device. An additional 24% (20 of 82) of patients were ambulating with a single point assist device by 6 weeks. 77% (63 of 82) of patients were pain free by 6 weeks post operatively and denied taking any prescription pain medications. Conclusions. Our analysis demonstrates that approximately 80% of patients undergoing elective total joint arthroplasty can be pain free without a need for prescription pain medication by 6 weeks post operatively. Moreover, while close to 90% of patients can expect to ambulate with at most, a single point assist, the majority (62%) can reliably expect to ambulate freely just 6 weeks after surgery. These results aid our understanding of post-operative return to function, and pain control. What is more, these data can inform a clinician in setting realistic, data-driven goals and expectations with patients undergoing elective total joint arthroplasty, thereby ultimately improving patient satisfaction with these commonly performed procedures

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores, VAS Pain, and Modified Harris Hip Scores (mHHS). Post-operatively, the DAA group had decreased length of stay [1.4 vs 2.2 days, p=0.0002] and increased distance walked on postoperative day 1 and 2 [95 vs 52 ft, p=0.011 and 251 vs. 163 ft, p=0.0004, respectively]. The DAA group had lower VAS pain scores [p<0.05] and required less day 1 and total narcotics [59 vs 80 morphine equivalents, p=0.029 and 138 vs 190, p=0.01, respectively]. The DAA cohort had improved PROMIS Physical Function scores and mHHS up to 5 weeks post- operatively. Anterior approach patients discontinued their assistive device 8 days earlier [p=0.01], left home 3 days earlier [p=0.001], and drove a car 5 days earlier [p=0.016] compared to posterior patients. Conclusion. Patients undergoing DAA THA had significantly shorter length of stay, improved mobilization, decreased narcotic requirements and improved inpatient VAS pain scores compared to mini-posterior THA. Furthermore, DAA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients. The significant improvement in physical function seen with DAA THA persisted up to 5 weeks post-operatively

Abstract. Objectives. Single-event multilevel surgery (SEMLS) is the standard orthopaedic treatment for gait abnormalities in children with diplegic cerebral palsy (CP). The primary aim of this study was to report the long-term functional mobility of these patients after surgery. The secondary aim was to assess the relationship between functional mobility and quality of life (QoL). Methods. Patients were included if they met the following criteria: 1) diplegic CP; 2) Gross Motor Function Classification System (GMFCS) I to III; 3) SEMLS at age ≤ 18. A total of 61 patients, mean age at surgery 11 years eight months (SD 2y 5m), were included. A mean of eight years (SD 3y 10m) after SEMLS, patients were contacted and asked to complete the Functional Mobility Scale (FMS) questionnaire over the telephone and given a weblink to complete an online version of the CP QOL Teen. FMS was recorded for all patients and CP QOL Teen for 23 patients (38%). Results. Of patients graded GMFCS I and II preoperatively, at long-term follow-up the proportion walking independently at home, school/work and in the community was 71% (20/28), 57% (16/28) and 57% (16/28), respectively. Of patients graded GMFCS III preoperatively, at long-term follow-up 82% (27/33) and 76% (25/33) were walking either independently or with an assistive device at home and school/work, respectively, while over community distances 61% (20/33) required a wheelchair. The only significant association between QoL and functional mobility was better ‘feelings about function’ in patients with better home FMS scores (r=0.55; 95% confidence interval 0.15 to 0.79; p=0.01). Conclusion. The majority of children maintained their preoperative level of functional mobility at long-term follow-up after SEMLS. Despite the favourable functional mobility, there was little evidence to establish a link between functional status and quality of life

Unicondylar knee arthroplasty (UKA) is growing in popularity with an increase in utilisation. As a less invasive, bone preserving procedure suitable for knee osteoarthritic patients with intact cruciate ligaments and disease confined to one compartment of the knee joint. The long term survival of a UKA is dependent on many factors, including the accuracy of prosthesis implantation and soft tissue balance. Robotic assisted procedures are generally technically demanding, can increase the operation time and are associated with a learning curve. The learning curve for new technology is likely to be influenced by previous experience with similar technologies, the frequency of use and general experience performing the particular procedure. The purpose of this study was to determine the time to achievement of a steady state with regards to surgical time amongst surgeons using a novel hand held robotic device. This study examined consecutive UKA cases which used a robotic assistive device from five surgeons. The surgeons had each performed at least 15 surgeries each. Two of the surgeons had previous experience with another robotic assistive device for UKA. All of the surgeons had experience with conventional UKA. All of the surgeons have used navigation for other knee procedures within their hospital. The system uses image free navigation with infrared optical tracking with real time feedback. The handheld robotic assistive system for UKA is designed to enable precision of robotics in the hands of the surgeon. The number of surgeries required to reach ‘steady state’ surgical time was calculated as the point in which two consecutive cases were completed within the 95% confidence interval of the surgeon's ‘steady state’ time. The average surgical time (tracker placement to implant trial acceptance phase) from all surgeons across their first 15 cases was 56.8 minutes (surgical time range: 27–102 minutes). The average improvement was 46 minutes from slowest to quickest surgical times. The ‘cutting’ phase was reported as decreasing on average by 31 minutes. This clearly indicates the presence of a learning curve. The surgeons recorded a significant decrease in their surgical time where the most improvement was in the process of bone cutting (as opposed to landmark registration, condyle mapping and other preliminary or planning steps). There was a trend towards decreasing surgical time as case numbers increase for the group of five surgeons. On average it took 8 procedures (range 5–11) to reach a steady state surgical time. The average steady state surgical time was 50 minutes (range 37–55 minutes). In conclusion, the average operative time was comparable with clinical cases reported using other robotic assistive devices for UKA. All five surgeons using the novel handheld robotic-assisted orthopaedic system for UKA reported significant improvement in bone preparation and overall operative times within the first 15 cases performed, reaching a steady state in surgical times after a mean of 8 cases. Therefore, this novel handheld device has a similar learning curve to other devices on the market

Utilisation of unicondylar knee arthroplasty (UKA) has been limited due in part to high revision rates. Only 8% of knee arthroplasty surgeries completed in England and Wales are UKAs. It is reported that the revision rate at 9 years for Total Knee Arthroplasty (TKA) was 3% compared to 12% for UKAs. In the last decade semi active robots have been developed to be used for UKA procedures. These systems allow the surgeon to plan the size and orientation of the tibial and femoral component to match the patient's specific anatomy and to optimise the balancing the soft tissue of the joint. The robotic assistive devices allow the surgeon to execute their plan accurately removing only ‘planned’ bone from the predefined area. This study investigates the accuracy of an imageless navigation system with robotic control for UKA, reporting the errors between the ‘planned’ limb and component alignment with the post-operative limb and component alignment using weight bearing long leg radiographs. We prospectively collected radiographic data on 92 patients who received medial UKA using an imageless robotic assisted device across 4 centres (4 surgeons). This system is CT free, so relies on accurate registration of intra-operative knee kinematic and anatomic landmarks to determine the mechanical and rotational axis systems of the lower limb. The surface of the condylar is based on a virtual model of the knee created intra-operatively by ‘painting’ the surface with the tip of a tracked, calibrated probe. The burring mechanism is robotically controlled to prepare the bone surface and remove the predefined volume of bone. The study shows the 89% of the patients' post-operative alignment recorded by the system was within 30 of the planned coronal mechanical axis alignment. The RMS error was 1.980. The RMS errors between the robotic system's implant plan and the post-operative radiographic implant position was; femoral coronal alignment (FCA) 2.6o, tibial coronal alignment (TCA) 2.9o and tibial slope (TS) 2.9o. In conclusion, the imageless robotic surgical system for UKA accurately prepared the bone surface of the tibia and femur which resulted in low errors when comparing planned and achieved component placement. This resulted in a high level of accuracy in the planned coronal mechanical axis alignment compared to that measured on post-operative radiographs

Introduction. The direct anterior (DA) approach for total hip arthroplasty has demonstrated successful short term outcomes. However, debate remains about which patients are candidates fo this approach. To our knowledge, there are no studies which specifically investigate short-term outcomes in obese versus non-obese patients undergoing THA through a DA approach. The purpose of this study was to evaluate complication rates and short term outcomes of obese, pre-obese, and normal BMI patients undergoing THA through DA approach. Methods. A retrospective review of 151 consecutive patients who underwent unilateral THA through a DA approach for osteoarthritis or avascular necrosis was performed after IRB approval. Forty patients had a normal BMI, 54 were pre-obese, and 57 were obese by WHO classification (37 class I obese, 12 class II obese, and 8 class III obese). Electronic and paper charts were reviewed to determine differences in surgical time, length of stay, disposition, wound and major complications, and short term outcome measures. Results. When comparing normal and pre-obese patients to a combined group of WHO class I, II, and III obese patients, surgical time was increased by 15.8 minutes (P <0.0001), narcotic use was increased at two weeks (P=0.0242), and assistive device use was increased at 2 weeks (P=0.0079) in the obese patient group. There were trends toward increased wound complications in obese patients, 14.3% vs 4.2% (P=0.0569), increased major complications, 7.1% vs 1.1% (P=0.0633), and a higher use of rehabilitation facilities, 20.0% vs 9.5% (p=0.0676). Conclusions. This study demonstrated significantly increased surgical time and higher use of narcotics and assistive devices in obese patients. Trends toward increased wound and major complications, and a higher likelihood of rehabilitation placement were found. This study helps determine appropriate candidates for THA through a DA approach as obese patients may have more complicated postoperative courses

Displaced femoral neck fractures can have devastating impacts on quality of life and patient function. Evidence for optimal surgical approach is far from definitive. The Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial aimed to evaluate unplanned secondary procedures following total hip arthroplasty (THA) versus hemi-arthroplasty (HA) within two years of initial surgery for displaced femoral neck fractures. Secondary objectives evaluated differences in patient function, health-related quality of life, mortality, and hip-related complications HEALTH is a large randomized controlled trial that included 1,495 patients across 81 centers in 10 countries. Patients aged 50 years or older with displaced femoral neck fractures received either THA or HA. Participants were followed for 24 months post-fracture and a Central Adjudication Committee adjudicated fracture eligibility, technical placement of prosthesis, additional surgical procedures, hip-related complications, and mortality. The primary analyses were a Cox proportional hazards model with time to the primary study endpoint as the outcome and THA versus HA as the independent variable. Using multi-level linear models with three levels (centre, patient, and time), with patient and centre entered as random effects, the effect of THA versus HA on quality of life (Short Form-12 (SF-12) and EQ-5D), function (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), and mobility (Timed Up and Go Test (TUG)) were estimated separately. The majority of patients were female (70.1%), 70 years of age or older (80.2%), and able to ambulate without the aid of an assistive device before their fracture (74.4%), and the injury in the majority of the patients was a subcapital femoral neck fracture (61.9%). The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to THA and 60 of 723 patients (8.3%) who were randomly assigned to HA (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; p=0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemi- arthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total WOMAC total score, pain score, stiffness score, and function score, modestly favored THA over HA. Mortality was similar in the two treatment groups (14.3% among the patients assigned to THA and 13.1% among those assigned to HA, p=0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to THA and in 265 patients (36.7%) assigned to HA. Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo THA and those who were assigned to undergo HA, and THA provided a clinically unimportant improvement over HA in function and quality of life over 24 months

Introduction. Primary total knee arthroplasties (TKA) performed in younger patients raise concerns regarding the potential for accelerated polyethylene wear, aseptic loosening, and thus revision TKA at a younger age. The purpose of this study was to determine the long-term implant survivorship, functional outcomes, and pain relief of primary TKA performed in patients under 35 years of age. Methods. A retrospective review of our institutional registry identified 185 TKAs performed in 119 patients under the age of 35 between 1985 and 2010. Medical records and radiographs were reviewed. Patients were contacted for two serial questionnaires in 2011–2012 and again in 2018. Implant survivorship was calculated using Kaplan-Meier survivorship curves and Cox proportional hazard model. The median age was 26.1 (21.5–30.1) years, with a BMI of 23.5 (20.4–26.6) kg/m. 2. Median follow-up was 13.9 (8.5–19.8) years. Results. Implant survivorship at 5, 10, 15, and 20 years were 83%, 72%, 52%, and 39% respectively. Inflammatory diagnoses had improved survivorship relative to osteoarthritis (p=0.028). Increasing age at primary TKA (HR 1.3), varus-valgus constrained devices (HR 1.7), and hinge-type prostheses (HR 6.4) were associated with revision TKA. The most common indications for revision were periprosthetic joint infection (26%), aseptic loosening (22%), and instability (22%). Median time to revision was 4.3 (1.2–11.0) years. Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were 76.3 (63.8–92.0) points at most recent follow-up. 74% of patients reported mild or no pain, 73% ambulated without assistive devices, and 51% could ambulate unlimited distances at most recent follow-up. Conclusions. Patients under the age of 35 years who underwent primary TKA had significant pain relief and continued functional ability in the long-term. However, implant survivorship was 52% at 15 years. The use of constrained implants, non-inflammatory diagnoses, and increasing age at primary TKA were risk factors for revision surgery. For figures, tables, or references, please contact authors directly

Introduction. Infection following TKA can be a catastrophic complication that can cause significant pain, morbidity and jeopardize limb viability. The integrity of the soft tissue envelope is critical to successful treatment and infection control. While local tissue flaps can provide adequate coverage for most soft tissue defects around the knee, there are cases that require salvage using microvascular free tissue transfers. The purpose of this study is to evaluate the 1) rate of limb salvage; 2) infection control; and 3) clinical function following free flap coverage for salvage of the infected TKA. Materials and Methods. We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and 7 women with a mean age of 61.2 years (range 39–81). The median number of procedures performed prior to soft tissue coverage was 5 (range 2–9) and all patients had failed at least one 2 stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. The rate of limb salvage and infection control were recorded. Results. One patient was lost to follow up prior to 12 months. The remainder 22 patients were followed for a mean of 46 months (range 12–92 months). At latest follow up, 4 patients (18%) had undergone amputation for failure of treatment and persistent infection. For the remainder 18 patients, 11 patients (50%) have maintained a knee prosthesis in place while 7 patients had undergone resections for persistent infection but maintained their limbs (32%). Reoperations were common following coverage and reimplantation procedure. The median number of additional procedures was 2 (range 0–6). Clinical function was poor in patients who were reimplanted and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (range 0–70) and 30 (range 0–65). All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. Conclusions. Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (81%) but clinical outcomes in salvaged limbs were poor. The data should be used to counsel patients when contemplating limb salvage in these severe, end-stage cases. For figures, tables, or references, please contact authors directly

Aim. Knee arthrodesis (KA) and above knee amputation (AKA) have been used for salvage of failed total knee arthroplasty (TKA) in the setting of periprosthetic joint infection (PJI). The factors that lead to a failed fusion and progression to AKA are not well understood. The purpose of our study was to determine factors associated with failure of a staged fusion for PJI and predictive of progression to AKA. Method. We retrospectively reviewed a single-surgeon series of failed TKA for PJI treated with two-stage KA between 2000 and 2016 with minimum 2-year follow-up. Patient demographics, comorbidities, surgical history, tissue compromise, and radiographic data were recorded. Outcomes were additional surgery, delayed union, Visual Analog Pain scale (VAS) and Western Ontario and McMaster Activity score (WOMAC). No power analysis was performed for this retrospective study. Medians are reported as data were not normally distributed. Results. Fifty-one knees underwent fusion with median follow-up of 7 years (interquartile range (IQR) of 2–18 years). Median age was 71 years old (IQR 47 – 98), with a M:F ratio of 23:28. Median BMI was 34.3 kg/m2 (IQR 17.9–61). Infection was eradicated in 47 knees (92.2%); 24 knees (47.0%) required no additional surgery. 41 patients (83.6%) remained ambulatory after knee fusion, with 21% of these patients (10 total) requiring no ambulatory assistive device. Median VAS following arthrodesis was 4.6 (range 0–10). Median WOMAC was 36.2 (range 9–86). Three TKAs (5.9%) underwent AKA for overwhelming infection. Predictors of AKA were chronic kidney disease (OR 4.0, 95% CI 0.6–26.8), peripheral vascular disease (OR 3.5, 95% CI 0.3–44.7), AORI III bone loss (OR 2.6, 95% CI 0.4–35.2), instability (OR 2.2, 95% CI 0.2–15.9), and immunosuppression (OR 1.1, 95% CI 0.1–7.8). Tobacco use (OR 8.6, 95%CI 2.4–31.4), BMI>25 (OR 3.8, 95% CI 0.43–32.5) and instability prior to arthrodesis (OR 2.51, 95% CI 0.77–8.21) were associated with non-union. All other risk factors (gender, diabetes mellitus, chronic kidney disease, peripheral vascular disease, massive bone stock loss, and immunosuppression) were not associated with arthrodesis failure. Conclusions. Staged KA for PJI in severely compromised hosts provides a functional limb free of infection and rarely results in conversion to AKA. Given our small sample size, ability to establish statistical significance of predictive factors for AKA after PJI was limited, but CKD, peripheral vascular disease, AORI III bone loss, instability, and immunosuppression trended towards significance as predictors of failure of KA after PJI predisposing to AKA

BACKGROUND. The obesity crisis in the United States has caused a significant increase of hip arthritis. Surgical complication rates are higher in this population and guidelines are being used to select patients who are acceptable candidates for surgical intervention. This retrospective study evaluated the complication rates for obese patients undergoing total hip replacement compared to non-obese patients as defined by the World Health Organization (WHO). Additionally, we compared complication rates of the direct anterior approach (ATHA) versus the posterior approach (PTHA) in a consecutive group of patients using similar protocols. METHODS. This study is an IRB approved retrospective review of 210 patients undergoing ATHA and 201 patients undergoing PTHA during the same time period by 2 experienced, high-volume total joint surgeons. Non-obese patients were compared to obese patients using WHO body mass index (BMI) classification. Minor and major complications were reviewed as well as surgical time, length of stay, disposition, and short-term outcome measures (including pain scores, narcotic use, and assistive device use). RESULTS. The non-obese cohort (BMI < 30) had lower complication rates (2.8% major, 4.4% minor) when compared to the obese cohort (8.7% major, 9.9% minor). Major complications by obese class were as follows: Class I 8.6%, Class II 7.1% and Class III 11.5%. The non-obese ATHA cohort had lower complication rates (0.8% major, 5.0% minor) compared to the PTHA cohort (5.0% major, 6.7% minor). ATHA obese patients had 6.3% major and 9.9% minor complication rates, compared to 11.1% major and 10.0% minor complication rates in PTHA. Lastly, the evaluation of short term outcomes showed more favorable results for ATHA compared to PTHA for both obese and non-obese patients. CONCLUSION. Obesity was associated with an increased risk of complications and less favorable short-term outcomes following THA. Direct anterior THA was also associated with lower complication rates and more favorable short-term outcomes

Aims

To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials.

The aim of this study was to assess the incidence, management and survival of unstable pelvic ring injuries in patient aged 65 years or older. Prospectively kept data was analysed from April 2008 to October 2016. Information regarding the mechanism, fracture type, associated injuries, treatment and complications of the treatment were collected. Annual incidence was calculated and a Kaplan Meier survival analysis for carried out at 30 days, 1 year and 5 years. 404 patient records were available. 125 were 65 years or older (60 males and 65 females). 24 (19%) patients required surgical stabilisation to permit mobilisation the remaining 101 patients, treated conservatively were mobilised with immediate weight-bearing under the supervision of a physical therapist with assistive devices. Mean age was 73.5 years (SD 9.9 yrs). Fracture types were − 61.B2 47(37.6%), 61.B1 24(32%), 61.A2 17(13.6%), 61.C1 16(12.8%), 61.C2 5(4%), 61.A1 2(1.6%) and 61.C3 3(2.4%). Mechanisms of injury included fall from standing height − 41 (32%), road traffic collisions − 46(36.8%), fall from higher than standing height − 10(8%), fall from horse − 6(4.8%), jumped from bridge − 3(2.4%) & others 19(15%). Complications in surgical group included 1 death from PE and 1 wound infection treated with vacuum assisted dressing. Survivorship was 91.7%(30 days), 82.5%(1 year) and 49.7%(5 years). Most common fracture type is 61.B2. Over one third of fractures resulted from low energy mechanism. The majority 81% could be managed conservatively. One-year survival figure closely resembles the fracture neck of femur group, highlighting the frailty of this population

Abductor deficiency commonly contributes to total hip dislocation. Successful treatment of the deficiency can improve function, decrease pain, and decrease reliance on implants to cure recurrent dislocation. The defining physical exam findings are dependence on ambulatory assistive devices, severe limp, positive Trendelenberg sign, and inability to abduct against gravity. Three techniques have been described for chronic abductor discontinuity in which the abductors have retracted or are absent and cannot reach the greater trochanter: Vastus lateralis muscle shift, Achilles tendon allograft, and gluteus maximus muscle transfer. None of the techniques were specifically performed for dislocation. The vastus lateralis shift transfers the entire muscle proximally maintaining the neurovascular bundle. The procedure requires an incision from the hip to the knee, isolation of the neurovascular bundle, and elevation of the muscle from the femur. The authors admitted that the technique is demanding and not easily applicable to many surgeons. Repair with an Achilles allograft requires an identifiable contractile abductor mass. The allograft is looped through the abductors to bridge the gap to the trochanter. Two variations of a gluteus muscle transfer for abductor deficiency after total hip have been described. A portion of the gluteus maximus with its distal fascial portion are transferred to the greater trochanter. As far as dislocation is concerned an advantage of this technique is the use of the posterior maximus flap to fill a posterior and superior capsular defect not addressed with the other techniques. In addition the technique is easy to perform in almost all cases

The number of Americans over the age of 80 is increasing at a faster rate than that of the 65–80 population. The cohort age 85–94 years had the fastest rate of growth from 2000–2010. The number of Americans older than 95 years grew at approximately 26% during the same period. This rapid growth has been associated with an increasing incidence of osteoarthritis of the hip and knee in this population. This surge in the growth rate of the elderly population has coincided with an increasing demand for primary and revision total joint arthroplasty. Surgeons need to be prepared to perform safely and appropriately these procedures in this rapidly growing segment of the population. Surgeons need to be aware of the 1) clinical outcomes that can be expected when total joint procedures are performed in this group of patients; 2) the morbidity and mortality associated with the performance of these procedures; and 3) the relative cost effectiveness of these interventions. Clinical outcomes of TJA in this population are generally good. Pain and satisfaction scores are similar to those of younger patients. Although pre-operative pain and functional impairment scores are higher pre-operatively in elderly patients, these improve significantly following TJA. However, functional outcome scores decline noticeably after 5 years, reflecting the impact of coexistent comorbidities. The continued need for assistive devices is greater in this age group than in younger total joint patients. The risk of falls, a particular issue of concern in this age group, is reduced after total hip and knee surgery. The rate of complications, including mortality, following TJA in this age group is greater than in the 65–79-year-old group. The use of hospitalists to co-manage peri-operative care is particularly important in this age group. The increased rate of complications is associated with longer lengths of stay. However, the length of stay for this age group after primary total joint replacement is decreasing significantly; reflecting the widespread streamlining of peri-operative care that is being incentivised and implemented nationwide. The use of extended care facilities is also greater in this age group. The performance of revision TJA in this age group is particularly challenging. The rates of revision in elderly patients are anticipated to rise significantly in coming years. Although revision TJA is associated with significant pain relief and patient satisfaction, it is accompanied by mortality and complication rates that are substantially greater than those in younger age groups

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.