Aims. National joint registries under-report revisions for periprosthetic joint infection (PJI). We aimed to validate PJI reporting to the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR) and the factors associated with its accuracy. We then applied these data to refine estimates of the total national burden of PJI. Methods. A total of 561 Australian cases of confirmed PJI were captured by a large, prospective observational study, and matched to data available for the same patients through the AOANJRR. Results. In all, 501 (89.3%) cases of PJI recruited to the prospective observational study were successfully matched with the AOANJRR database. Of these, 376 (75.0%) were captured by the registry, while 125 (25.0%) did not have a revision or reoperation for PJI recorded. In a multivariate logistic regression analysis, early (within 30 days of implantation) PJIs were less likely to be reported (adjusted odds ratio (OR) 0.56; 95% confidence interval (CI) 0.34 to 0.93; p = 0.020), while two-stage revision procedures were more likely to be reported as a PJI to the registry (OR 5.3 (95% CI 2.37 to 14.0); p ≤ 0.001) than debridement and implant retention or other surgical procedures. Based on this data, the true estimate of the incidence of PJI in Australia is up to 3,900 cases per year. Conclusion. In Australia, infection was not recorded as the indication for revision or reoperation in one-quarter of those with confirmed PJI. This is better than in other registries, but suggests that registry-captured estimates of the total national burden of PJI are underestimated by at least one-third. Inconsistent PJI reporting is multifactorial but could be improved by developing a nested PJI registry embedded within the national arthroplasty registry. Cite this article: Bone Jt Open 2022;3(5):367–373

Heterotopic ossification (HO) is a well-known complication of traumatic elbow injuries. The reported rates of post-traumatic HO formation vary from less than 5% with simple elbow dislocations, to greater than 50% in complex fracture-dislocations. Previous studies have identified fracture-dislocations, delayed surgical intervention, and terrible triad injuries as risk factors for HO formation. There is, however, a paucity of literature regarding the accuracy of diagnosing post-traumatic elbow HO. Therefore, the purpose of our study was to determine the inter-rater reliability of HO diagnosis using standard radiographs of the elbow at 52 weeks post-injury, as well as to report on the rate of mature compared with immature HO. We hypothesized inter-rater reliability would be poor among raters for HO formation. Prospectively collected data from a large clinical trial was reviewed by three independent reviewers (one senior orthopedic resident, one senior radiology resident, and one expert upper extremity orthopedic surgeon). Each reviewer examined anonymized 52-week post-injury radiographs of the elbow and recorded: 1. the presence or absence of HO, 2. the location of HO, 3. the size of the HO (in cm, if present), and 4. the maturity of the HO formation. Maturity was defined by consensus prior to image review and defined as an area of well-defined cortical and medullary bone outside the cortical borders of the humerus, ulna, or radius. Immature lesions were defined as an area of punctate calcification with an ill-defined cloud-like density outside the cortical borders of the humerus, ulna or radius. Data were collected using a standardized online data collection form (CognizantMD, Toronto, ON, CA). Inter-rater reliability was calculated using Fleiss’ Kappa statistic and a multivariate logistic regression analysis was performed to identify risk factors for HO formation in general, as well as mature HO at 52 weeks post injury. Statistical analysis was performed using RStudio (version1.4, RStudio, Boston, MA, USA). A total of 79 radiographs at the 52-week follow-up were reviewed (54% male, mean age 50, age SD 14, 52% operatively treated). Inter-rater reliability using Fleiss’ Kappa was k= 0.571 (p = 0.0004) indicating moderate inter-rater reliability among the three reviewers. The rate of immature HO at 52 weeks was 56%. The multivariate logistic regression analysis identified male sex as a significant risk factor for HO development (OR 5.29, 1.55-20.59 CI, p = 0.011), but not for HO maturity at 52 weeks. Age, time to surgery, and operative intervention were not found to be significant predictors for either HO formation or maturity of the lesion in this cohort. Our study demonstrates moderate inter-rater reliability in determining the presence of HO at 52 weeks post-elbow injury. There was a high rate (56%) of immature HO at 52-week follow-up. We also report the finding of male sex as a significant risk factor for post traumatic HO development. Future research directions could include investigation into possible male predominance for traumatic HO formation, as well as improving inter-rater reliability through developing a standardized and validated classification system for reporting the radiographic features of HO formation around the elbow

Anterior approach total hip arthroplasty (AA-THA) has a steep learning curve, with higher complication rates in initial cases. Proper surgical case selection during the learning curve can reduce early risk. This study aims to identify patient and radiographic factors associated with AA-THA difficulty using Machine Learning (ML). Consecutive primary AA-THA patients from two centres, operated by two expert surgeons, were enrolled (excluding patients with prior hip surgery and first 100 cases per surgeon). K- means prototype clustering – an unsupervised ML algorithm – was used with two variables - operative duration and surgical complications within 6 weeks - to cluster operations into difficult or standard groups. Radiographic measurements (neck shaft angle, offset, LCEA, inter-teardrop distance, Tonnis grade) were measured by two independent observers. These factors, alongside patient factors (BMI, age, sex, laterality) were employed in a multivariate logistic regression analysis and used for k-means clustering. Significant continuous variables were investigated for predictive accuracy using Receiver Operator Characteristics (ROC). Out of 328 THAs analyzed, 130 (40%) were classified as difficult and 198 (60%) as standard. Difficult group had a mean operative time of 106mins (range 99–116) with 2 complications, while standard group had a mean operative time of 77mins (range 69–86) with 0 complications. Decreasing inter-teardrop distance (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95–0.99, p = 0.03) and right-sided operations (OR 1.73, 95% CI 1.10–2.72, p = 0.02) were associated with operative difficulty. However, ROC analysis showed poor predictive accuracy for these factors alone, with area under the curve of 0.56. Inter-observer reliability was reported as excellent (ICC >0.7). Right-sided hips (for right-hand dominant surgeons) and decreasing inter-teardrop distance were associated with case difficulty in AA-THA. These data could guide case selection during the learning phase. A larger dataset with more complications may reveal further factors

The use of cannabis is increasingly medically relevant as it is legalized and gains acceptance more broadly. However, the effects of marijuana use on postoperative outcomes following orthopedic surgery have not been well-characterized. This study seeks to illuminate the relationship between marijuana use and the incidence postoperative complications including: DVT, PE, nonunion, and infection following common orthopedic procedures. This study was conducted using a national orthopaedic claims insurance database. We identified all patients undergoing knee arthroscopy, shoulder arthroscopy, operatively managed long bone fractures (humerus, femur, tibia and/or fibula, and radius and/or ulna), and single-level lumbar fusion. The proportion of patients within each surgery cohort who had a diagnostic code for marijuana dependence was assessed. The rates of DVT, PE, and infection within 90 days were assessed for all patients. The rate of nonunion was assessed for the long bone fracture and lumbar fusion cohorts. Univariate analyses of marijuana dependence on all outcomes were performed, followed by a multivariate logistic regression analysis controlling for known patient comorbidities. We identified 1,113,944 knee arthroscopy, 747,938 shoulder arthroscopy, 88,891 lumbar fusion, and 37,163 long bone fracture patients. Out of the 1,987,936 patients, 24,404 patients had a diagnostic code for marijuana dependence. Within all four surgical subgroups, the marijuana dependence cohort experienced increased rates of infection, PE, and DVT, as well as increased rates of nonunion in the lumbar fusion and long bone fracture populations. In the multivariate analyses controlling for a variety of patient risk factors including tobacco use, marijuana dependence was identified as an independent risk factor for infection within all four surgical subgroups (Knee: OR 1.85, p < 0.001; Shoulder: OR 1.65, p < 0.001; Spine: OR 1.45, p < 0.001; Long bone: OR 1.28, p < 0.001), and for nonunion in the lumbar fusion (OR 1.38, p < 0.001) and long bone fracture (OR 1.31, p < 0.001) subgroups. Our data suggests that marijuana dependence may be associated with increased rates of infection and nonunion following a variety of orthopaedic procedures. During preoperative evaluation, surgeons may consider marijuana use as a potential risk factor for postoperative complications, especially within the context of marijuana legalization. Future research into this relationship is necessary

Aim. Whether laminar airflow (LAF) in the operating room (OR) is effective for decreasing periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant yet controversial issue. This study investigated the association between operating room ventilation systems and the risk of PJI in TJA patients. Method. We performed a retrospective observational study on consecutive patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from January 2013-September 2017 in two surgical facilities within a single institution, with a minimum 1-year follow-up. All procedures were performed by five board-certified arthroplasty surgeons. The operating rooms at the facilities were equipped with LAF and turbulent ventilation systems, respectively. Patient characteristics were extracted from clinical records. PJI was defined according to Musculoskeletal Infection Society criteria within 1-year of the index arthroplasty. A multivariate logistic regression model was performed to explore the association between LAF and risk of 1-year PJI, and then a sensitivity analysis using propensity score matching (PSM) was performed to further validate the findings. Results. A total of 6,972 patients (2,797 TKA, 4,175 THA) were included. The incidence of PJI within 1 year for patients from the facility without laminar flow was similar at 0·4% to that of patients from the facility with laminar flow at 0·5%. In the multivariate logistic regression analysis, after all confounding factors were taken into account, the use of LAF was not significantly associated with reduction of the risk of PJI. After propensity score matching, there was no significant difference in the incidence of PJI within 1 year for patients between the two sites. Conclusions. The use of LAF in the operating room was not associated with a reduced incidence of PJI following primary TJA. With an appropriate perioperative protocol for infection prevention, LAF does not seem to play a protective role in PJI prevention

Solitary fibrous tumor (SFT) is a rare mesenchymal tumor with an intermediate tendency to metastasize, which is found in many different locations including head and neck, abdomen, chest cavity and extremities. Also, meningeal hemangiopericytoma (HPC) is considered an SFT which arises in the meningeal membranes. SFT family shows an undetermined biologic behavior varying from a silent indolent tumor to an aggressive malignant form; however, benign and malignant variants of SFT may have similar cytopathologic characteristics. In this study, we defined the factors correlated with SFT's aggressive behavior and patient's survival. This is a retrospective study based on medical records of 85 patients who were suffering from SFT and had been treated at McGill University Health Centre (MUHC) between 1984 and 2017. We used multivariate logistic regression analysis to address any association between the variables including patient's demographics, tumor size, primary location of the tumor, pathological features, treatment methods and outcomes. The median of the follow-up period was 60 months. The patient's age or gender had no association with tumor aggressive behavior or patient's survival. Anatomical origin of primary tumor had no strong correlation with the patient's disease related death (DRD); however, tumors originated from CNS showed more aggressive behavior. There was an association between tumor size more than 7 cm and distant metastasis (MT) (p= 0.03) and DRD (p=0.03). The tumor size also correlated with the 5-year disease-free survival (p=0.017). We had three histologic groups: 1- Benign SFT (30 cases), 2- cellular SFT or HPC (29 cases), 3- malignant SFT or anaplastic HPC (26 cases). Although univariate analysis demonstrates that patients suffering from cellular SFT and malignant SFT showed increased aggressive behavior of the tumor, multivariate analysis didn't verify the mentioned association. Patients with positive margins had increased odds ratio to experience tumor local recurrence (LR) (p= 0.05) and LR was correlated with DRD in our patients (p=0.006). Radiotherapy had no statistical association with LR, MT or DRD. Frequency of LR and MT in the study were 25.7% and 29.8% respectively. 5-year disease-free survival in our patients was 76%. The size of SFT is the most correlative predictor of the tumor's aggressive behavior. The local recurrence of SFT is associated with disease related death; therefore, resection of the tumor with negative margins provides the highest chance of cure. In addition, a cellular SFT should be treated like a malignant variant of the tumor

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

Introduction. Antibiotic-impregnated bone cement (AIBC) has been used for decades to treat and prevent post-operative infections in joint arthroplasty. Local delivery of antibiotics may theoretically have a bactericidal effect, however evidence supporting this is controversial and literature suggests its prophylactic use in primary total knee arthroplasty (TKA) is seldom justified. With evolving standards of care, historical data is no longer relevant in addressing the efficacy of AIBC in the contemporary TKA. The purpose of this study was to evaluate outcomes following primary TKA using AIBC and regular non-AIBC by comparing rates of surgical site infection (SSI) and prosthetic joint infection (PJI). Methods. A retrospective review was conducted of all cemented primary TKA procedures from a large institutional database between January 1, 2015 and December 31st, 2016. This identified 6,073 cases, n=2,613 in which AIBC was used and n=3,460 cases using bone cement without antibiotics. Patients were stratified into low risk and high-risk groups based on age (>65 years), BMI (>40), and Charlson Comorbidity Index (CCI; >3). Medical records were reviewed for diagnoses of SSI (skin and superficial wound infections) and PJI (deep joint infections requiring surgery) over a 2-year postoperative period. Univariate analysis and multivariate regression models were used to ascertain the effects of cement type, patient factors (age, gender, BMI, CCI), operative time, and length of stay on infection rates. Additionally, mixed models (adjusted for gender, age, race, BMI, and CCI) were built to account for surgeon variability. Results. The use of AIBC and risk group distributions were equal across the study period and no collinearity was found between the study variables. The SSI rate was 3.0% and the PJI rate was 0.8% in the total study population. Univariate analysis showed there was no significant difference in SSI rates with AIBC compared to non-AIBC (3.3% vs. 2.8%, p=0.278) or in PJI rates (1.0% vs. 0.7%, p=0.203). Multivariate logistic regression analysis adjusted for patient factors, operative time, and length of stay showed no significant difference in SSI rates with a procedure using AIBC compared to non-AIBC (OR=0.90; 95% CI, 0.66–1.23; p=0.515) and no significant difference in PJI rates (OR=1.01; 95% CI, 0.55–1.84; p=0.984). Mixed models also showed no difference in PJI rates with AIBC use after adjusting for surgeon variability as well as patient factors (gender, race, age, BMI, and CCI). Discussion. Prophylactic use of AIBC in primary TKA is not without consequence when considering the significant increase in cost and its potential side effects, namely organism specific antibiotic resistance and mechanical loosening. This study shows that even when adjusted for patient factors, procedure-related factors, and length of stay, there is no clinically significant decrease in infection rates with the use of AIBC in primary TKAs

Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management, VTE prophylaxis and early mobilization and early intake. The primary outcome was transfusion requirement, other parameters such as blood loss, hemoglobin (Hb) level, VTE, adverse events and length of hospital stay were also compared. Multivariate logistic regression analysis and meta-analysis were also performed to identify the risk factors of transfusion and confirm the results of current study. Results. Transfusion of at least 1U of erythrocyte blood cell occurred in 25 patients (8.65%) in treatment group and in 77 (24.06%, OR=0.299, p<0.001) in control group. The mean level of Hb on POD 1 (111.70±18.40 g/L) and POD 3 (108.16±17.25 g/L) in TXA group were higher than control group (107.29±18.70 g/L, p= 0.008; 104.22±15.16 g/L, p= 0.005 respectively). More patients get off bed to ambulate within 24 hours after surgery in TXA group (37.02% Vs 26.25%, p= 0.004). And the length of hospital stay was shorter (11.82±4.39 Vs 15.96±7.30, p= 0.003). No statistical significance were detected regarding VTE and other adverse events. Logistic regression analysis showed that the relative odds reduction after adjustment for these covariates was 67% (OR= 0.327, 95%CIs= 0.197 to 0.544) in favor of tranexamic acid. Other risk factors included preoperative hemoglobin level, operation time, VTE prophylaxis. Pooling the data showed that tranexamic acid led to a significant reduction in transfusion (OR= 0.33, 95%CIs= 0.25 to 0.43) without sacrificing safety (OR= 0.70, 95%CIs= 0.25 to 1.97). Conclusion. Tranexamic acid was effective and safe to reduce blood loss and transfusion in geriatric hip fracture patients undergoing fast-track hemiarthroplasty

Objective. By retrospective analysis of clinical data, to find new risk factors for postoperative dislocation after total hip replacement and the dose-effect relationship when multiple factors work simultaneously. Methods. A nested case-control study was used to collect the dislocated hips from 5513 primary hip replacement case from 2000 to 2012. Apart from the patients with given cause of dislocation, 39 dislocated hips from 38 cases were compared with 78 hip from 78 cases free from dislocation postoperatively, which matched by the admission time. The factors that may affect the prosthetic unstable was found by the univariate analysis, and then they were performed multivariate logistic regression analysis and evaluation of a dose-effect factors. Results. The clinical scores between the two groups was no significant difference before and after surgery. Univariate analysis revealed the position of acetabular prosthesis (P = 0.05) and the big ball (P=0.01) differences were statistically significant. While patient with adduction deformity incorporating limb lengthening≧2cm(P<0.01) or the knee valgus deformity incorporating pelvic obliquity (P=0.01), as well as bilateral cases (P=0.02) were also the risk factors for dislocation. Big head decrease the dislocation rate. Multivariate analysis confirmed these newly founded factors are more important than the classic factors in this group of patients. Conclusion. Patients with hip adduction deformity combined with limb lengthening, knee valgus deformity combined with pelvic obliquity and bilateral pathological hip seem more predisposed to dislocation after total hip arthroplasty, who should be strengthened preoperative education and postoperative management to prevent. Key Word. total hip arthroplasty, dislocation, multivariate analysis

Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases

This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs. 4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery, co-morbidities and duration of post-operative opioid use. The high incidence of gastrointestinal morbidity after paediatric spinal surgery and consequent prolonged hospital stay has clinical implications to both the patient and the institution. Awareness of those with significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Purpose. Pediatric tibial shaft fractures (TSF) account for 15% of long bone fractures in children. Compartment syndrome (CS) is difficult to diagnose in children, often leading to disastrous outcomes. This study investigated the incidence of CS in TSF and its associated risk factors. Method. A detailed five-year retrospective chart review of TSF treated at a major pediatric hospital. CS was diagnosed clinically or by intra-compartment pressure. Multivariate logistic regression analysis tested age, gender, mechanism of injury, time to surgery, fracture type, and treatment intervention as possible risk factors for CS. Results. There were 216 TSF in 212 children (160 males, 52 females; mean age 13.6 years, range eight-18 years). One hundred and thirty-two (61%) fractures were treated with closed reduction and casting, 36 with external fixation, 21 with flexible intramedullary nails, and 27 with locked intramedullary nails. There were 23 cases of CS (10.6%). Multivariate predictors of CS included age 14 years and older (21/96 = 22%, p < 0.001) and motor vehicle accident (MVA) (12/57 = 21%, p = 0.002). Incidence of CS was 44% among patients 14 and older who sustained MVA (11 of 25). Gender, AO fracture type, time to surgery and surgical fixation were not predictive of CS. Conclusion. This is the first large study to report the incidence of CS from TSF in children. The incidence of 10.6% is higher than previously reported and much higher in patients 14 years of age and older and involved in an MVA. Surgeons should be especially aware and suspicious of CS in children with tibial shaft fractures who have these risk factors

Introduction. Among patients with ankle osteoarthritis (OA) a post-traumatic origin is much more frequent than among those with knee or hip OA. However, long-term studies evaluating risk factors for the development of OA after ankle fractures are lacking. Methods. Retrospective cohort study including consecutive patients operated at our institution between 1/1988 and 12/1997 for malleolar fractures treated with open-reduction and internal fixation (ORIF). Ankle OA was independently assessed by two reviewers on standardized radiographs using the Kellgren and Lawrence (K&L) scale. Multivariate logistic regression analysis was performed to determine predictors for OA. Results. 374 patients (56% men) underwent ankle surgery during the study period. 9% had a Weber A, 58% a Weber B and 33% a Weber C fracture. Mean age at operation was 42.9 years. 12–22 years after surgery, 47 patients had died, 126 were lost to follow-up, and 99 did not respond or refused to participate. 102 patients were available at follow-up (similar age, gender, BMI and type of fracture than those not seen). Mean follow up was 17.3 years. Advanced OA (K&L 3–4) was present in 37 patients (36.3%). Significant risk factors for advanced OA were: fracture type (Weber C 53% vs. Weber B 31% vs. Weber A 0%, p = 0.006), presence of medial malleolus fracture, fracture-dislocation, increasing BMI, older age, and longer follow-up time. Conclusion. Advanced ankle osteoarthritis is frequent (36%) 12–22 years after a malleolar fracture, especially after Weber C fractures, medial malleolus fractures or fracture-dislocation. Obese and older patients are at increased risk

Introduction This study was conducted to quantify the incidence of gastrointestinal morbidity and identify risk factors for developing gastrointestinal morbidity following spinal surgery in children. Method A retrospective review was conducted on 253 surgical spinal procedures performed over a 5 year period at Starship Children’s Hospital. Multivariate logistic regression analysis was used to identify significant risk factors. Co-morbidity included co-existing cardiac, respiratory, genitorurinary or central nervous system problems, or delayed development. Results Seventy eight (77.9%) percent of the study population developed gastrointestinal morbidity and this significantly prolonged the median post-operative hospital stay (8 days vs.4 days; p< 0.0001). Emesis (50.6%), paralytic ileus (42.3%) and constipation (22.5%) were the most frequent gastrointestinal morbidities. Significant risk factors for developing gastrointestinal morbidity were fusion surgery (p< 0.01), co-morbidities (p-value) and duration of post-operative opioid use (p-value). Discussion There is a high incidence of gastrointestinal morbidity after paediatric spinal surgery. The consequent prolonged hospital stay has clinical implications to both the patient and the institution. We have further identified risk factors for developing gastrointestinal morbidity, of which the duration of post-operative opioid use is modifiable. Awareness of those with the other significant risk factors identified by this study could assist in the timely implementation of appropriate treatment

Hypothesis. Does the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms provide a good predictor of the outcome of later carpal tunnel release (CTR). Methods. A retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome (CTS) over a two year period was conducted. A total of 23 patients and 28 wrists met inclusion criteria. Patients were evaluated to determine if pre-operative factors or result of injection predicted the outcome of revision CTR. A multivariate logistic regression analysis (MLRA) was used to predict surgical success when multiple pre-operative findings were considered. Results. No patient characteristic or physical exam finding was found to predict successful revision CTR. Twenty-two (86.4%) of patients who had relief from injection had symptom relief/improvement with revision CTR whereas only 4 (13.6%) were not improved by the surgery; the difference was not statistically significant. The sensitivity and positive predictive value for injection alone predicting outcome of revision CTR was 86.4%. MLRA combining injection results with physical exam findings (Numbness and/or motor weakness in median nerve distribution, Positive Durkin's, and Positive Phalen's test) provided a sensitivity of 100% and specificity of 80%. Conclusions. In contrast to primary CTS, cortisone injection into the carpal tunnel in the face of recurrent CTS is not, by itself, a statistically significant predictor of successful revision surgery. However, patients with a positive result from injection had an 86.4% success with revision CTR with an average DASH score of 28.87. Relief from injection as a diagnostic test for success from revision CTR was found to have both high sensitivity and positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish success with revision CTR, sensitivity of 100% and specificity of 80%

Background: Percutaneous compression plating (PCCP) is used for the fixation of intertrochanteric hip fractures by a minimally invasive technique. While offering several advantages compared to classic open reduction and internal fixation, the technique does not allow direct hemostasis. We aimed to assess the effect of regular aspirin use on blood loss, transfusion requirements and wound complications in patients undergoing urgent fixation using this technique. Methods: The study involved 326 patients who presented to our hospital with an intertrochanteric fracture. Parameters recorded included time to surgery, blood loss (assessed by pre and post operative hemoglobin concentrations), and transfusion requirements. The status of wound healing was evaluated, with specific reference to hematoma formation. The influence of regular pre-operative aspirin use was analyzed with respect to these outcome measures. Results: 32% of patients were regular aspirin users, and were comparable to the non aspirin group. There was no significant difference between the aspirin and non aspirin groups in terms of preoperative hemoglobin concentrations, perioperative changes in hemoglobin levels, and transfusion requirements. The severity of wound hematoma and the number of drainage procedures was not significantly different between the two groups. In a multivariate logistic regression analysis (composite complications. *. versus no complications as the dependent variable. R. 2. =0.108, P< 0.001), only delay to surgery was associated with a higher complication rate. *. Composite complications defined as transfusion ≥3 units, abnormal wound hematoma and length of stay ≥ 10 days. Conclusion: Regular aspirin use pre-operatively is not associated with increased blood loss, transfusion requirements and wound complications in patients treated with this percutaneous fixation technique. Rather, it is the delay to surgery that is associated with a composite bad outcome. Our data suggest that patients on aspirin can safely undergo urgent non-delayed fracture fixation using the PCCP

Background. The anterior approach for total hip arthroplasty has recently been hypothesized to result in less muscle damage. While clinical outcome studies are essential, they are subject to patient and surgeon bias. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients receiving anterior and posterior minimally-invasive total hip arthroplasty to provide objective evidence of the surgical insult. Methods. 29 patients receiving an anterior and 28 patients receiving a posterior total hip arthroplasty were analyzed. Peri-operative and radiographic data were collected to ensure similar cohorts. Creatine kinase, C-reactive protein, Interleukin-6, Interleukin-1beta, and Tumor necrosis factor-alpha were collected pre-operatively, post-operatively, and on post-operative days 1 and 2. Comparisons between the groups were made using the Student's t-test and Fisher's Exact test. Independent predictors of elevation in markers of inflammation and muscle damage were determined using multivariate logistic regression analysis. Results. Markers of inflammation were slightly decreased in direct anterior group (mean differences in C-reactive protein 27.5 [95% confidence interval −24.7–79.6] mg/dL, Interleukin-6 13.5 [95% confidence interval −11.5–38.4] pg/ml, Interleukin-1beta 42.6 [95% confidence interval −10.4–95.6], and Tumor necrosis factor-alpha 148.6 [95% confidence interval −69.3–366.6] pg/ml). The rise in creatine kinase was 5.5 times higher in the post anesthesia care unit (mean difference 150.3 [95% confidence interval 70.4–230.2] units/L, p < 0.05) and nearly twice as high cumulatively in the miniposterior approach group (305.0 [95% confidence interval −46.7–656.8] units/L, p < 0.05). Conclusion. Anterior total hip arthroplasty caused significantly less muscle damage compared to traditional posterior surgery as indicated by creatine kinase levels. The clinical importance of this rise needs to be delineated by further clinical studies. The overall physiologic burden as measured by markers of inflammation, however, appears to be similar. Objective measurement of muscle damage and inflammation provides an unbiased way of determining the immediate effects of surgical intervention in total hip arthroplasty patients

Introduction: The use of intramedullary nailing (IMHS) has increased at the expense of the dynamic hip screw (DHS), although the outcome is not different in the studies of pertrochanteric fractures (PTF), known as AO/OTA type 31A1-2 fractures with a preoperative intact lateral femoral wall. We therefore investigated the two implants in the subgroup of PTF with a fractured greater trochanter. Materials and Methods: Six hundred thirty-five consecutive patients with PTF fixated by a short IMHS or by a DHS mounted on a four hole lateral plate were prospectively included between 2002 and 2008. The fractures were preoperatively classified according to AO/OTA classification system, including status of the greater and lesser trochanter. The integrity of the lateral femoral wall, fracture reduction and implant positioning were assessed postoperatively. Reoperations due to technical failures were recorded for one year. Results: Among the 311 patients sustaining a PTF with a fractured greater trochanter, 4% (6/158) operated with an IMHS were reoperated compared to 14% (22/153) with a DHS (p=0.001). Multivariate logistic regression analysis combining demographic and biomechanical parameters showed the IMHS to have a lower rate of reoperation (p=0.002). During the operative procedure, the lateral femoral wall was fractured in 6% (9/158) of patients, in which an IMHS was performed versus 28% (42/153) operated with a DHS (p< 0.001). Among the DHS, a fractured lateral femoral wall was confirmed to be a predictor of a reoperation (31% (13/42) of patients with a fractured lateral femoral wall versus 8% (9/111) with an intact lateral femoral wall, p< 0.001). As in other studies, the different reoperation rate would have been overseen in the main group of AO/ OTA type 31A1-2 PTF fractures (4% (6/164) IMHS versus 6% (30/471) DHS, p=0.196). Conclusion: The IMHS seems to have a lower reoperation rate than the DHS in the subgroup of PTF with a fractured greater trochanter. In contrast to the DHS, the IMHS presumably keeps the integrity of the lateral femoral wall. In future studies, PTF should be divided into subgroups

The aim of the study is to evaluate the results obtained in patients older than 70 years who were treated with open surgical repair for massive ruptures of the rotator cuff and the functional outcome. This is a retrospective analysis of a consecutive series of 280 patients who underwent open repair of a massive rotator cuff tear between 1999 and 2003. The inclusion criteria were: age 65 or over, symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size > = 5 cm, minimum follow-up of 2 y since surgery. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views) and nmr of the shoulder. Patients were assessed with the Costant score, Simple Shoulder test, UCLA score before and after surgery. Pain was assessed by use of a visual analog scale. The mean age of patients was 75b years (range 65–91). There were 41 men and 28 women. The mean duration of symptoms before repair was 18 months (range 1–58). The dominant arm was affected in 54 patients (78%). The change in UCLA scores, SST, Costant score and their subcomponents were analyzed with the paired Student’s test, assuming a normal distribution of the total score. In an exploratory analysis trying to identify preoperative variables that could be associated with a good surgical outcome, a multivariate logistic regression analysis was performed including the following variables: age equal or more than 80 years, sex history, shoulder different affected, UCLA score, SST, costant score and use of formal physical therapy. Satisfactory results were achieved in 250 patients: the mean preoperative UCLA score was 9.3, Costant score 45, and the mean score after surgery was 16.9 and 65 rispectively. The mean preoperative function score was 2.4, after surgery was 8.1. The UCLA preoperative score for active forward flexion averaged 1.3 (30°–90°), and postoperative rating increased to 4.5 points (p=0,0001)corresponding to an active forward flexion between 120° and 150°