The August 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Comparing augmented and nonaugmented locking-plate fixation for proximal humeral fractures in the elderly; Elevated five-year mortality following shoulder arthroplasty for fracture; Total intravenous anaesthesia with propofol reduces discharge times compared with inhaled general anaesthesia in shoulder arthroscopy: a randomized controlled trial; The influence of obesity on outcomes following arthroscopic rotator cuff repair; Humeral component version has no effect on outcomes following reverse total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial; What is a meaningful improvement after total shoulder arthroplasty by implant type, preoperative diagnosis, and sex?; The safety of corticosteroid injection prior to shoulder arthroplasty: a systematic review; Mortality and subsequent fractures of patients with olecranon fractures compared to other upper limb osteoporotic fractures.

Aims

The COVID-19 pandemic has disrupted the provision of arthroplasty services in England, Wales, and Northern Ireland. This study aimed to quantify the backlog, analyze national trends, and predict time to recovery.

Background. Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including early post-operative weight bearing and surgical complications. Methods. A national-multicentre retrospective cohort study was conducted between January to June 2019 in 56 centres (10 Major- Trauma-Centres and 46 Trauma-Units) in the United Kingdom; 1360 specifically defined complex ankle-fractures were enrolled. Demographics, fixation choice, surgical and functional outcomes were recorded. Statistical analysis was performed to compare high-risk patients with/without diabetes. Results. There were 316 patients in the diabetes cohort with mean age 63.9yrs (vs. 49.3yrs in non-diabetes cohort), and greater frailty score >4 (24% vs.14% (non-diabetes cohort) (p<0.03); 7.5% had documented neuropathy. In the diabetes cohort, 79.7% underwent standard ORIF, 7.1% extended ORIF and 10.2% a HFN compared to 87.7%, 3.0% and 10.3% in the non-diabetes cohort. Surgical wound complications after standard-ORIF were higher in the diabetes cohort (15.1% vs. 8.7%) (p<0.02) but patients with diabetes who underwent augmented techniques showed little difference in surgical outcomes/complications to non-diabetes, even though early-weight- bearing rates were greater than standard-ORIF. Conclusion. Ankle fractures in diabetes occur in older, frailer patients; whilst lower than expected neuropathy rates suggest a need for improved assessment. Augmented surgical techniques may allow earlier weight-bearing without increasing complications in keeping with modern guidelines in ankle fracture management

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

Aims

The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

The aims were to assess whether preoperative joint-specific function (JSF) and health-related quality of life (HRQoL) were associated with level of clinical frailty in patients waiting for a primary total hip arthroplasty (THA) or knee arthroplasty (KA). Patients waiting for a THA (n=100) or KA (n=100) for more than six months were prospectively recruited from the study centre. Overall, 162 patients responded to the questionnaire (81 THA; 81 KA). Patient demographics, Oxford score, EuroQol five dimension (EQ-5D) score, EuroQol visual analogue score (EQ-VAS), Rockwood Clinical Frailty Score (CFS), and time spent on the waiting list were collected. There was a significant correlation between CFS and the Oxford score (THA r=ˆ’0.838; p<0.001, KA r=ˆ’0.867; p<0.001), EQ-5D index (THA r=ˆ’0.663, p<0.001; KA r=ˆ’0.681; p< 0.001), and EQ-VAS (THA r=ˆ’0.414; p<0.001, KA r=ˆ’0.386; p<0.001). Confounding variables (demographics and waiting time) where adjusted for using multiple regression analysis. For each 8.5 (THA, 95% CI 7.1 to 10.0; p<0.001) and 9.9 (KA, 95% CI 8.4 to 11.4; p<0.001) point change in the Oxford score, there was an associated change in level of the CFS. For each 0.16 (THA, 95% CI 0.10 to 0.22; p<0.001) and 0.20 (KA, 95% CI 0.12 to 0.27; p<0.001) utility change in EQ-5D, there was an associated change in level of the CFS. EQ-VAS (THA, B=ˆ’11.5; p<0.001, KA B=ˆ’7.9; p=0.005) was also associated with CFS. JSF and HRQoL in patients awaiting THA or KA for more than six months, were independently associated with level of clinical frailty. With further prospective studies, clinical frailty may prove to be a useful metric to assist in the prioritization of arthroplasty waiting lists

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Aims

Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria.

Aims. Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. Methods. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS. Results. In the derivation cohort, five of the 27 variables were strongly predictive of the CFS (regression coefficient B = 6.383 (95% confidence interval 5.03 to 7.74), p < 0.001): age, Abbreviated Mental Test score, admission haemoglobin concentration (g/l), pre-admission mobility (needs assistance or not), and mechanism of injury (falls from standing height). In the validation cohort, there was strong agreement between the NTFI and the CFS (mean difference 0.02) with no apparent systematic bias. Conclusion. We have developed a clinically applicable tool using easily and routinely measured physiological and functional parameters, which clinicians and researchers can use to guide patient care and to stratify the analysis of quality improvement and research projects. Cite this article: Bone Joint J 2024;106-B(4):412–418

The April 2024 Wrist & Hand Roundup³⁶⁰ looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique.

Aims. Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods. A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results. In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion. A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing. Cite this article: Bone Jt Open 2024;5(3):236–242

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Periprosthetic femur fracture (PPF) are heterogeneous, complex, and thought to be increasingly prevalent. The aims were to evaluate PPF prevalence, casemix, management, and outcomes. This nationwide study included all PPF patients aged >50 years from 16 Scottish hospitals in 2019. Variables included: demographics; implant and fracture factors; management factors, and outcomes. There were 332 patients, mean age 79.5 years, and 220/332 (66.3%) were female. One-third (37.3%) were ASA1-2 and two-thirds (62.3%) were ASA3+, 91.0% were from home/sheltered housing, and median Clinical Frailty Score was 4.0 (IQR 3.0). Acute medical issues featured in 87/332 (26.2%) and 19/332 (5.7%) had associated injuries. There were 251/332 (75.6%) associated with a proximal femoral implant, of which 232/251 (92.4%) were arthroplasty devices (194/251 [77.3%] total hip, 35/251 [13.9%] hemiarthroplasty, 3/251 [1.2%] resurfacing). There were 81/332 (24.4%) associated with a distal femoral implant (76/81 [93.8%] were total knee arthroplasties). In 38/332 (11.4%) there were implants proximally and distally. Most patients (268/332; 80.7%) were treated surgically, with 174/268 (64.9%) requiring fixation only and 104/268 (38.8%) requiring an arthroplasty or combined solution. Median time to theatre was longer for arthroplasty versus fixation procedures (120 vs 46 hours), and those requiring inter-hospital transfer waited longer (94 vs 48 hours). Barriers to investigating PPF include varied classification, coding challenges, and limitations of existing registries. This is the first study to examine a national PPF cohort and presents important data to guide service design and research. Additional findings relating to fracture patterns, implant types, surgeon skill-mix, and outcomes are reported herein

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Aims

The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare.