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The Bone & Joint Journal
Vol. 106-B, Issue 12 | Pages 1372 - 1376
1 Dec 2024
Kennedy JW Meek RMD

Hip fractures pose a major global health challenge, leading to high rates of morbidity and mortality, particularly among the elderly. With an ageing population, the incidence of these injuries is rising, exerting significant pressure on healthcare systems worldwide. Despite substantial research aimed at establishing best practice, several key areas remain the subject of ongoing debate. This article examines the latest evidence on the place of arthroplasty in the surgical treatment of hip fractures, with a particular focus on the choice of implant, the use of cemented versus uncemented fixation, and advances in perioperative care.

Cite this article: Bone Joint J 2024;106-B(12):1372–1376.


Bone & Joint Research
Vol. 13, Issue 10 | Pages 525 - 534
1 Oct 2024
Mu W Xu B Wang F Maimaitiaimaier Y Zou C Cao L

Aims

This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification.

Methods

We conducted a retrospective analysis of 162 knees (162 patients) that received treatment for PJI post-TKA with combined IV and topical antibiotic infusions at a single academic hospital from 1 January 2010 to 31 December 2022. The incidence of AKI was evaluated using the KDIGO criteria, focussing on the identification of significant predictors and the temporal pattern of AKI development.


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1044 - 1049
1 Oct 2024
Abelleyra Lastoria DA Ogbolu C Olatigbe O Beni R Iftikhar A Hing CB

Aims. To determine whether obesity and malnutrition have a synergistic effect on outcomes from skeletal trauma or elective orthopaedic surgery. Methods. Electronic databases including MEDLINE, Global Health, Embase, Web of Science, ScienceDirect, and PEDRo were searched up to 14 April 2024, as well as conference proceedings and the reference lists of included studies. Studies were appraised using tools according to study design, including the Oxford Levels of Evidence, the Institute of Health Economics case series quality appraisal checklist, and the CLARITY checklist for cohort studies. Studies were eligible if they reported the effects of combined malnutrition and obesity on outcomes from skeletal trauma or elective orthopaedic surgery. Results. A total of eight studies (106,319 patients) were included. These carried moderate to high risk of bias. Combined obesity and malnutrition did not lead to worse outcomes in patients undergoing total shoulder arthroplasty or repair of proximal humeral fractures (two retrospective cohort studies). Three studies (two retrospective cohort studies, one case series) found that malnourishment and obesity had a synergistic effect and led to poor outcomes in total hip or knee arthroplasty, including longer length of stay and higher complication rates. One retrospective cohort study pertaining to posterior lumbar fusion found that malnourished obese patients had higher odds of developing surgical site infection and sepsis, as well as higher odds of requiring a revision procedure. Conclusion. Combined malnutrition and obesity have a synergistic effect and lead to poor outcomes in lower limb procedures. Appropriate preoperative optimization and postoperative care are required to improve outcomes in this group of patients. Cite this article: Bone Joint J 2024;106-B(10):1044–1049


The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 935 - 941
1 Sep 2024
Ailaney N Guirguis PG Ginnetti JG Balkissoon R Myers TG Ramirez G Thirukumaran CP Ricciardi BF

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

Methods

This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.


Bone & Joint Research
Vol. 13, Issue 8 | Pages 372 - 382
1 Aug 2024
Luger M Böhler C Puchner SE Apprich S Staats K Windhager R Sigmund IK

Aims

Serum inflammatory parameters are widely used to aid in diagnosing a periprosthetic joint infection (PJI). Due to their limited performances in the literature, novel and more accurate biomarkers are needed. Serum albumin-to-globulin ratio (AGR) and serum CRP-to-albumin ratio (CAR) have previously been proposed as potential new parameters, but results were mixed. The aim of this study was to assess the diagnostic accuracy of AGR and CAR in diagnosing PJI and to compare them to the established and widely used marker CRP.

Methods

From 2015 to 2022, a consecutive series of 275 cases of revision total hip (n = 129) and knee arthroplasty (n = 146) were included in this retrospective cohort study. Based on the 2021 European Bone and Joint Infection Society (EBJIS) definition, 144 arthroplasties were classified as septic. Using receiver operating characteristic curve (ROC) analysis, the ideal thresholds and diagnostic performances were calculated. The areas under the curve (AUCs) were compared using the z-test.


Bone & Joint 360
Vol. 13, Issue 3 | Pages 35 - 36
3 Jun 2024

The June 2024 Spine Roundup360 looks at: Intraoperative navigation increases the projected lifetime cancer risk in patients undergoing surgery for adolescent idiopathic scoliosis; Intrawound vancomycin powder reduces delayed deep surgical site infections following posterior spinal fusion for adolescent idiopathic scoliosis; Characterizing negative online reviews of spine surgeons; Proximal junctional failure after surgical instrumentation in adult spinal deformity: biomechanical assessment of proximal instrumentation stiffness; Nutritional supplementation and wound healing: a randomized controlled trial.



The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 492 - 500
1 May 2024
Miwa S Yamamoto N Hayashi K Takeuchi A Igarashi K Tada K Taniguchi Y Morinaga S Asano Y Tsuchiya H

Aims

Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment.

Methods

A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients.


The Bone & Joint Journal
Vol. 106-B, Issue 4 | Pages 412 - 418
1 Apr 2024
Alqarni AG Nightingale J Norrish A Gladman JRF Ollivere B

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.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_17 | Pages 68 - 68
24 Nov 2023
Luger M Windhager R Sigmund I
Full Access

Aim. Serum parameters continue to be a focus of research in diagnosing periprosthetic joint infections (PJI). Several workgroups have recently proposed serum Albumin-Globulin-Ratio (AGR) as a potential new biomarker. Due to controversies in the literature, its usability in clinical practice remains uncertain. The aim of this study was to assess the value of serum AGR in diagnosing PJI preoperatively, especially in comparison with the well-established marker C-reactive Protein (CRP). Method. From January 2015 to June 2022, patients with indicated revision hip (rTHA) and knee (rTKA) arthroplasty were included in this retrospective cohort study of prospectively collected data. A standardized diagnostic workup was performed using the 2021 European Bone and Joint Infection Society (EBJIS) definition of PJI, excluding CRP. Diagnostic accuracies of serum AGR and CRP were calculated by receiver operating characteristic curve (ROC) analysis. A z-test was used to compare the area under the curves (AUC). Results. A total of 275 patients with rTHA and rTKA were included, 144 joints (52.4%) were identified as septic. Decreased AGR and elevated CRP were strongly associated with PJI, optimal diagnostic thresholds were calculated with 1.253 and 9.4 mg/L, respectively. Sensitivities were 62.5% (95%-confidence interval: 54.3–70.0) and 73.6% (65.8–80.1), and specificities 84.7% (77.5–89.9) and 87.8% (80.9–92.4), respectively. CRP showed a significantly higher AUC than AGR (0.807 (0.761–0.853) and 0.736 (0.686–0.786); p<0.0001). Subgroup analysis of acute versus chronic infections yielded significantly higher diagnostic accuracies in acute PJI for both parameters (p<0.0001). Similar results were observed when focusing on the causative microorganism; a better diagnostic performance was observed in high-virulence PJI compared to low-virulence PJI (p≤0.005). Furthermore, higher AUCs were calculated in knee PJI compared with hip PJI, with a significant difference for AGR (p=0.043). Conclusions. Due to its limited diagnostic accuracy, serum AGR cannot be recommended as an additional marker for diagnosing PJI. Serum parameters are generally unspecific and can be influenced by comorbidities and other foci of infection. Additionally, parameters may remain within normal levels in low-grade PJI. Evaluating AGR, further possible pitfalls must be considered, for example an increased latency until bottom values are reached and the impact of malnutrition


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_15 | Pages 41 - 41
7 Nov 2023
Ragunandan S Goller R
Full Access

The aims of this study was to determine the incidence of malnutrition in children with supracondylar fractures. It was hypothesised that the presence of malnutrition will increase the severity type of fractures. The study was a retrospective, cross-sectional study at a single institution. Children between 0 years and 12 years of age, who sustained documented supracondylar fracture treated surgically as a result of low velocity trauma were included in the study. Patients who sustained high velocity trauma, who had known bone disorders or had incomplete chart data, were excluded from the study Data was captured from children's’ notes who have been treated surgically for supracondylar fractures from casualty, theatre and the clinic notes. The nutritional status of children and fracture grade were identified and the two sets of data were compared against each other to try to identify a possible relation between fracture severity and malnutrition. Data was analysed in STATA and 5% level of significance was used to signify statistically significant associations. 150 patients were identified and included in the study. The majority of patients reviewed were in the normal nutritional range according to their z-scores. The severity of the fracture was not only associated with a poorer nutritional status however children with high and low z-scores (over weight as well as undernourished children) had the more severe fracture patterns, while children with normal z-scores had a fracture patterns of varying severity. Children who were malnourished were more likely to sustain more severe fracture types. The results highlighted the need for all children to have a good nutritional status as this may play a role in preventing more complex fractures


The Bone & Joint Journal
Vol. 105-B, Issue 11 | Pages 1149 - 1158
1 Nov 2023
Chen B Zhang JH Duckworth AD Clement ND

Aims. Hip fractures are a major cause of morbidity and mortality, and malnutrition is a crucial determinant of these outcomes. This meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with a hip fracture. Methods. A systematic literature search was conducted in August 2022. ONS was defined as high protein-based diet strategies containing (or not containing) carbohydrates, fat, vitamins, and minerals. Randomized trials documenting ONS in older patients with hip fracture (aged ≥ 50 years) were included. Two reviewers evaluated study eligibility, conducted data extraction, and assessed study quality. Results. There were 812 studies identified, of which 18 studies involving 1,522 patients met the inclusion criteria. The overall meta-analysis demonstrated that ONS was associated with significantly elevated albumin levels (weighted mean difference (WMD) 1.24 (95% confidence interval (CI) 0.95 to 1.53)), as well as a significant risk reduction in infective complications (odds ratio (OR) 0.54 (95% CI 0.39 to 0.76)), pressure ulcers (OR 0.54 (95% CI 0.33 to 0.88)), and total complications (OR 0.57 (95% CI 0.42 to 0.79)). Length of hospital stay (LOS) was also significantly reduced (WMD -2.36 (95% CI -4.14 to -0.58)), particularly in rehabilitation LOS (WMD -4.17 (95% CI -7.08 to -1.26)). There was a tendency towards a lower mortality risk (OR 0.93 (95% CI 0.62 to 1.4)) and readmission (OR 0.52 (95% CI 0.16 to 1.73)), although statistical significance was not achieved (p = 0.741 and p = 0.285, respectively). The overall compliance with ONS ranged from 64.7% to 100%, but no factors influencing compliance were identified. Conclusion. This meta-analysis is the first to quantitatively demonstrate that ONS could nearly halve the risk of infective complications, pressure ulcers, total complications, as well as improve serum albumin and reduce LOS. ONS should be a regular and integrated part of the perioperative care of these patients, especially given that the compliance with ONS is acceptable. Cite this article: Bone Joint J 2023;105-B(11):1149–1158


Bone & Joint 360
Vol. 12, Issue 3 | Pages 30 - 32
1 Jun 2023

The June 2023 Spine Roundup360 looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.


Bone & Joint Research
Vol. 12, Issue 6 | Pages 362 - 371
1 Jun 2023
Xu D Ding C Cheng T Yang C Zhang X

Aims

The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD.

Methods

A comprehensive literature search was conducted to identify eligible studies reporting postoperative outcomes in IBD patients undergoing joint arthroplasty. The primary outcomes included postoperative complications, while the secondary outcomes included unplanned readmission, length of stay (LOS), joint reoperation/implant revision, and cost of care. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model when heterogeneity was substantial.


Hip fractures are a major cause of morbidity and mortality, and malnutrition is a critical determinant of these outcomes. This systematic review and meta-analysis aims to determine whether oral nutritional supplementation (ONS) improves postoperative outcomes in older patients with hip fracture. An electronic systematic literature search was conducted in August 2022 using four databases. Randomized trials documenting ONS in older patients with hip fracture (aged 50+) were included. Two reviewers evaluated study eligibility, data extraction and assessed study quality. There were 812 studies identified of which 18 studies involving 1,512 patients met the inclusion criteria. The overall meta-analysis demonstrates that ONS was associated with a significant risk reduction in infective complications (odds ratio (OR) 0.54, 95%CI 0.38, 0.76), pressure ulcers (OR 0.54, 95%CI 0.33, 0.88), total complications rate (OR 0.57, 95%CI 0.42, 0.79). Length of hospital stay (LOS) was also significantly reduced (weighted mean difference (WMD) −2.01, 95%CI −3.52, −0.5), particularly in the rehabilitation LOS (WMD −4.17, 95%CI −7.08, −1.26). There was a tendency towards lower risk in mortality (OR 0.93, 95%CI 0.62, 1.4) and readmission (OR 0.52, 95%CI 0.16, 1.73), though statistical significance was not achieved. The overall compliance to ONS ranged from 64.1% to 100%, but no factors influencing compliance were identified. This systematic review was the first to quantitatively demonstrate that ONS reduces half the risk of infective complications, pressure ulcers, total complication rate and reduces LOS. ONS should be a regular and integrated part of medical practice, especially given that the compliance to ONS is acceptable


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_3 | Pages 106 - 106
23 Feb 2023
Caughey W Zaidi F Shepherd C Rodriguez C Pitto R
Full Access

Malnutrition is considered a risk factor for postoperative complications in total hip and knee arthroplasty, though prospective studies investigating this assumption are lacking. The aim of this study was to prospectively analyse the 90-day postoperative complications, postoperative length of stay (LOS) and readmission rates of patients undergoing primary total hip and total kneearthroplasty using albumin, total lymphocyte count (TLC) and transferrin as serum markers of potential malnutrition. 603 primary hip and 823 primary knee arthroplasties over a 3-year period from a single centre wereprospectively analysed. BMI, demographic and comorbidity data were recorded. Complications werecategorised as surgical site infection, venous thromboembolism (deep vein thrombosis andpulmonary embolus), implant related (such as dislocation), and non-implant related (such aspneumonia). Outcomes were compared between groups, with malnutrition defined as serumalbumin <3.5g/dL, transferrin <200 mg/dL, or TLC <1,500 cells/mm³. Potential malnutrition was present in 9.3% of the study population. This group experienced a longeraverage LOS at 6.5 days compared to the normal albumin group at 5.0 days (p=0.003). Surgical siteinfection rate was higher in the malnourished group (12.5 vs 7.8%, p=0.02). There was no differencebetween the two groups in implant related complications (0.8 vs 1.0%, p=0.95) medicalcomplications (7.8 vs 13.3%, p=0.17), rate of venous thromboembolism (2.3 vs 2.7%) or 90-dayreadmission rate (14.1 vs 17.0%, p=0.56). TLC and transferrin were not predictive of any of theprimary outcomes measured (p<0.05). Pacific Island (p<0.001), Indian (p=0.02) and Asian (p=0.02) patients had lower albumin than NZ European. This study demonstrates an association between low albumin levels and increased postoperativeLOS and surgical site infection in total joint arthroplasty, providing rationale for consideration ofpreoperative nutritional screening and optimisation


The Bone & Joint Journal
Vol. 104-B, Issue 11 | Pages 1249 - 1255
1 Nov 2022
Williamson TK Passfall L Ihejirika-Lomedico R Espinosa A Owusu-Sarpong S Lanre-Amos T Schoenfeld AJ Passias PG

Aims

Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

Methods

ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders.


The Bone & Joint Journal
Vol. 104-B, Issue 11 | Pages 1193 - 1195
1 Nov 2022
Rajput V Meek RMD Haddad FS

Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area.

Cite this article: Bone Joint J 2022;104-B(11):1193–1195.


The Bone & Joint Journal
Vol. 104-B, Issue 10 | Pages 1156 - 1167
1 Oct 2022
Holleyman RJ Khan SK Charlett A Inman DS Johansen A Brown C Barnard S Fox S Baker PN Deehan D Burton P Gregson CL

Aims. Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England. Methods. We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England’s SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models. Results. Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days. Conclusion. COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival. Cite this article: Bone Joint J 2022;104-B(10):1156–1167


Bone & Joint Open
Vol. 3, Issue 7 | Pages 543 - 548
7 Jul 2022
Singh V Anil U Kurapatti M Robin JX Schwarzkopf R Rozell JC

Aims

Although readmission has historically been of primary interest, emergency department (ED) visits are increasingly a point of focus and can serve as a potentially unnecessary gateway to readmission. This study aims to analyze the difference between primary and revision total joint arthroplasty (TJA) cases in terms of the rate and reasons associated with 90-day ED visits.

Methods

We retrospectively reviewed all patients who underwent TJA from 2011 to 2021 at a single, large, tertiary urban institution. Patients were separated into two cohorts based on whether they underwent primary or revision TJA (rTJA). Outcomes of interest included ED visit within 90-days of surgery, as well as reasons for ED visit and readmission rate. Multivariable logistic regressions were performed to compare the two groups while accounting for all statistically significant demographic variables.