We aimed to examine outcomes between displaced femoral neck fracture (FNF) patients managed with total hip arthroplasty (THA) or hemi-arthroplasty (HA) via the anterolateral vs. posterior approach.

We used data from the HEALTH trial (1,441 patients aged ≥50 with displaced FNFs randomized to THA vs. HA). We calculated each patient's propensity to undergo arthroplasty via the posterior approach, and matched them to 1 control (anterolateral approach) based on age (±5 years), and propensity score. We used Chi-Square/Fisher-Exact tests to compare dichotomous outcomes, and repeated measures ANOVA to examine differences in patient-reported outcomes (via the WOMAC subscores) from baseline to one-year postoperative. We used logistic regression to identify independent predictors of reoperation for instability in the posterior group.

We identified 1,306 patients for this sub-analysis, 876 (67.1%) who received arthroplasty via an anterolateral approach, and 430 (32.9%) a posterior approach. The unadjusted rate of reoperation was significantly higher in the posterior group (10.7% vs. 7.1%).

Following propensity score matching, we retained 790 patients (395 per group), with no between-group differences in patient, fracture, or implant characteristics. The matched cohort had a higher rate of comorbidities, and were less likely to be employed vs. the unmatched cohort. The rate of treatment for dislocation remained higher in the posterior group (6.1% vs. 2.0%) following matching.

Repeated measures ANOVA revealed significantly better WOMAC pain, stiffness, function, and total scores in the posterior group. Between-group differences at 12-months were: pain - 0.59 (0.03–1.15); stiffness - 0.62 (0.35–0.87); function - 2.99 (0.12–5.86); total - 3.90 (0.24–7.56). We identified THA (vs. HA, odds ratio 2.05 [1.05–4.01]) as the only independent predictor of treatment for dislocation in the posterior group.

Our analyses revealed that compromised patients with displaced FNFs who undergo arthroplasty via the posterior approach may report better symptoms at one-year vs. the anterolateral approach, despite a higher odds of reoperation for instability.

Aims

Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we sought to determine if a difference in functional outcomes exists between monopolar and bipolar hemiarthroplasty (HA).

Aims

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

Aims

To evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures.

Aims

This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads.

Many studies report the incidence and prevalence of surgical site infections (SSIs) following open fractures; however, there is limited information on the treatment and subsequent outcomes of superficial SSIs in open fracture patients. There is also a lack of clinical studies describing the prognostic factors that are associated with failure of antibiotic treatment (non-operative) for superficial SSI. To address this gap, we used data from the FLOW (Fluid Lavage in Open Fracture Wounds) trial to determine how successful antibiotic treatment was for superficial SSIs and to identify prognostic factors that could be predictive of antibiotic treatment failure.

This is a secondary analysis of the FLOW trial dataset. The FLOW trial included 2,445 operatively managed open fracture patients. FLOW participants who had a non-operatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Participants were grouped into two categories: 1) participants whose superficial SSI resolved with antibiotics alone and 2) participants whose SSI did not resolve with antibiotics alone (defined as requiring surgical management or SSI being unresolved at final follow-up (12-months post-fracture for the FLOW trial)). Antibiotic treatment success and the date when this occurred was defined by the treating surgeon. A logistic binary regression analysis was conducted to identify factors associated with superficial SSI antibiotic success. Based on biologic rationale and previous literature, a priori we identified 13 (corresponding to 14 levels) potential factors to be included in the regression model.

Superficial SSIs were diagnosed in168 participants within 12 months of their fracture. Of these, 139 (82.7%) had their superficial SSI treated with antibiotics alone. The antibiotic treatment was successful in resolving the superficial SSI in 97 participants (69.8%) and unsuccessful in resolving the SSI in 42 participants (30.2%). We found that superficial SSIs that were diagnosed later in follow-up were associated with failure of treatment with antibiotic alone (Odds ratio 1.05 for every week in diagnosis delay, 95% Confidence Interval 1.004–1.099; p=0.03). Age, sex, fracture severity, fracture pattern, wound size, time from injury to initial surgical irrigation and debridement were not associated with antibiotic treatment failure.

Our secondary analysis of prospectively collected FLOW data found antibiotics alone resolved superficial SSIs in 69.8% of patients diagnosed with superficial SSIs. We also found that superficial SSIs that were diagnosed earlier in follow-up were associated with successful treatment with antibiotics alone. This suggests that if superficial SSIs are diagnosed and treated promptly, there is a higher probability that they will resolve with antibiotic treatment.

The primary objectives of this study were to: 1) identify risk factors for subsequent surgery following initial treatment of proximal humerus fractures, stratified by initial treatment type; 2) generate risk prediction tools to predict subsequent shoulder surgery following initial treatment; and 3) internally validate the discriminative ability of each tool.

We identified patients ≥ 50 years with a diagnosis of proximal humerus fracture from 2004 to 2015 using linkable health datasets in Ontario, Canada. We used procedural and fee codes within 30 days of the index fracture to classify patients into treatment groups: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used intervention and diagnosis codes to identify all instances of complication-related subsequent shoulder surgery following initial treatment within two years post fracture. We developed logistic regression models for randomly selected two thirds of each treatment group to evaluate the association of patient, fracture, surgical, and hospital variables on the odds of subsequent shoulder surgery following initial treatment. We used regression coefficients to compute points associated with each of the variables within each category, and calculated the risk associated with each point total using the regression equation. We used the final third of each cohort to evaluate the discriminative ability of the developed risk tools (via the continuous point total and a dichotomous point cut-off value for “higher” vs. “lower” risk determined by Receiver Operating Curves) using c-statistics.

We identified 20,897 patients with proximal humerus fractures that fit our inclusion criteria for analysis, 2,414 treated with fixation, 1,065 treated with replacement, and 17,418 treated conservatively. The proportions of patients who underwent subsequent shoulder surgery within two years were 13.8%, 5.1%, and 1.3%, for fixation, replacement, and conservative groups, respectively. Predictors of reoperation following fixation included the use of a bone graft, and fixation with a nail or wire vs. a plate. The only significant predictor of reoperation following replacement was poor bone quality. The only predictor of subsequent shoulder surgery following conservative treatment was more comorbidities while patients aged 70+, and those discharged home following initial presentation (vs. admitted or transferred to another facility) had lower odds of subsequent shoulder surgery. The risk tools developed were able to discriminate between patients who did or did not undergo subsequent shoulder surgery in the derivation cohorts with c-statistics of 0.75–0.88 (continuous point total), and 0.82–0.88 (dichotomous cut-off), and 0.53–0.78 (continuous point total) and 0.51–0.79 (dichotomous cut-off) in the validation cohorts.

Our results present potential factors associated with subsequent shoulder surgery following initial treatment of proximal humerus fractures, stratified by treatment type. Our developed risk tools showed good to strong discriminative ability in both the derivation and validation cohorts for patients treated with fixation, and conservatively. This indicates that the tools may be useful for clinicians and researchers. Future research is required to develop risk tools that incorporate clinical variables such as functional demands.

Unstable chest wall injuries have high rates of mortality and morbidity. These injuries can lead to respiratory dysfunction, and are associated with high rates of pneumonia, sepsis, prolonged ICU stays, and increased health care costs. Numerous studies have demonstrated improved outcomes with surgical fixation compared to non-operative treatment. However, an adequately powered multi-centre randomized controlled study using modern fixation techniques has been lacking.

We present a multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries with the current standard of non-operative management. Patients aged 16–85 with a flail chest (3 or more consecutive, segmental, displaced rib fractures), or severe deformity of the chest wall, were recruited from multiple trauma centers across North America. Exclusion criteria included: severe pulmonary contusion, severe head trauma, randomization>72 hours from injury, inability to perform surgical fixation within 96 hours from injury (in those randomized to surgery), fractures of the floating ribs, or fractures adjacent to the spine not amendable to surgical fixation. Patients were seen in follow-up for one year. The primary outcome was days free from mechanical ventilation in the first 28 days following injury. Secondary outcomes were days in ICU, rates of pneumonia, sepsis, need for tracheostomy, mortality, general health outcomes, pulmonary function testing, and other complications of treatment. A sample size of 206 was required to detect a difference of 2 ventilator-free days between the two groups, using a 2-tailed alpha error of 0.05 and a power of 0.80.

A total of 207 patients were recruited from 15 sites across Canada and USA, from 2011–2018. Ninety-nine patients were randomized to non-operative treatment, and 108 were randomized to surgical fixation. Overall, the mean age was 53 years, and 75% of patients were male, with 25% females. The commonest mechanisms of injury were: motor vehicle collisions (34%), falls (20%), motorcycle collisions (14%), and pedestrian injuries (11%). The mean injury severity score (ISS) at admission was 26, and patients had a mean of 10 rib fractures. Eighty-nine percent of patients had pneumothorax, 76% had haemothorax, and 54% had pulmonary contusion. There were no differences between the two groups in terms of demographics. The final results will be available and presented at the COA meeting in Halifax.

This is the largest randomized controlled trial to date, comparing surgical fixation to non-operative treatment of unstable chest wall and flail chest injuries. The results of this study will shed light on the best treatment options for patients with such injuries, help understand outcomes, and guide treatment. The final results will be available and presented at the COA meeting in Halifax.

Displaced femoral neck fractures can have devastating impacts on quality of life and patient function. Evidence for optimal surgical approach is far from definitive. The Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty (HEALTH) trial aimed to evaluate unplanned secondary procedures following total hip arthroplasty (THA) versus hemi-arthroplasty (HA) within two years of initial surgery for displaced femoral neck fractures. Secondary objectives evaluated differences in patient function, health-related quality of life, mortality, and hip-related complications HEALTH is a large randomized controlled trial that included 1,495 patients across 81 centers in 10 countries. Patients aged 50 years or older with displaced femoral neck fractures received either THA or HA. Participants were followed for 24 months post-fracture and a Central Adjudication Committee adjudicated fracture eligibility, technical placement of prosthesis, additional surgical procedures, hip-related complications, and mortality. The primary analyses were a Cox proportional hazards model with time to the primary study endpoint as the outcome and THA versus HA as the independent variable. Using multi-level linear models with three levels (centre, patient, and time), with patient and centre entered as random effects, the effect of THA versus HA on quality of life (Short Form-12 (SF-12) and EQ-5D), function (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), and mobility (Timed Up and Go Test (TUG)) were estimated separately.

The majority of patients were female (70.1%), 70 years of age or older (80.2%), and able to ambulate without the aid of an assistive device before their fracture (74.4%), and the injury in the majority of the patients was a subcapital femoral neck fracture (61.9%). The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to THA and 60 of 723 patients (8.3%) who were randomly assigned to HA (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; p=0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemi- arthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total WOMAC total score, pain score, stiffness score, and function score, modestly favored THA over HA. Mortality was similar in the two treatment groups (14.3% among the patients assigned to THA and 13.1% among those assigned to HA, p=0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to THA and in 265 patients (36.7%) assigned to HA.

Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo THA and those who were assigned to undergo HA, and THA provided a clinically unimportant improvement over HA in function and quality of life over 24 months.

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

This study was designed to compare length of hospital stay, and 30-day major and minor complications between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal or epidural anesthesia with or without regional nerve blocks.

Patients 18 years and older undergoing TKA between the years of 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Patients with “primary anesthesia technique” codes for either spinal or epidural anesthesia along with “other anesthesia technique” codes for regional anesthesia were assumed to have been given a regional nerve block. Chi square tests, and analysis of variance were utilized to evaluate unadjusted differences in demographics and outcomes between anesthesia types. Multivariable regression was utilized to compare outcomes (length of stay and complications) between anesthesia types, while adjusting for age, American Society of Anesthesiologist (ASA) class, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status.

A total of 214,665 TKA patients were identified (average age 67 ± 10 years). Of these, 257 (0.12%) underwent epidural anesthesia with a nerve block (EB), while 2,318 (1.08%) underwent epidural anesthesia with no block (E), 14,468 (1.08%) underwent spinal anesthesia with a block (SB), and 85,243 (39.7%) underwent spinal anesthesia with no block (S), and 112,377 (52.4%) underwent general anesthesia (G).

The unadjusted length of stay (LOS) was significantly longer in the E group (3.67 ± 5 days) compared to the G group (3.1 ± 3.9 days), while the unadjusted LOS was significantly shorter in the EB group (2.6 ± 1.2), and both SB and S groups (2.6 ± 3 and 2.9 ± 3, respectively), compared to the G group p < 0 .001. Following covariable adjustment, anesthesia type remained an independent predictor of length of stay. Compared to the G group, patients in the E group stayed 0.56 days longer (95% Confidence interval [95%CI] 0.42 – 0.71 days), while patients in the SB were discharged 0.28 days (95%CI 0.21 – 0.35 days) earlier, and those in the S group were discharged 0.06 days earlier (95%CI 0.02–0.09), (p < 0 .0001).

While the unadjusted rates of major complications were not significantly different between groups, the unadjusted rates of minor complications were higher in the E, EB, and G groups compared to the S and SB groups. Following covariable adjustment, there were no differences between groups in the risk of minor complications.

In conclusion, these data indicate that anesthesia type following TKA is associated with length of hospital stay, but not with 30-day complications. After adjusting for relevant covariables, patients who received epidural anesthesia without a nerve block for TKA were discharged later, while patients who received spinal anesthesia, both with and without a nerve block for TKA were discharged earlier, compared to patients who received general anesthesia for TKA.

This study was designed to compare atypical hip fractures with a matched cohort of standard hip fractures to evaluate the difference in outcomes.

Patients from the American College of Surgeons National Surgical Quality Improvement Program's (NSQIP) targeted hip fracture data file (containing a more comprehensive set of variables collected on 9,390 specially targeted hip fracture patients, including the differentiation of atypical from standard hip fractures) were merged with the standard 2016 NSQIP data file. Atypical hip fracture patients aged 18 years and older in 2016 were identified via the targeted hip fracture data file and matched to two standard hip fracture controls by age, sex, and fracture location. Patient demographics, length of hospital stay, 30-day mortality, major and minor complications, and other hip-specific variables were identified from the database. Binary outcomes were compared using the McNemar's test for paired groups, and continuous outcomes were compared using a paired t-test.

Ninety-five atypical hip fractures were identified, and compared to 190 age, sex, and fracture location matched standard hip fracture controls. There was no statistical difference in body mass index (BMI), race, ASA score, smoking status, timing of fixation, or functional status between the two groups (P>0.05). Thirty-day mortality was significantly higher in the atypical hip fracture group (atypical 7.36%, standard 2.11% p

This is the first study, to our knowledge, that demonstrates an increase in the rate of mortality in atypical hip fractures. Comparing atypical hip fractures with a matched cohort of standard hip fractures revealed a significantly greater 30-day mortality rate with an odds ratio of 3.62 in atypical hip fractures (95% CI 1.03–12.68). Prospective, clinical studies are recommended to further investigate these findings.

Tibial cut is a crucial step in ensuring adequate and appropriate proximal tibial resection for mechanical orientation and axis in total knee replacement. We evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects individual mechanical orientation and alignment.

We used Condylar Differential in 37 consecutive total knee replacements including valgus knees and severe advanced osteoarthritis. First a vertical line is drawn on digital weight bearing anteroposterior radiograph for mechanical axis of tibia. Then a horizontal line is drawn across and perpendicular to the mechanical axis. The distances between the horizontal line and the lowest reproducible points of articular surfaces of medial and lateral tibial condyles respectively are measured. The difference between two measurements obviously represents Condylar Differential. Condylar Differential, adjusted to the nearest millimetre, is maintained in executing tibial cuts, successively if necessary.

Condylar Differential measurement showed a very wide variation, ranging from 8–6 (2 mm) to 10-0 (10 mm). We found that prior measurement of Condylar Differential is a simple, consistent and effective estimate and individualises the tibial cut for optimal templating of tibia. We encountered no problems, adopting this technique, in our series.

Condylar Differential contributes to optimal individualised tibial cut in conventional total knee replacement and is a useful alternative to computer navigated option with comparable accuracy in this respect. While we used the technique in digitised radiographs, this technique can also be applied to plain films, allowing for magnification.

Background

Mechanics and kinematics of the knee following total knee replacement are related to the mechanics and kinematics of the normal knee. Restoration of neutral alignment is an important factor affecting the long-term results of total knee replacement. Tibial cut is a vital and crucial step in ensuring adequate and appropriate proximal tibial resection, which is essential for mechanical orientation and axis in total knee replacement. Tibial cut must be individually reliable, reproducible, consistent and an accurate predictor of individual anatomical measurements. Conventional tibial cuts of tibia with fixed measurements cannot account for individual variations. While computer navigated total knee replacement serves as a medium to achieve this objective, the technology is not universally applicable for differing reasons. Therefore we evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects the individual mechanical orientation and alignment.

Introduction

Previous studies have indicated that prolonged surgical time may lead to higher rates of infection following total hip arthroplasty (THA). The purpose of this study was to evaluate the influence of surgical time on 30-day complications following THA and to determine if there was a time interval associated with worse outcomes.

Introduction

This study was designed to evaluate the effect of discharge timing on 30-day major and minor complications in patients undergoing total knee arthroplasty (TKA) while adjusting for other variables.

Aims

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

Proximal humerus fractures are a common fragility fracture in older adults. A variety of treatment options exist, yet longer term outcomes of newer surgical treatments have not been extensively researched. Additionally, intermediate term outcomes following both surgical and non-surgical initial treatment of these injuries have not been evaluated at a population level. The purpose of this study was to utilise administrative data from Ontario, Canada to evaluate intermediate term outcomes following initial treatment of proximal humerus fractures.

We used data from the Canadian Institute for Health Information to identify all patients aged 50 and older who presented to an ambulatory care facility with a “main diagnosis” of proximal humerus fracture from April 1, 2004 to March 31, 2013. Intervention codes from the Discharge Abstract Database were used to categorise patients into fixation, replacement, reduction or non-surgically treated groups. We used intervention codes to identify instances of complication-related operations following initial treatment (including fixation, replacement, hardware removal, rotator cuff repair and irrigation and debridement [I&D]) at one year post initial treatment.

The majority of patients (28,369, 86.6%, 95% confidence interval [95% CI] 86.2–87.0%) were initially treated non-surgically, while 2835 (8.7%, 95% CI 8.4–9.0%) underwent initial fixation, 1280 (3.9%, 95% CI 3.7–4.1%) received primary joint replacement, and 276 (0.8%, 95% CI 0.8–1.0%) were initially treated with a reduction procedure. In the year following the initial treatment period, 127 (0.4%, 95%CI 0.4–0.5%) non-surgically treated patients underwent a replacement surgery, 292 (1.0%, 95%CI 0.9–1.2%) underwent fixation, and 12 (0.04%, 95% CI 0.02–0.07%) underwent a reduction procedure. Of the 2835 patients who received initial fixation, 57 (2.0%, 95% CI 1.6–2.6%) returned for a shoulder replacement, 80 received secondary fixation (2.8%, 95% CI 2.3–3.5%), 57 (2.0%, 95%CI 1.6–2.6%) underwent rotator cuff repair, 300 (10.6%, 95% CI 9.5–11.8%) had their implants removed, and 16 (0.6%, 95% CI 0.4–0.9%) returned for I&D. Of the 1280 patients who underwent initial replacement surgeries, 30 (2.3%, 95% CI 1.7–3.3%) returned for a secondary replacement, nine (0.7%, 95% CI 0.4–1.3%) underwent rotator cuff repair, and seven (0.6%, 95% CI 0.3–1.1%) had their implant removed. In the group who received initial reduction, eight (2.9%, 95% CI 1.5–5.6%) underwent a fixation procedure, six (2.2%, 95% CI 1.0–4.7%) received replacement surgeries, and five (1.8%, 95% CI 0.8–4.2%) each received rotator cuff repair and I&D in the year following initial treatment.

The majority of proximal humerus fractures in patients 50 and older in Ontario, Canada are treated non-surgically. Complication-related operations in the year following initial non-operative treatment are relatively low. The most commonly observed procedure following initial fixation surgery is hardware removal.

Proximal femur fractures are increasing in prevalence, with femoral neck (FN) and intertrochanteric (IT) fractures representing the majority of these injuries. The salvage procedure for failed open reduction internal fixation (ORIF) is often a conversion to total hip arthroplasty (THA). The use of THA for failed ORIF improves pain and function, however the procedure is more challenging. The aim of this study was to investigate the clinical and radiographic outcomes in patients who have undergone THA after ORIF.

This retrospective case-control study compared patients who underwent THA after failed ORIF to a matched cohort undergoing primary THA for non-traumatic osteoarthritis. From 2004 to 2014, 40 patients were identified. The matched cohort was matched for date of operation, age, gender, and type of implant. Preoperative, intraoperative, and postoperative data were collected and statistical analysis was performed.

The cohort of patients with a salvage THA included 18 male and 22 female patients with a mean age of 73 years and mean follow up of 3.1 years. Those with failed fixation included 12 IT fractures and 28 FN fractures. The mean time between ORIF and THA was 2.1 years for IT fractures and 8.5 years for FN fractures (p=0.03). The failed fixation group had longer procedures, greater drop in hemoglobin, and greater blood transfusion rate (p<0.05). There was one revision and one dislocation in the failed fixation group with no revisions or dislocations in the primary THA group. Length of admission, medical complications, and functional outcome as assessed with a standardised hip score and were found not to be statistically different between the groups.

Salvage THA for failed initial fixation of proximal femur fractures yields comparable clinical results to primary THA with an increased operative time, blood loss, and blood transfusion rate.