Aims

Hip fracture patients have high morbidity and mortality. Patient-reported outcome measures (PROMs) assess the quality of care of patients with hip fracture, including those with chronic cognitive impairment (CCI). Our aim was to compare PROMs from hip fracture patients with and without CCI, using the Norwegian Hip Fracture Register (NHFR).

Aims

Periprosthetic joint infections (PJIs) and osteomyelitis are clinical challenges that are difficult to eradicate. Well-characterized large animal models necessary for testing and validating new treatment strategies for these conditions are lacking. The purpose of this study was to develop a rabbit model of chronic PJI in the distal femur.

Introduction. Hip resurfacing arthroplasty (HRA) is an alternative to traditional total hip arthroplasty (THA) in young active patients. While comparative implant survival rates are well documented, there is a paucity of studies reporting the patient mortality rates associated with these procedures. The purpose of this study was to evaluate the mortality rates in patients age 55 years and younger who underwent HRA versus THA and to assess whether the type of operation was independently associated with mortality. Patients and Methods. The database of a single high-volume surgeon was reviewed for all consecutive patients age 55 years and younger who underwent hip arthroplasty between 2002 and 2010. HRA became available in the United States in 2006. This yielded 504 patients who had undergone HRA from 2006 to 2010 and 124 patients who had undergone a THA. Patient characteristics were collected from the electronic medical record including age, gender, body mass index, Charleston comorbidity index, smoking status, and primary diagnosis. Mortality was determined through a combination of electronic chart reviews, patient phone calls, and online obituary searches. Univariate analysis was performed to identify a survival difference between the two cohorts. Multivariable Cox-Regression analyses were used to determine whether the type of operation was independently associated with mortality. Results. The mean follow up for consecutive patients was 7 years (up to 11 years) in the HRA group and 8 years (up to 16 years) in the THA group. A total of 467 HRA patients (92%) and 105 THA patients (85%) were followed for a minimum of 5-years. 92% of the THA procedures were performed prior to the availability of HRA. There were 8 mortalities (1.6%) in the HRA cohort and 11 (8.9%) in the THA cohort, a statistically significant difference (p<0.001) on univariate analysis. Low mortality rates produced underpowered multivariate models. Conclusion. We have demonstrated that patients under age 55 who undergo HRA have a significantly lower mortality rate than those undergoing THA at mid-term follow-up. This is consistent with previously published large database studies. Such studies typically analyze large heterogeneous populations of patients and surgeons. Our study uniquely examined only patients age 55 or younger from a single high-volume surgeon, and we primarily reviewed THA performed prior to the availability of HRA as a surgical option. Thus, surgeon selection bias was largely eliminated. To our knowledge, this is the first single surgeon study comparing HRA and THA in terms of mortality

Introduction. Knee arthroplasty is one of the most common inpatient surgeries procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following knee arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing knee arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,352,505 (57.8% Medicare, 35.6% private insurance, 2.6% Medicaid or uninsured, 3.3% Other) patients fulfilled criteria for inclusion into the study. Most were primary total knee arthroplasties (96.1%) with 3.9% revision knee arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.82, p=<0.001) compared to Medicare patients. Similar trends were found for surgical complications and mortality. Patients with Medicare or no insurance had more surgical complications but equivalent rates of medical complications and mortality. The matched cohort showed Medicare and private insurance patients had overall low mortality rates and complication. The most common complication was postoperative anemia, occurring in 16.2% of Medicare patients and 15.3% of patients with private insurance (RR=1.06, p<0.001). Mortality (RR 1.34), wound dehiscence (RR 1.32), CNS, GI complications, although rare, were all statistically more common in Medicare patients (p<0.05) while cardiac complications (RR 0.93, p=0.003) was more common in patients with private insurance. Discussion and Conclusion. This data reveals that patients with Medicare insurance have higher risk of medical complications, surgical complications and mortality following knee arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications were low overall (with the exception of postoperative anemia), but in general were more common in Medicare patients

We assessed the age-related differences in the use of total shoulder arthroplasty (TSA) and outcomes, and associated time-trends using the United States Nationwide Inpatient Sample (NIS) between 1998 and 2010. Age was categorised as < 50, 50 to 64, 65 to 79 and ≥ 80 years. Time-trends in the use of TSA were compared using logistic regression or the Cochran Armitage test.

The overall use of TSA increased from 2.96/100 000 in 1998 to 12.68/100 000 in 2010. Significantly lower rates were noted between 2009 and 2010, compared with between 1998 and 2000, for: mortality, 0.1% versus 0.2% (p = 0.004); discharge to an inpatient facility, 13.3% versus 14.5% (p = 0.039), and hospital stay > median, 29.4% versus 51.2% (p < 0.001).

The rates of use of TSA/100 000 by age groups, < 50, 50 to 64, 65 to 79 and ≥ 80 years were: 0.32, 4.62, 17.82 and 12.56, respectively in 1998 (p < 0.001); and 0.65, 17.49, 75.27 and 49.05, respectively in 2010 (p < 0.001) with an increasing age-related difference over time (p <  0.001). Across the age categories, there were significant differences in the proportion: discharged to an inpatient facility, 3.2% versus 4.2% versus 14.7% versus 36.5%, respectively in 1998 (p < 0.001) and 1.8% versus 4.3% versus 12.5% versus 35.5%, respectively in 2010 (p <  0.001) and the proportion with hospital stay > median, 39.7% versus 40.2% versus 53% versus 69%, respectively in 1998 (p < 0.001) and 17.2% versus 20.6% versus 28.7% versus 50.7%, respectively in 2010 (p < 0.001).

In a nationally representative sample, we noted a time-related increase in the use of TSA and increasing age-related differences in outcomes indicating a changing epidemiology of the use of TSA. Age-related differences in outcomes suggest that attention should focus on groups with the worst outcomes.

Cite this article: Bone Joint J 2015;97-B:1385–9.

Introduction: Joint replacement has a low mortality rate, few adverse occurrences, excellent survivorship and is considered a cost-effective intervention to reduce disability in the community. However, the assessment of complications and survivorship fail to measure the success of joint replacement in achieving pain relief and restoration of functional ability. The aim of this large cross-sectional postal survey was to provide information on the prevalence of pain, disability, poor quality of life and patient dissatisfaction at 1–3 years after a range of lower limb orthopaedic surgeries in the UK. Patient and Methods: A questionnaire was posted to all 3,125 consecutive alive patients who underwent a primary THR, hip resurfacing, TKR, UKR or patellar resurfacing at the Avon Orthopaedic Centre between January 2004 – April 2006. The questionnaire included the WOMAC, HOOS/KOOS quality of life scale and a validated satisfaction scale. All questionnaires are scored on a 0–100 scale (worst-best) and a poor outcome was defined as a score of ≤ 50 on the outcome measure. Results: Completed questionnaires were received from 2,085 patients (response rate of 67%). Patients had a mean age of 67 years and 42% were male. The mean length of follow-up was 28 months (range 14–44 months). 911 patients had a THR, 157 patients had a hip resurfacing, 866 patients had a TKR, 100 patients had a UKR and 51 patients had a patellar resurfacing. Pain: the prevalence of poor outcomes were 6% of patients with a THR, 4% with a hip resurfacing, 12% with a TKR, 9% with a UKR and 31% with a patellar resurfacing. Function: the prevalence of poor outcomes were 12% of patients with a THR, 4% with a hip resurfacing, 16% with a TKR, 9% with a UKR and 35% with a patellar resurfacing. Hip-related quality of life: the prevalence of poor outcomes were 26% of patients with a THR, 12% with a hip resurfacing, 33% with a TKR, 32% with a UKR and 67% with a patellar resurfacing. Satisfaction: the prevalence of poor outcomes were 13% of patients with a THR, 8% with a hip resurfacing, 17% with a TKR, 11% with a UKR and 45% with a patellar resurfacing. Conclusion: This survey has provided descriptive data on the prevalence of patient-reported levels of pain, disability, poor joint-related quality of life and dissatisfaction after lower limb arthroplasty. It is important that patient-reported outcomes after joint replacement are rigorously assessed in order to provide information on which patients do poorly after surgery, with the aim of targeting these patients with an intervention to improve their outcome. North Bristol Trust Small Grants Scheme provided funding for the consumables for this study

Objective: Descriptive retrospective analysis of hip peri-prosthetic fractures treated surgically from 2000 to 2005 analysing risk factors and Results:. Material and Methods: 31 patients with a mean age of 77 years (56–94) were operated of a periprosthetic fracture which happened 73 months (0–300) after the index arthroplasty. Fractures were classified following the Vancouver system: 1 patient presented a type Al(3%), 4 a B1(13%), 23 suffered a B2(74%), 1 a B3(3%) and 2 patients presented a type C(6%). The risk factors described in the literature were evaluated, as well as the different types of treatment with their clinical and radiological results. Risk factors:. Personal: 21(68%) patients were women. Previous condition of arthroplasty: 22(71%) non cemented, 23(74%) total prosthesis, 3(10%) revision surgery; 13(54%) presented osteointegration, 2(8%) stable fibrous fixation and 9 (38%) were unstable; in (7%) there was subsidence. Surgical technique: 11(52%) patients had insufficient size of the implant and 15 stems were in varus (54%). Bone status: 5 femur (20%) presented stress risers and 29(97%) diffuse osteopenia. Polyethylene wear: 10(50%) of THA. Osteolysis was observed in 21 patients (70%): 19(90%) in zone 1, 4(19%) in zone 2, 3(14%) in zone 3, 2(10%) in zone 4, 2(10%) in zone 5, 4(19%) in zone 6 and 15(71%) in zone 7. 5(24%) patients presented osteolysis in one zone, 9(43%) in two zones, 4(19%) in three zones, 2(10%) in four zones and 1(5%) in six zones. Type of treatment: 19(61%) patients were treated with open reduction and internal fixation (ORIF) without revision of the prosthesis, 11(35%) with revision surgery plus ORIF and 1(3%) with a resection arthroplasty. Bone graft was used in only 1(3%) patient. Type of osteosynthesis: 16(52%) only cables, 1(3%) cables and plates, 2(6%) plates and screws, 11(35%) plates and cables and screws, 1(3%) intramedullary nail. Clinical results:. There were 0(0%) infections and 0(0%) exitus but 7(23%) patients suffered postoperative medical complications. The mean time for allow weight-bearing was 3 months (2–6). For the 25 patients that achieved the complete follow up, maximum recovery was recorded after 9 months (3–13); 24(89%) patients recovered their previous status and 15(60%) had no pain. 15 patients maintained the instrumental level before the fracture and 10(66%) recovered it. Radiological results:. The mean time for fracture union was 6 months (3–18). At the end of follow-up 1(4%) patient presented non-union. 0(0%) patients presented mal-union, 2(8%) a refracture, and 6(24%) evolved to implant loosening. Conclusions:. Patients with periprosthetic fractures present a high number of previous local risk factors. Surgical treatment achieves a very low mortality rate and a good/excellent clinical result. Overuse of ORIF without prosthesis revision obtains consolidation in most cases but with a high risk of loosening

We investigated whether simultaneous bilateral sequential total hip replacement (THR) would increase the rate of mortality and complications compared with unilateral THR in both low- and high-risk groups of patients.

We enrolled 978 patients with bilateral and 1666 with unilateral THR in the study. There were no significant pre-operative differences between the groups in regard to age, gender, body mass index, diagnosis, comorbidity as assessed by the grading of the American Society of Anesthesiologists (ASA), the type of prosthesis and the duration of follow-up. The mean follow-up was for 10.5 years (5 to 13) in the bilateral THR group and 9.8 years (5 to 14) in the unilateral group.

The peri-operative mortality rate of patients who had simultaneous bilateral THR (0.31%, three of 978 patients) was similar to that of patients with unilateral THR (0.18%, three of 1666 patients). The peri-operative mortality rate of patients in the bilateral group was similar in high risk and low risk patients (0.70%, two of 285 patients vs 0.14%, one of 693 patients) and this was also true in the unilateral THR group (0.40%, two of 500 patients vs 0.09%, one of 1166 patients). Patients with bilateral THR required more blood transfusions and a longer hospital stay than those in the unilateral THR group. There was no significant difference (p = 0.32) in the overall number of complications between the groups. This was also true for the low-risk (p = 0.81) vs high-risk (p = 0.631) patients.

Our findings confirm that simultaneous sequential bilateral THR is a safe option for patients who are considered to be either high or low risk according to the ASA classification.

We wished to determine whether simultaneous bilateral sequential total knee replacement (TKR) carried increased rates of mortality and complications compared with unilateral TKR in low- and high-risk patients.

Our study included 2385 patients who had undergone bilateral sequential TKR under one anaesthetic and 719 who had unilateral TKR. There were no significant pre-operative differences between the groups in terms of age, gender, height, weight, body mass index, diagnosis, comorbidity and duration of follow-up, which was a mean of 10.2 years (5 to 14) in the bilateral and 10.4 years (5 to 14) in the unilateral group.

The peri-operative mortality rate (eight patients, 0.3%) of patients who had bilateral sequential TKR was similar to that (five patients, 0.7%) of those undergoing unilateral TKR. In bilateral cases the peri-operative mortality rate (three patients, 0.4%) of patients at high risk was similar to that (five patients, 0.3%) of patients at low risk as it was also in unilateral cases (two patients, 1.0% vs three patients, 0.6%). There was no significant difference (p = 0.735) in either the overall number of major complications between bilateral and unilateral cases or between low- (p = 0.57) and high-risk (p = 0.61) patients. Also, the overall number of minor complications was not significantly different between the bilateral and unilateral group (p = 0.143).

Simultaneous bilateral sequential TKR can be offered to patients at low and high risk and has an expected rate of complications similar to that of unilateral TKR.

Aims: To determine patterns and outcomes of pelvic injury resulting from motorcycle and car accidents. Methods: Review of the records of 233 patients (151 male, 82 female, median age 31(6–91) years) admitted to a teaching hospital (1996–2001) with pelvic injuries resulting from a road trafþc accident. Results: Ninety-One (39.1%) car occupants (53 drivers, 23 front and 15 rear seat passengers) and 57 (24.5%) motorcyclists (52 riders, 5 pillion) sustained pelvic injuries. Both groups had similar median ages (27.0 years (15–81) and 33.7 years (12–72)) and mean Injury Severity Scores (23.0(4–75) and 20.4(4–57)) respectively. Motorcyclists more commonly sustained pelvic fractures associated with major blood loss (18% vs 9%) and fractures more commonly involved the sacro-iliac joint (40% vs 24%). Head*, facial* and thoracic* injuries predominated in car occupants and extremity injuries in motorcyclists. Two (2%) car occupants and 2(4%) motorcyclists died. Operative procedures were required in 49(86.0%) motorcyclists and 67(73.6%) car occupants. Thirty (52.6%) car occupants and 28(30.8%) motorcyclists required pelvic surgery. The median hospital stay was 19(1– 93) and 20(1–93) days respectively. Conclusions: Patterns of pelvic and associated injuries differ markedly between car occupants and motorcyclists reßecting differing injury mechanisms. Although pelvic injuries sustained in car and motorcycle accidents have a relatively low mortality rate they are associated with a high incidence of injury to intra-abdominal and intra-pelvic organs. Understanding common patterns of injury associated with pelvic trauma is vital in their prevention and management. (*P< 0.05)